Attention-Deficit/Hyperactivity Disorder (ADHD) is one of the most common neurodevelopmental disorders across childhood, adolescence, and adulthood. The decision to initiate pharmacological treatment is often a turning point for families, patients, and clinicians. While there is no universal “one-size-fits-all” approach, major international guidelines—from the National Institute for Health and Care Excellence (NICE, 2018) to the American Academy of Pediatrics (AAP, 2019)—offer a clear and evidence-based framework for starting ADHD medication.

This article provides a detailed overview of when, why, and how to start ADHD medications, with special emphasis on the Indian clinical context.

Step 1: Confirming the Diagnosis

Before starting any medication, a thorough diagnostic evaluation is essential.

• Criteria: ADHD must meet DSM-5 or ICD-11 standards. Symptoms should be persistent, pervasive (in at least two settings, e.g., home and school), and impairing.

• Differential diagnosis: Sleep disorders, anxiety, depression, substance use, and thyroid dysfunction may mimic ADHD.

• Comorbidities: Conditions such as learning disorders, tics, autism, mood disorders, or substance use must be identified, as they influence treatment choice.

Step 2: Psychoeducation and Non-Pharmacological Approaches

All guidelines agree that medication should never be the only treatment.

• Parents, teachers, and patients should be educated about ADHD as a neurodevelopmental condition, not “bad behavior.”

• Behavioral interventions (positive reinforcement, structured routines, parent training programs) are first-line for preschool children (<6 years).

• School accommodations—extra time for assignments, seating near teachers, and reduced distractions—are vital at all ages.

• In adolescents and adults, cognitive-behavioral therapy (CBT) can complement medication by addressing procrastination, organization, and emotional dysregulation.

Step 3: When to Start Medication

Pharmacological treatment is indicated when:

• ADHD symptoms are moderate to severe, causing academic, social, or occupational impairment.

• Non-pharmacological interventions alone are insufficient.

• The child is ≥6 years old (per AAP and NICE).

• Adults experience persistent inattention, impulsivity, or poor executive functioning impacting work or relationships.

Step 4: Choice of First-Line Medication

Different guidelines have slightly different hierarchies, but the broad consensus is:

• Children and Adolescents

  • NICE (UK): Start with methylphenidate.

  • AAP (US): Either methylphenidate or amphetamines can be used.

  • Indian Psychiatric Society: Methylphenidate is first-line; atomoxetine if stimulants are not suitable.

• Adults

  • NICE: Lisdexamfetamine or methylphenidate, depending on response and tolerability.

  • Canadian ADHD Guidelines (2021): Either methylphenidate or amphetamines can be started; tailor to individual needs.

Step 5: Starting and Titrating

• Begin with a low dose to minimize side effects.

• Increase gradually (usually weekly), monitoring attention, hyperactivity, impulsivity, sleep, appetite, mood, and academic/work performance.

• Long-acting formulations are preferred (improved adherence, less misuse risk).

• Vital sign monitoring: blood pressure, heart rate, weight, and height in children.

• ECG only if there is a family history of sudden cardiac death, congenital heart disease, or unexplained syncope.

Step 6: Non-Stimulant Options

Not all patients tolerate stimulants. For these cases:

• Atomoxetine: Useful if comorbid anxiety, tic disorders, or substance use risk.

• Guanfacine or Clonidine: Helpful in hyperactivity, aggression, and sleep difficulties.

• Bupropion: Sometimes considered in adults with comorbid depression.

Step 7: Ongoing Monitoring

• Initial review: Within 2–4 weeks of starting medication.

• Regular follow-up: Every 3–6 months.

• Track growth (in children), cardiovascular parameters, and psychiatric side effects (mood swings, irritability, misuse).

• In children, consider an annual drug holiday to reassess ongoing need, especially during school breaks.

Putting It All Together

The art of initiating ADHD medication lies in balancing clinical evidence, individual needs, and family preferences.

• For school-aged children: methylphenidate first is the safest bet.

• For adults: lisdexamfetamine or methylphenidate are both reasonable starts.

• Atomoxetine remains a reliable second-line option when stimulants are unsuitable.

Pharmacotherapy is not a “cure,” but when carefully initiated and monitored, it can dramatically improve functioning, self-esteem, and quality of life.

✦ About the Author
I’m Dr. Srinivas Rajkumar T, MD (AIIMS, New Delhi), Consultant Psychiatrist in Chennai. At my clinic, I adopt a holistic approach to ADHD and other mental health conditions—combining pharmacotherapy, psychotherapy, and cutting-edge neuromodulation techniques like rTMS, tDCS, neurofeedback, and ketamine therapy. My focus is on evidence-based psychiatry, helping children, adolescents, and adults achieve their fullest potential.

 Mind and Memory Clinic, Apollo Clinic, Velachery, Chennai (Opp. Phoenix Mall)
 +91 85951 55808