A 7-year-old boy from Delhi is referred for evaluation of inattention and hyperactivity. His parents report he is restless, forgetful, and struggles to complete homework. His school teacher confirms similar difficulties in the classroom. Investigations include IQ testing (normal), hearing assessment (normal), and thyroid function tests (normal). All of the following pharmacological agents are first-line or evidence-based treatments for ADHD EXCEPT:

Explanation

## Pharmacological Management of ADHD **Key Point:** Fluoxetine is an SSRI used for depression and anxiety in children, NOT a first-line or evidence-based treatment for ADHD. While SSRIs may be used adjunctively in ADHD with comorbid depression/anxiety, they do not address core ADHD symptoms. ### First-Line and Evidence-Based ADHD Medications | Agent | Class | Mechanism | Status in ADHD | Notes | |-------|-------|-----------|----------------|-------| | **Methylphenidate** | Stimulant | Dopamine/noradrenaline reuptake inhibitor | **First-line** | Rapid onset; multiple formulations (IR, ER, transdermal) | | **Amphetamine salts** | Stimulant | Dopamine/noradrenaline releaser | **First-line** | Longer duration than methylphenidate | | **Atomoxetine** | Non-stimulant | Selective noradrenaline reuptake inhibitor | **Evidence-based alternative** | Useful when stimulants contraindicated or ineffective | | **Guanfacine** | Alpha-2 agonist | Presynaptic α2A receptor agonist | **Evidence-based alternative** | Particularly effective for hyperactivity-impulsivity | | **Clonidine** | Alpha-2 agonist | Presynaptic α2 receptor agonist | **Evidence-based alternative** | Often combined with stimulants | | **Fluoxetine** | SSRI | Serotonin reuptake inhibitor | **NOT for core ADHD** | Used only for comorbid depression/anxiety | **High-Yield:** The neurochemistry of ADHD involves **dopamine and noradrenaline deficiency** in prefrontal cortex and striatum. SSRIs (which target serotonin) do not address this core pathology. **Mnemonic:** **SNAG** = Stimulants, Non-stimulants (atomoxetine), Alpha-2 agonists (guanfacine, clonidine), Guanfacine specifically — these are your ADHD agents. **Clinical Pearl:** In this case, the child has confirmed ADHD (multi-setting symptoms, normal development/hearing/thyroid). Methylphenidate would be the first choice; atomoxetine or guanfacine are alternatives if stimulants are contraindicated or poorly tolerated. **Warning:** Do NOT confuse ADHD pharmacotherapy with depression/anxiety treatment. SSRIs have no role in treating core ADHD inattention or hyperactivity.