Pharmacological management of attention deficit hyperactivity disorder in children and adolescents

SUMMARY

Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder characterised by developmentally inappropriate levels of hyperactivity, impulsivity and/or inattention, with substantial impact on functioning.

Stimulants (methylphenidate, dexamfetamine, lisdexamfetamine) are the main pharmacological treatment for children and adolescents with ADHD and are highly effective at reducing core ADHD symptoms.

Non-stimulants such as atomoxetine, clonidine and guanfacine can also be useful in some patients.

 

Introduction

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterised by developmentally inappropriate levels of hyperactivity, impulsivity and/or inattention.¹ Onset occurs in childhood, but persistence into adolescence and adult life is common. The paediatric prevalence is between 5 and 10%.² The presentation of ADHD can evolve across developmental stages,³ and is associated with substantially impaired social, academic and mental health outcomes.^4,5

Diagnosis of ADHD requires symptoms to be present across multiple settings (usually home and school), with demonstrated functional impairment (e.g. academic performance, family and social relationships, self-esteem).⁶ Comprehensive assessment is required, including screening for comorbidities.

 

Management of ADHD

Management needs to be individualised and multimodal, including encouraging a healthy lifestyle, and behavioural and educational strategies to manage common comorbidities.⁷ The purpose of any intervention is to enhance cognitive, academic and emotional development. Shared goal setting and collaborative decision-making with a chronic-care lens increase the likelihood of adherence to management plans and good outcomes.

Nonpharmacological interventions, including psychological and allied health therapies, can improve broader functioning for children with ADHD (e.g. for anxiety, social skills, self-care). These interventions play an important role in holistic ADHD care, alongside pharmacological therapies that help to address core symptoms. This article focuses on the drugs used to treat ADHD in children and adolescents.

 

Drugs for ADHD

Medication is recommended for patients with significant ADHD symptoms that persist after nonpharmacological approaches have been implemented.⁸ Drugs for ADHD include stimulants and non-stimulants. Approximately 6% of boys and 2% of girls aged under 18 years in Australia are prescribed ADHD medications.⁹

Stimulants

The Australian Evidence-Based Clinical Practice Guideline for ADHD recommends stimulants as first-line pharmacological treatment for children and adolescents who require medication for ADHD.⁷ Decades of research have demonstrated that the most effective way to reduce the core symptoms of ADHD is by taking psychostimulants,¹⁰ with approximately 70% of children having a positive clinical response.¹¹ Their primary mechanism of action is increased catecholamine activity via reuptake blockade, and increased release and inhibition of metabolism of dopamine and noradrenaline.¹²

Children taking stimulants typically pay attention longer, have improved social skills, and fidget less.¹³ Parents and teachers often report reduced emotional reaction to frustration and improved peer interactions.

The stimulants used to treat ADHD are methylphenidate and amphetamines (dexamfetamine and lisdexamfetamine) (Table 1). Patients who do not respond to or tolerate the first stimulant prescribed may respond better to an alternative.¹⁴ A 2018 meta-analysis found that, while amphetamines had slightly greater efficacy for ADHD symptoms according to clinicians, methylphenidate remained the recommended first-line treatment for children and adolescents due to better acceptability and improved classroom performance according to teachers.¹⁵

Most treated children take a stimulant every day, although some children or families prefer to use it predominantly on school days, and only as needed on weekends and during school holidays.

