Evaluation and Management of Elevated Blood Pressure in Children and Adolescents with Attention Deficit Hyperactivity Disorder

  • Ikuyo YamaguchiEmail author
  • Coral Hanevold
Pediatric Hypertension (B Falkner, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Pediatric Hypertension


Purpose of Review

To understand the impact of attention deficit hyperactivity disorder (ADHD) and its medications on blood pressure (BP) in children and adolescents and provide recommendations for management of elevated BP in children and adolescents with ADHD.

Recent Findings

ADHD medications have cardiovascular effects including elevated BP. However, the bulk of the evidence indicates that stimulants and other ADHD medications are safe and do not cause severe cardiovascular diseases. BP should be assessed carefully at the time of ADHD diagnosis, because some behavioral changes similar to ADHD may be associated with hypertension.


ADHD medications appear to be safe. However, their long-term impact on the cardiovascular system is not clearly understood and needs further investigation. BP should be monitored regularly during ADHD pharmacotherapy in order to optimize the management of both conditions.


ADHD Pediatric hypertension Elevated blood pressure Stimulants Cardiovascular disease 


Compliance with Ethical Standards

Conflict of Interest

The authors declare no conflicts of interest relevant to this manuscript.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Berger I. Diagnosis of attention deficit hyperactivity disorder: much ado about something. Isr Med Assoc J. 2011;13(9):571–4.PubMedGoogle Scholar
  2. 2.
    Faraone SV, Sergeant J, Gillberg C, Biederman J. The worldwide prevalence of ADHD: is it an American condition? World Psychiatry. 2003;2(2):104–13.PubMedPubMedCentralGoogle Scholar
  3. 3.
    Polanczyk GV, Salum GA, Sugaya LS, Caye A, Rohde LA. Annual research review: a meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. J Child Psychol Psychiatry. 2015;56(3):345–65. Scholar
  4. 4.
    •• Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. These are the most recent clinical guidelines for the diagnosis, evaluation, and management of pediatric hypertension by the American Academy of Pediatrics (AAP) and its council on quality improvement and patient safety. These guidelines are also endorsed by the American Heart Association. CrossRefGoogle Scholar
  5. 5.
    Becton LJ, Shatat IF, Flynn JT. Hypertension and obesity: epidemiology, mechanisms and clinical approach. Indian J Pediatr. 2012;79(8):1056–61. Scholar
  6. 6.
    Shapiro DJ, Hersh AL, Cabana MD, Sutherland SM, Patel AI. Hypertension screening during ambulatory pediatric visits in the United States, 2000-2009. Pediatrics. 2012;130(4):604–10. Scholar
  7. 7.
    Sharma AK, Metzger DL, Rodd CJ. Prevalence and severity of high blood pressure among children based on the 2017 American Academy of Pediatrics guidelines. JAMA Pediatr. 2018;172(6):557–65. Scholar
  8. 8.
    Grisaru S, Yue M, Samuel SM, Chaput KH, Hamiwka LA. Blood pressure in children with attention deficit/hyperactivity disorder. Paediatr Child Health. 2018;23(6):e102–e8. Scholar
  9. 9.
    Hailpern SM, Egan BM, Lewis KD, Wagner C, Shattat GF, Al Qaoud DI, et al. Blood pressure, heart rate, and CNS stimulant medication use in children with and without ADHD: analysis of NHANES data. Front Pediatr. 2014;2:100. Scholar
  10. 10.
    Association AP. Attention-deficit/hyperactivity disorder. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: Americal Psychiatric Association; 2013.CrossRefGoogle Scholar
  11. 11.
    Xu G, Strathearn L, Liu B, Yang B, Bao W. Twenty-year trends in diagnosed attention-deficit/hyperactivity disorder among US children and adolescents, 1997-2016. JAMA Netw Open. 2018;1(4):e181471. Scholar
  12. 12.
