Raising the Bar 2008Raising the Bar 2008

Medication for ADHDMedication for ADHD

Presentation to Families with ADHDPresentation to Families with ADHDFrank W. Gearing, MDFrank W. Gearing, MDHarrisonburg PediatricsHarrisonburg Pediatrics

March 20, 2008March 20, 2008

Medication for ADHDMedication for ADHD Goals for this presentation:Goals for this presentation:

To leave the participant aware of the To leave the participant aware of the complexity of successful management of complexity of successful management of ADHD.ADHD.

To familiarize the participant with medication To familiarize the participant with medication options and some rationale to therapy options and some rationale to therapy decisions.decisions.

To encourage a philosophy of treating the To encourage a philosophy of treating the whole person within their daily context.whole person within their daily context.

To present research about adults who were To present research about adults who were treated for ADHD as children.treated for ADHD as children.

Principles of Management of ADHD Principles of Management of ADHD MedicationsMedications

Correct diagnosisCorrect diagnosis Patient profile Patient profile Target symptomsTarget symptoms Chronic disease management model of Chronic disease management model of

carecare Education of key playersEducation of key players CommunicationCommunication

Principles of Management of ADHDPrinciples of Management of ADHD Selection of an appropriate medication at an Selection of an appropriate medication at an

appropriate dose in combination with behavioral appropriate dose in combination with behavioral therapy are the foundation of therapy.therapy are the foundation of therapy.

Adequate behavioral therapy involves intensive Adequate behavioral therapy involves intensive and prolonged parent involvement and and prolonged parent involvement and cooperation from the teacher.cooperation from the teacher.

All children with ADHD should be evaluated for All children with ADHD should be evaluated for LD and treatment of LD, when present, should LD and treatment of LD, when present, should be included in management.be included in management.

Individuals with ADHD should get enough to eat, Individuals with ADHD should get enough to eat, get enough sleep, and have sufficient exercise.get enough sleep, and have sufficient exercise.

Why Treat ADHDWhy Treat ADHD Individuals with ADHD are impacted over Individuals with ADHD are impacted over

a lifetime by:a lifetime by: Parents who do not understand, are frustrated Parents who do not understand, are frustrated

and feel guiltyand feel guilty Teachers who may label a child as lazy, slow, Teachers who may label a child as lazy, slow,

bad, or lacking motivation.bad, or lacking motivation. Rejection by peers because of poor social Rejection by peers because of poor social

skills.skills. Spouse or boss who are exasperated by lack Spouse or boss who are exasperated by lack

of organization, forgetfulness, and inability to of organization, forgetfulness, and inability to complete tasks.complete tasks.

Risks of co morbid conditionsRisks of co morbid conditions

Medications for ADHDMedications for ADHD

PsychostimulantsPsychostimulants Methylphenidate based (Ritalin)Methylphenidate based (Ritalin) Dexamphetamine based (Dexedrine)Dexamphetamine based (Dexedrine)

Non-stimulantsNon-stimulants Atomoxetine (Strattera)Atomoxetine (Strattera) Guanfacine (Tenex)Guanfacine (Tenex)

AntidepressantsAntidepressants Buproprion (Wellbutrin)Buproprion (Wellbutrin)

ADHD Medication BenefitsADHD Medication Benefits

Improve selective and sustained attentionImprove selective and sustained attention Improve impulse controlImprove impulse control Improve regulation of activity and arousalImprove regulation of activity and arousal Improve memoryImprove memory Improve productivity, accuracy, and organizationImprove productivity, accuracy, and organization Improve reinforceabilityImprove reinforceability Improve emotional controlImprove emotional control

ADHD Medication Side EffectsADHD Medication Side Effects

ManageableManageable Decreased appetiteDecreased appetite HeadacheHeadache StomachacheStomachache InsomniaInsomnia Suicidal thoughts (Strattera)Suicidal thoughts (Strattera) Skin rash (Daytrana)Skin rash (Daytrana)

ADHD Medication Side EffectsADHD Medication Side Effects• UnacceptableUnacceptable

• Personality Change or social withdrawalPersonality Change or social withdrawal• Labile mood/irritabilityLabile mood/irritability• Excessive Lethargy (Zombie)Excessive Lethargy (Zombie)• Liver Injury (Strattera)Liver Injury (Strattera)• Mania (caution should be taken in treating Mania (caution should be taken in treating

individuals with Bipolar disorder)individuals with Bipolar disorder)• Psychosis rarely may develop in individuals Psychosis rarely may develop in individuals

with no prior historywith no prior history

ADHD Medication Side EffectsADHD Medication Side Effects

• Possibly ManageablePossibly Manageable

• TicsTics

• SeizuresSeizures

• Family history of heart diseaseFamily history of heart disease

Rebound from ADHD MedicationRebound from ADHD Medication

Irritability, hyperactivity and impulsiveness Irritability, hyperactivity and impulsiveness exceeding untreated symptomsexceeding untreated symptoms

