ADHD Hyperactive in Children and Adolescents

Understanding Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive Presentation

ADHD symptoms can range from mild to severe. In severe cases, ADHD can greatly hinder a child's academic achievement and social development. Left untreated, children and adolescents with ADHD experience poor outcomes in several domains of life, leading to substantial impairment, parent distress, and societal costs. Many children and adolescents with ADHD also have learning disorders and other psychiatric conditions, such as oppositional defiant disorder, conduct disorder, and anxiety disorders.

ADHD is characterized by deficits in neurocognitive processes known as executive functions, which include processes that are important for regulating attention and behavior, such as attentional control, inhibitory control, cognitive flexibility, and planning. ADHD stems from multiple causes, including a strong genetic component. Genetics appears to be the principal cause of ADHD, likely accounting for up to approximately 75% of all cases. In a smaller percentage of cases, ADHD may arise from early brain injuries or other disruptions to brain development, such as pregnancy or birth complications. Research does not support the claim that ADHD is a result of food additives, preservatives, or sugar.

For preschool-aged children (4-5 years old):  

First Line Treatments

   
• Evidence-based parent- and/or teacher-administered behavior therapy, implemented under the guidance of a behavior therapist, should be prescribed as the first-line treatment. Behavioral approaches, including behavioral parent training, classroom management, and peer interventions, and organizational interventions currently have the most research evidence for the treatment of children and adolescents with ADHD and are considered well-established treatments. In evidence-based behavioral approaches, professionally trained behavior therapists work directly with the parents and/or teachers to implement behavior interventions in the home and/or school settings. For children and adolescents with ADHD, Predominantly Hyperactive Presentation, these interventions focus on reducing impulsive and disruptive behaviors (e.g., interrupting, getting out of their seat at inappropriate times, blurting out) and improving behavioral regulation.

Second Line Treatments

   
• Methylphenidate may be prescribed if the behavior interventions do not yield significant improvement and there is continued moderate-to-severe disturbance in the child's functioning.
       
  • In areas in which evidence-based behavioral treatments are not available, the risks of starting medication at an early age must be weighed against the harm of delaying diagnosis and treatment
     

For school-aged children and adolescents (6-18 years old):

First Line Treatments

   
• Treatment guidelines generally recommend the use of both FDA-approved medications for ADHD and evidence-based parent- and/or teacher-administered behavior therapy under the guidance of a behavior therapis
 

   
• Stimulant medications have been demonstrated to reduce symptoms of ADHD, predominantly hyperactive presentation, such as disruptive and noisy behavior, and improve impulse control. Specific first-line medications for ADHD, predominantly hyperactive presentation, in school-aged children and adolescents include:
       
  • Methylphenidate
           
    • dexmethylphenidate
           
    • extended release dexmethylphenidate
           
    • extended release methylphenidate
           
    • methylphenidate hydrochloride
         
             
  • Amphetamines
           
    • mixed amphetamine salts
           
    • extended release mixed amphetamine salts
           
    • dextroamphetamine
           
    • Lisdexamfetamine (extended release)
     
     

Second Line Treatments

In cases of nonresponse to first-line treatment, alternative treatments with reasonable evidence of efficacy include:

   
• Atomoxetine
   
• Extended release guanfacine
   
• Extended release clonidine
       
  • The school environment, program, or placement should be part of any treatment plan.
     
     

Additional Treatments to Consider

Preliminary evidence suggests that the following strategies, while not a substitute for the more well-validated treatments listed above, might be considered:

   
• Neurofeedback training
   
• Cognitive training
 

Healthcare professionals are encouraged to stress the value of a balanced diet, good nutrition, and regular exercise for children and adolescents with ADHD.