    Subcommittee on Attention-Deficit/Hyperactivity D, Steering Committee on Quality I, Management, Wolraich M, Brown L, Brown RT, et al. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011;128(5):1007–22.
  13. 13.
    Froehlich TE, Lanphear BP, Epstein JN, Barbaresi WJ, Katusic SK, Kahn RS. Prevalence, recognition, and treatment of attention-deficit/hyperactivity disorder in a national sample of US children. Arch Pediatr Adolesc Med. 2007;161(9):857–64. Scholar
  14. 14.
    Reale L, Bartoli B, Cartabia M, Zanetti M, Costantino MA, Canevini MP, et al. Comorbidity prevalence and treatment outcome in children and adolescents with ADHD. Eur Child Adolesc Psychiatry. 2017;26(12):1443–57. Scholar
  15. 15.
    Lo-Castro A, D'Agati E, Curatolo P. ADHD and genetic syndromes. Brain Dev. 2011;33(6):456–61. Scholar
  16. 16.
    Bélanger SA, Andrews D, Gray C, Korczak D. ADHD in children and youth: part 1—etiology, diagnosis, and comorbidity. Paediatr Child Health. 2018;23(7):447–53. Scholar
  17. 17.
    Clark B, Bélanger SA. ADHD in children and youth: part 3—assessment and treatment with comorbid ASD, ID, or prematurity. Paediatr Child Health. 2018;23(7):485–90. Scholar
  18. 18.
    Demaso DR, Calderon J, Taylor GA, Holland JE, Stopp C, White MT, et al. Psychiatric disorders in adolescents with single ventricle congenital heart disease. Pediatrics. 2017;139(3):e20162241. Scholar
  19. 19.
    Tsao P-C, Lee Y-S, Jeng M-J, Hsu J-W, Huang K-L, Tsai S-J, et al. Additive effect of congenital heart disease and early developmental disorders on attention-deficit/hyperactivity disorder and autism spectrum disorder: a nationwide population-based longitudinal study. Eur Child Adolesc Psychiatry. 2017;26:1351–9. Scholar
  20. 20.
    Hansen E, Poole TA, Nguyen V, Lerner M, Wigal T, Shannon K, et al. Prevalence of ADHD symptoms in patients with congenital heart disease. Pediatr Int. 2012;54(6):838–43. Scholar
  21. 21.
    Yamada DC, Porter AA, Conway JL, LeBlanc JC, Shea SE, Hancock-Friesen CL, et al. Early repair of congenital heart disease associated with increased rate of attention deficit hyperactivity disorder symptoms. Can J Cardiol. 2013;29(12):1623–8. Scholar
  22. 22.
    Shillingford AJ, Glanzman MM, Ittenbach RF, Clancy RR, Gaynor JW, Wernovsky G. Inattention, hyperactivity, and school performance in a population of school-age children with complex congenital heart disease. Pediatrics. 2008;121(4):e759–67. Scholar
  23. 23.
    Adams HR, Szilagyi PG, Gebhardt L, Lande MB. Learning and attention problems among children with pediatric primary hypertension. Pediatrics. 2010;126(6):e1425–9. Scholar
  24. 24.
    Fuemmeler BF, Ostbye T, Yang C, McClernon FJ, Kollins SH. Association between attention-deficit/hyperactivity disorder symptoms and obesity and hypertension in early adulthood: a population-based study. Int J Obes. 2011;35(6):852–62. Scholar
  25. 25.
    Krause I, Cleper R, Kovalski Y, Sinai L, Davidovits M. Changes in behavior as an early symptom of renovascular hypertension in children. Pediatr Nephrol. 2009;24(11):2271–4. Scholar
  26. 26.
    Haws R, Joseph M, Adelman R. Two cases of pheochromocytoma presenting with ADHD (attention deficit hyperactivity disorder)-like symptoms. Pediatr Nephrol. 2008;23(3):473–5. Scholar
  27. 27.
    • Batsis M, Dagalakis U, Stratakis CA, Prodanov T, Papadakis GZ, Adams K, et al. Attention deficit hyperactivity disorder in pediatric patients with pheochromocytoma and paraganglioma. Horm Metab Res. 2016;48(8):509–13. . This study demonstrates that patients with pheochromocytoma or paraganglioma may present with ADHD-like symptoms as well as hypertension. CrossRefGoogle Scholar
  28. 28.
    Danielson ML, Visser SN, Chronis-Tuscano A, Dupaul GJ. A national description of treatment among United States children and adolescents with attention-deficit/hyperactivity disorder. J Pediatr. 2018;192:240–6.e1. Scholar
