National Institute on Minority Health and Health Disparities (Dr. Wonnum); Uniformed Services University (Dr. Krassow), Bethesda, MD sundania.wonnum@nih.gov
The authors reported no potential conflict of interest relevant to this article.
The opinions of the authors do not represent the opinions of the National Institute on Minority Health and Health Disparities, the National Institutes of Health, the Department of Health and Human Services, the Department of Defense, or the federal government.
Risks that arise over time. As ADHD persists, adolescents are at greater risk for psychiatric comorbidities, suicidality, and functional impairments (eg, risky behaviors, occupational problems, truancy, delinquency, and poor self-esteem).4,8 Adolescents with internalized behaviors are more likely to experience comorbid depressive disorders with increased risk for self-harm.4,5,8 As adolescents age and their sense of autonomy increases, there is a tendency among those who have received a diagnosis of ADHDto minimize symptoms and decrease the frequency of routine clinic visits along with medication use and treatment compliance.3 Additionally, abuse, misuse, and misappropriation of stimulants among teens and young adults are commonplace.
Wide-scope, multidisciplinary evaluation and close clinical management reduce the potential for imprecise diagnoses, particularly at critical developmental junctures. AAP suggests that PCPs can treat mild and moderate cases of ADHD, but if the treating clinician does not have adequate training, experience, time, or clinical support to manage this condition, early referral is warranted.6
A guide to pharmacotherapy
Approximately 77% of children ages 2 to 17 years with a diagnosis of ADHD receive any form of treatment.2 Treatment for ADHD can include behavioral therapy and medication.2 AAP clinical practice guidelines caution against prescribing medications for children younger than 6 years, relying instead on caregiver-, teacher-, or clinician-administered behavioral strategies and parental training in behavioral modification. For children and adolescents between ages 6 and 18 years, first-line treatment includes pharmacotherapy balanced with behavioral therapy, academic modifications, and educational supports (eg, 504 Plan, individualized education plan [IEP]).6
Psychostimulants are preferred. These agents (eg, methylphenidate, amphetamine) remain the most efficacious class of medications to reduce hyperactivity and inattentiveness and to improve function. While long-acting psychostimulants are associated with better medication adherence and adverse-effect tolerance than are short-acting forms, the latter offer more flexibility in dosing. Start by titrating any stimulant to the lowest effective dose; reassess monthly until potential rebound effects stabilize.
More than twothirds of ADHD patients with a co-occurring condition are either inaccurately diagnosed or not referred for additional assessment and adjunct treatment.
Due to potential adverse effects of this class of medication, screen for any family history or personal risk for structural or electrical cardiac anomalies before starting pharmacotherapy. If any such risks exist, arrange for further cardiac evaluation before initiating medication.6 Adverse effects of stimulants include reduced appetite, gastrointestinal symptoms, headaches, anxiousness, parasomnia, tachycardia, and hypertension.
