ADHD: Treatment Algorithm
An evidence-graded path for ADHD in children and adults, built on the AADPA 2022 Australian guideline and NICE: assess well, treat co-occurring conditions, then titrate medication with clear monitoring. Prescribing rules for stimulants vary by state: check yours.
Evidence grades: A strong · B moderate · C weak or mixed · D anecdotal · X avoid.
Step 0 · Assess
- DSM-5 criteria: symptoms before 12, in 2 or more settings, with impairment. Collateral history (family, school reports) matters.
- Screen: ASRS v1.1 (adults), Vanderbilt or Conners (children). Screens don’t diagnose.
- Look for co-occurring and mimicking conditions: autism, anxiety, depression, bipolar disorder, substance use, sleep apnoea and poor sleep, learning disorders, thyroid disease, iron deficiency, hearing or vision problems, trauma.
- Cardiac screen before stimulants: personal or family history of sudden death, syncope on exertion, structural heart disease; BP and heart rate. ECG only if indicated.
- Baseline height, weight, BP, heart rate, sleep and appetite.
Step 1 · For everyone
- A · StrongPsychoeducationExplain ADHD, strengths and challenges, and treatment options.
- Evidence
- Guideline-recommended; improves engagement
- How
- Written plan; reputable sources
- Watch for
- A · StrongParent training (children)First line for preschoolers and alongside medication in older children.
- Evidence
- Strong evidence for behaviour and family outcomes (AADPA, NICE)
- How
- Triple P, Tuning in to Kids and similar programs
- Watch for
- B · ModerateCBT for adult ADHDOrganisation, planning, procrastination skills.
- Evidence
- Moderate evidence, especially combined with medication
- How
- Psychologist via a Mental Health Treatment Plan; group programs
- Watch for
- B · ModerateSchool and workplace adjustmentsSeating, breaks, extra time, written instructions.
- Evidence
- Consensus; practical benefit
- How
- Letters to school or employer
- Watch for
Step 2 · Medication
Titrate weekly to effect or side effects; review at each step.
- A · StrongStimulants: methylphenidate (children first line) or lisdexamfetamine / dexamfetamine (adults first line)Short- or long-acting; long-acting preferred for adherence.
- Evidence
- Large effect sizes in a network meta-analysis (Cortese 2018): roughly 0.8–1.0 in children and 0.5–0.8 in adults
- How
- Start low; titrate weekly; S8 rules apply
- Watch for
- Appetite, sleep, heart rate and BP, mood, tics, growth in children.
- A · StrongAtomoxetineWhen stimulants fail, aren’t tolerated or misuse is a concern.
- Evidence
- Moderate effect size (~0.5); 4–12 weeks to work
- How
- 0.5 then 1.2 mg/kg in children; 40 then 80 mg in adults
- Watch for
- Nausea, sexual side effects, suicidal thoughts in youth, liver.
- B · ModerateGuanfacine extended releaseNon-stimulant; helpful with tics, sleep, emotional dysregulation, or as an add-on.
- Evidence
- Moderate evidence in children and adolescents; adult evidence growing
- How
- 1 mg, titrate weekly to 0.05–0.12 mg/kg; PBS for 6–17 with criteria
- Watch for
- Sedation, low BP, rebound hypertension if stopped suddenly.
- C · Weak / mixedClonidineSleep onset, tics, aggression; add-on.
- Evidence
- Small trials
- How
- 50 µg at night, titrate
- Watch for
- Sedation, low BP; taper to stop.
- C · Weak / mixedBupropion (off label)Adults with co-occurring depression or substance use concerns.
- Evidence
- Small to moderate benefit, less than stimulants
- How
- 150 mg, then 150 mg twice daily
- Watch for
- Seizure risk, insomnia; CYP2D6 interactions.
- D · Anecdotal or mechanisticModafinil (off label)Occasionally tried in adults.
- Evidence
- Trials in adults negative or mixed
- How
- Watch for
- Contraception interaction; rash.
- X · AvoidNeurofeedback, elimination diets, supplement stacks
- Evidence
- Blinded trials show little or no benefit
- How
- Watch for
Special situations
- ADHD and autism: stimulants still help, though response is lower and side effects (irritability) more common: start lower, go slower.
- Anxiety: treat the most impairing first; stimulants often reduce anxiety caused by ADHD chaos. Atomoxetine or guanfacine if anxiety worsens.
- Substance use: long-acting formulations (lisdexamfetamine) have lower misuse potential; consider atomoxetine.
- Bipolar disorder: stabilise mood first.
- Pregnancy: individualise; recent data are reassuring for stimulants, but discuss risks and benefits.
- Monitoring: BP, heart rate, weight (height in children) every 6 months; yearly review of need and dose.
Common questions
What is first-line medication for ADHD?
Stimulants: methylphenidate first in children, and lisdexamfetamine or methylphenidate in adults, titrated weekly. Atomoxetine and guanfacine are alternatives.
Do children need an ECG before stimulants?
Not routinely. Take a cardiac history and measure BP and heart rate; do an ECG if there’s personal or family cardiac history or abnormal findings.
Evidence and references
- AADPA: Australian evidence-based clinical practice guideline for ADHD (2022)
- NICE NG87: ADHD diagnosis and management
- Cortese S et al. Comparative efficacy and tolerability of medications for ADHD (Lancet Psychiatry 2018)
- RUPP Autism Network. Methylphenidate in children with pervasive developmental disorders and hyperactivity (2005)
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