  29. 29.
    Berger S. Attention deficit hyperactivity disorder medications in children with heart disease. Curr Opin Pediatr. 2016;28(5):607–12. Scholar
  30. 30.
    Sowinski H, Karpawich PP. Management of a hyperactive teen and cardiac safety. Pediatr Clin N Am. 2014;61(1):81–90. Scholar
  31. 31.
    Liang EF, Lim SZ, Tam WW, Ho CS, Zhang MW, McIntyre RS, et al. The effect of methylphenidate and atomoxetine on heart rate and systolic blood pressure in young people and adults with attention-deficit hyperactivity disorder (ADHD): systematic review, meta-analysis, and meta-regression. Int J Environ Res Public Health. 2018;15(8):1789. Scholar
  32. 32.
    Stowe CD, Gardner SF, Gist CC, Schulz EG, Wells TG. 24-hour ambulatory blood pressure monitoring in male children receiving stimulant therapy. Ann Pharmacother. 2002;36(7–8):1142–9. Scholar
  33. 33.
    Samuels JA, Franco K, Wan F, Sorof JM. Effect of stimulants on 24-h ambulatory blood pressure in children with ADHD: a double-blind, randomized, cross-over trial. Pediatr Nephrol. 2006;21(1):92–5. Scholar
  34. 34.
    Grisaru S, Yue MW, Mah JC, Hamiwka LA. Ambulatory blood pressure monitoring in a cohort of children referred with suspected hypertension: characteristics of children with and without attention deficit hyperactivity disorder. Int J Hypertens. 2013;2013:1–4. Scholar
  35. 35.
    Barkley RA, Fischer M, Smallish L, Fletcher K. The persistence of attention-deficit/hyperactivity disorder into young adulthood as a function of reporting source and definition of disorder. J Abnorm Psychol. 2002;111(2):279–89.CrossRefGoogle Scholar
  36. 36.
    Faraone SV, Biederman J, Mick E. The age-dependent decline of attention deficit hyperactivity disorder: a meta-analysis of follow-up studies. Psychol Med. 2006;36(2):159–65. Scholar
  37. 37.
    Vitiello B, Elliott GR, Swanson JM, Arnold LE, Hechtman L, Abikoff H, et al. Blood pressure and heart rate over 10 years in the multimodal treatment study of children with ADHD. Am J Psychiatr. 2012;169(2):167–77. Scholar
  38. 38.
    Conzelmann A, Muller S, Jans T, Trott GE, Keil T, Gerlach M, et al. Long-term cardiovascular safety of psychostimulants in children with attention deficit hyperactivity disorder. Int J Psychiatry Clin Pract. 2019;23:1–3. Scholar
  39. 39.
    Kelly AS, Rudser KD, Dengel DR, Kaufman CL, Reiff MI, Norris AL, et al. Cardiac autonomic dysfunction and arterial stiffness among children and adolescents with attention deficit hyperactivity disorder treated with stimulants. J Pediatr. 2014;165(4):755–9. Scholar
  40. 40.
    •• Fay TB, Alpert MA. Cardiovascular effects of drugs used to treat attention deficit/hyperactivity disorder part 2: impact on cardiovascular events and recommendations for evaluation and monitoring. Cardiol Rev 2018. doi: This is a comprehensive reveiw article about the cardiovascular effects of ADHD medications. CrossRefGoogle Scholar
  41. 41.
    • Fay TB, Alpert MA. Cardiovascular effects of drugs used to treat attention-deficit/hyperactivity disorder: part 1: epidemiology, pharmacology, and impact on hemodynamics and ventricular repolarization. Cardiol Rev. 2019;27(3):113–21. This is a comprehensive review article on cardiovascular events associated with ADHD medications. CrossRefPubMedGoogle Scholar
  42. 42.
    Snircova E, Marcincakova Husarova V, Ondrejka I, Hrtanek I, Farsky I, Nosalova G. QTc prolongation after ADHD medication. Neuro Endocrinol Lett. 2018;38(8):549–54.PubMedGoogle Scholar
  43. 43.
    Martinez-Raga J, Knecht C, Szerman N, Martinez MI. Risk of serious cardiovascular problems with medications for attention-deficit hyperactivity disorder. CNS Drugs. 2013;27(1):15–30. Scholar
  44. 44.