Table 1 Drugs for attention deficit hyperactivity disorder^16,17

Drug	Brand name	Preparation	Advantages	Dose frequency	Duration of action (hours)	Available strengths	Dose conversion
Methylphenidate	Ritalin 10	Immediate-release (IR) tablet	Allows dose titration especially when starting stimulant trial	2 to 3 times a day	3 to 4	10 mg	–
	Ritalin LA	Modified-release capsule containing 2 types of beads (biphasic): immediate release 50% and delayed release 50%	Biphasic release allows for a gradual onset and offset, and longer duration of action Capsule can be opened, and beads can be sprinkled on soft foods for ingestion	Once daily (morning)	6 to 8	10, 20, 30, 40, 60 mg	1:1 conversion with total daily dose of methylphenidate IR (Ritalin 10)
	Concerta	Osmotic modified-release tablet (ascending plasma profile): immediate release 22% and delayed release 78%	Provides consistent release throughout the day	Once daily (morning)	6 to 12	18, 27, 36, 54 mg	Dose conversion from methylphenidate IR (Ritalin 10) to Concerta depends on the number of doses of methylphenidate IR per day the patient has been receiving – refer to guidelines16 for detailed guidance on switching Dose conversion from Ritalin LA to Concerta generally involves adding approximately 50% of previous total daily dose of Ritalin LA (e.g. switch from Ritalin LA 20 mg to Concerta 36 mg)
Dexamfetamine	–	Immediate-release tablet	Allows dose titration especially when starting stimulant trial	1 to 2 times a day	4 to 6	5 mg	Methylphenidate IR (Ritalin 10) 10 mg = dexamfetamine 5 mg
Lisdexamfetamine (prodrug of dexamfetamine)	Vyvanse	Capsule	Longer duration of activity compared with dexamfetamine Contents of capsule can be dissolved in water	Once daily (morning)	6 to 12	20, 30, 40, 50, 60, 70 mg	No direct conversion between dexamfetamine and lisdexamfetamine due to different metabolism and first-pass effect No trial of dexamfetamine required before starting lisdexamfetamine
Atomoxetine	–	Capsule	Can be used as alternative to stimulants if stimulants ineffective or not tolerated, or as adjunct therapy with stimulants	Once daily (morning or evening)	24 [NB1]	10, 18, 25, 40, 60, 80, 100 mg	–
Clonidine	Catapres	Tablet	As above	2 to 3 times a day	4 to 8	100, 150 micrograms	–
Guanfacine	Intuniv	Modified-release tablet	As above	Once daily (morning or evening)	Usually over 8	1, 2, 3, 4 mg	–
NB1: Reaches steady state over 1 to 2 weeks; takes up to 8 weeks to achieve full effect

Starting stimulant treatment

A treatment trial should be started at a low dose, titrating up gradually according to tolerance and response as reported by the child, parents and teachers. When starting methylphenidate, the optimal dose is first established using the immediate-release preparation before converting to the corresponding long-acting dose. The Pharmaceutical Benefits Scheme (PBS) criteria require a trial of immediate-release methylphenidate before switching to a modified-release preparation. Standardised questionnaires, such as the Vanderbilt,¹⁸ enable structured feedback on treatment response.

Although there is some variation between jurisdictions, in most Australian states and territories the initiation of stimulant treatment for patients aged under 18 years is restricted to paediatricians and child and adolescent psychiatrists (except in Queensland). However, this is evolving as more states introduce models of shared ADHD care with general practitioners (GPs) (see 'Emerging roles of the GP' below). PBS subsidy for most ADHD drugs is for those above 6 years of age, although dexamfetamine is approved for use from the age of 3.

Adverse effects of stimulants

The most common adverse effects of stimulants are appetite suppression, irritability, insomnia, abdominal pain and headache.¹⁹ Apart from appetite suppression, many of these adverse effects subside with time. Stimulants can exacerbate tics and anxiety, but the presence of these symptoms is not a contraindication to starting medication. A minority of children and adolescents may become subdued and less able to enjoy social interactions.

Stimulants are associated with a slight mean increase in heart rate and blood pressure in children and adolescents,²⁰ potentially increasing the risk of a cardiac event in children with cardiovascular risk factors (e.g. hypertension) or some types of cardiac disease (e.g. arrhythmia syndromes, hypertrophic cardiomyopathy). It is therefore important to monitor heart rate and blood pressure while on treatment and exclude cardiac symptoms (e.g. palpitations, syncope) or signs (e.g. murmur) before starting medication. If these are identified, or if there is a family history of sudden death, Wolff–Parkinson–White syndrome, hypertrophic cardiomyopathy, or long QT syndrome, the patient should have a cardiologist review (which generally includes a Holter monitor) before starting a stimulant.^9,16

Safe storage of stimulants is important to prevent access by other children in the household. The risk of accidental ingestion of tablets or capsules by young children appears lower than with liquid preparations.²¹

Non-stimulants

Non-stimulants may provide symptomatic benefit but are less effective than stimulants.^15,22 These include the selective noradrenaline reuptake inhibitor atomoxetine,²³ and the alpha-2 adrenergic agonists clonidine and guanfacine.²⁴ They are often prescribed if patients do not tolerate stimulants and might be considered if there is stimulant misuse. They can also help treat comorbid conditions such as anxiety, insomnia and tics. They are commonly used in combination with stimulants to optimise treatment or minimise adverse effects, by allowing lower doses of stimulants.¹⁹ Adverse effects of atomoxetine include lethargy or sedation, nausea, headache and behaviour change. Clonidine and guanfacine can cause sedation, dizziness, nausea and irritability.