    • Zito JM, Burcu M. Stimulants and pediatric cardiovascular risk. J Child Adolesc Psychopharmacol. 2017;27(6):538–45. This is a summary of recently published articles related to cardiovascular events associated with stimulants. CrossRefPubMedGoogle Scholar
  45. 45.
    Gould MS, Walsh BT, Munfakh JL, Kleinman M, Duan N, Olfson M, et al. Sudden death and use of stimulant medications in youths. Am J Psychiatr. 2009;166(9):992–1001. Scholar
  46. 46.
    Winterstein AG, Gerhard T, Shuster J, Saidi A. Cardiac safety of methylphenidate versus amphetamine salts in the treatment of ADHD. Pediatrics. 2009;124(1):e75–80. Scholar
  47. 47.
    Winterstein AG, Gerhard T, Shuster J, Johnson M, Zito JM, Saidi A. Cardiac safety of central nervous system stimulants in children and adolescents with attention-deficit/hyperactivity disorder. Pediatrics. 2007;120(6):e1494–501. Scholar
  48. 48.
    Cooper WO, Habel LA, Sox CM, Chan KA, Arbogast PG, Cheetham TC, et al. ADHD drugs and serious cardiovascular events in children and young adults. N Engl J Med. 2011;365(20):1896–904. Scholar
  49. 49.
    Habel LA, Cooper WO, Sox CM, Chan KA, Fireman BH, Arbogast PG, et al. ADHD medications and risk of serious cardiovascular events in young and middle-aged adults. JAMA. 2011;306(24):2673–83. Scholar
  50. 50.
    Mick E, McGough JJ, Middleton FA, Neale B, Faraone SV. Genome-wide association study of blood pressure response to methylphenidate treatment of attention-deficit/hyperactivity disorder. Prog Neuro-Psychopharmacol Biol Psychiatry. 2011;35(2):466–72. Scholar
  51. 51.
    Reed VA, Buitelaar JK, Anand E, Day KA, Treuer T, Upadhyaya HP, et al. The safety of atomoxetine for the treatment of children and adolescents with attention-deficit/hyperactivity disorder: a comprehensive review of over a decade of research. CNS Drugs. 2016;30(7):603–28. Scholar
  52. 52.
    • King SA, Casavant MJ, Spiller HA, Hodges NL, Chounthirath T, Smith GA. Pediatric ADHD medication exposures reported to US poison control centers. Pediatrics. 2018;141(6):e20173872. The retrospective study examined pediatric ADHD medication exposures reported to US poison control centers. Unintentional and intentional pediatric ADHD medication exposures are an increasing problem in children of all ages in the US. CrossRefPubMedGoogle Scholar
  53. 53.
    Cairns R, Daniels B, Wood DA, Brett J. ADHD medication overdose and misuse: the NSW Poisons Information Centre experience, 2004–2014. Med J Aust. 2016;204(4):154. Scholar
  54. 54.
    Graham J, Banaschewski T, Buitelaar J, Coghill D, Danckaerts M, Dittmann RW, et al. European guidelines on managing adverse effects of medication for ADHD. Eur Child Adolesc Psychiatry. 2011;20(1):17–37. Scholar
  55. 55.
    Kendall T, Taylor E, Perez A, Taylor C. Guideline development G. diagnosis and management of attention-deficit/hyperactivity disorder in children, young people, and adults: summary of NICE guidance. Bmj. 2008;337:a1239. Scholar
  56. 56.
    Wernicke JF, Faries D, Girod D, Brown J, Gao H, Kelsey D, et al. Cardiovascular effects of atomoxetine in children, adolescents, and adults. Drug Saf. 2003;26(10):729–40. Scholar
  57. 57.
    Cortese S, Holtmann M, Banaschewski T, Buitelaar J, Coghill D, Danckaerts M, et al. Practitioner review: current best practice in the management of adverse events during treatment with ADHD medications in children and adolescents. J Child Psychol Psychiatry. 2013;54(3):227–46. Scholar
  58. 58.
    • Luebbert J, Gidding SS. A patient with attention deficit hyperactivity disorder and hypertension. J Pediatr. 2016;173:254–7. This is a pediatric case report with discussion of ADHD and hypertension.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Pediatrics, Division of NephrologyUniversity of Texas Health San AntonioSan AntonioUSA
  2. 2.Department of Pediatrics, Division of NephrologyUniversity of Washington School of Medicine, Seattle Children’s HospitalSeattleUSA

Personalised recommendations