Other drugs occasionally used to treat ADHD include tricyclic antidepressants, the antidepressant bupropion, and the wakefulness-promoting drug modafinil. A number of novel drugs are under investigation.²⁵

 

Monitoring and long-term outcomes

Patients prescribed ADHD drugs should have their height, weight, heart rate and blood pressure measured at least every 6 months. If there is significant faltering in growth or persistently abnormal cardiovascular parameters, the patient should be reviewed by a paediatrician.⁹ Regular monitoring of ADHD symptoms through clinical review and repeat standardised questionnaires should be undertaken.

While the long-term impacts of ADHD drugs on academic achievements, social functioning and employment outcomes remain unclear,²⁶ research shows a protective effect on substance use disorder, criminality, car accidents and suicide.²⁷ The long-term effects of stimulants on neuropsychiatric outcomes are not well understood.²⁸ Consistent long-term stimulant use may negatively affect linear growth and adult height,²⁹ highlighting the importance of regular monitoring and follow-up.

 

General principles of prescribing in ADHD

Box 1 summarises general principles of prescribing drugs for ADHD.

 

Duration of treatment

A 2024 large international study (including Australian data) found that one-third of children and half of adolescents discontinued their ADHD medication within 12 months of starting due to adverse effects or lack of efficacy.³⁰ Treatment reinitiation is common.

When treatment with ADHD medication is effective and well tolerated, it is typically continued for some years. If patients have been stable for some time and appear to be making developmental gains in attentional and impulse control, consideration should be given to stopping treatment. This is usually conducted as a trial, ideally during school term, so feedback from teachers can be gathered to inform ongoing treatment decisions.

Stimulants can be stopped abruptly. There are no reported withdrawal effects from stopping atomoxetine abruptly; however, clonidine and guanfacine should be tapered off gradually.

 

Emerging roles of the GP

In Australia, GPs play a crucial role in ADHD management, including identifying potential cases, facilitating access to support services, monitoring patients between paediatrician or psychiatrist visits and, increasingly, providing prescriptions. Some jurisdictions are moving towards GP-led assessment and diagnosis, and treatment initiation.³¹ A recent survey revealed most Australian GPs are willing to take on expanded roles in ADHD management, although they emphasised the need for additional training and education.³² This aligns with the second recommendation in the Australian Government's report on Assessment and Support Services for People with ADHD, which called for improved healthcare access, including through telehealth and shared care models.³³ Multiple shared care initiatives are currently running or being established throughout Australia.^34,35 Each shared care program has specific partnerships tailored to the learning needs of the GP group and regional requirements. This is an evolving area of practice that warrants close observation as more states and territories move towards GP-led diagnosis and management.

 

Conclusion

Management of ADHD requires a holistic approach including consideration of appropriate pharmacological therapy. First-line drug treatments are stimulants (methylphenidate, dexamfetamine and lisdexamfetamine), which are effective at reducing core symptoms. Non-stimulants such as atomoxetine and guanfacine can be used as adjunct therapy or serve as alternatives for children and adolescents who cannot tolerate stimulants. Treatment with ADHD drugs requires ongoing monitoring of height, weight, heart rate and blood pressure, as well as symptom control.

This article was finalised on 9 September 2025.

Conflicts of interest: Daryl Efron was a member of the guideline development group for the 2022 Australian Evidence-Based Clinical Practice Guideline for ADHD.

Nadia Coscini is involved in the Victorian ADHD shared care pilot program as a paediatrician working with GPs in managing children with ADHD. Nadia is a committee member of the Australasian Society for Developmental Paediatrics.

This article is peer reviewed.

 

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