Related to psychostimulants “wearing off”Related to psychostimulants “wearing off” Often coincides with homework timeOften coincides with homework time Increases family stressIncreases family stress May suggest need for increased dose or May suggest need for increased dose or

change of medicationchange of medication Often requires short acting stimulant Often requires short acting stimulant

supplementsupplement

Black Box WarningsBlack Box Warnings StimulantsStimulants

Risk of sudden deathRisk of sudden death 25 deaths and 54 cardiovascular problems in adults 25 deaths and 54 cardiovascular problems in adults

and children between 1999 and 2003and children between 1999 and 2003 Report does not indicate the drugs were responsible Report does not indicate the drugs were responsible

for the deathsfor the deaths Screen all patients for high risk conditions including Screen all patients for high risk conditions including

structural heart defects.structural heart defects. StratteraStrattera

Increased suicidal thoughtsIncreased suicidal thoughts No increase in suicide attemptsNo increase in suicide attempts Monitoring is recommended.Monitoring is recommended. Liver injuryLiver injury

PsychostimulantsPsychostimulants Methylphenidate products (Ritalin)Methylphenidate products (Ritalin)

Ritalin (4 hours average duration of effect)Ritalin (4 hours average duration of effect) Ritalin LA (8-10 hours)Ritalin LA (8-10 hours) Metadate CD (10 hours)Metadate CD (10 hours) Concerta (10-12 hours)Concerta (10-12 hours) Focalin (dexmethylphenidate) (4-6 Focalin (dexmethylphenidate) (4-6

hours)hours) Focalin XR (8-10 hours)Focalin XR (8-10 hours) Daytrana (methylphenidate transdermal Daytrana (methylphenidate transdermal

system) (2-3hr. after patch removed)system) (2-3hr. after patch removed)

PsychostimulantsPsychostimulants

Amphetamine productsAmphetamine products Dextrostat (4-5 hours)Dextrostat (4-5 hours) Mixed amphetamine saltsMixed amphetamine salts

• Adderall (4-6 hours) Adderall (4-6 hours)

• Adderall XR (10-12 hours)Adderall XR (10-12 hours) Lisdexamfetamine (Vyvanse)Lisdexamfetamine (Vyvanse)

• 11-13 hours11-13 hours

Vyvanse (lisdexamphetamine)Vyvanse (lisdexamphetamine) Prodrug that must be metabolized to active Prodrug that must be metabolized to active

ingredient (single dextro isomer of ingredient (single dextro isomer of amphetamine)amphetamine)

Available as 30 mg, 50 mg, 70 mgAvailable as 30 mg, 50 mg, 70 mg No genericNo generic FDA has approved 20 mg, 40 mg, 60 mg that FDA has approved 20 mg, 40 mg, 60 mg that

are not available at this timeare not available at this time Onset in 1-2 hours and reaches peak at 3.5 Onset in 1-2 hours and reaches peak at 3.5

hours with duration of 11-13 hourshours with duration of 11-13 hours Food prolongs time to peak concentrationFood prolongs time to peak concentration

Non Stimulant MedicationsNon Stimulant Medications

Strattera (atomoxetine)Strattera (atomoxetine) Tenex (guanfacine)Tenex (guanfacine) Wellbutrin (buproprion)Wellbutrin (buproprion)

Strattera (atomoxetine)Strattera (atomoxetine) Strattera is a selective norepinephrine Strattera is a selective norepinephrine

reuptake inhibitorreuptake inhibitor It is not recommended but it is known to It is not recommended but it is known to

be stable when capsule contents dissolved be stable when capsule contents dissolved in grape juice for those unable to swallow in grape juice for those unable to swallow capsulecapsule

Absorption unaffected by foodAbsorption unaffected by food

Tenex (guanfacine)Tenex (guanfacine) Tenex is an antihypertensive (alpha adrenergic) Tenex is an antihypertensive (alpha adrenergic)

medication that has been used to treat medication that has been used to treat hyperactive-impulsive and aggressive behaviors hyperactive-impulsive and aggressive behaviors in individuals with ADHD.in individuals with ADHD.

Tenex has been used for insomnia in ADHD Tenex has been used for insomnia in ADHD patients and to suppress Tics in Tourettes patients and to suppress Tics in Tourettes patientspatients

Recent research has shown that with continued Recent research has shown that with continued use, inattention shows continuous improvementuse, inattention shows continuous improvement

A sustained release and a patch are currently in A sustained release and a patch are currently in clinical trials with the sustained release showing clinical trials with the sustained release showing greater benefit and flexibility than the immediate greater benefit and flexibility than the immediate release formulationrelease formulation

Wellbutrin (buproprion)Wellbutrin (buproprion) Wellbutrin is an atypical antidepressant Wellbutrin is an atypical antidepressant

that is a dopamine and norepinephrine that is a dopamine and norepinephrine reuptake inhibitor that has been shown to reuptake inhibitor that has been shown to be effective for ADHDbe effective for ADHD

Wellbutrin has been advocated in ADHD Wellbutrin has been advocated in ADHD patients with substance abuse disorderpatients with substance abuse disorder

Zyban is also buproprion marketed under Zyban is also buproprion marketed under another name as a smoking cessation aid.another name as a smoking cessation aid.

It is recommended for ADHD with unstable It is recommended for ADHD with unstable mood disorder, and seasonal affective mood disorder, and seasonal affective disorder.disorder.

Management of ADHDManagement of ADHD

Prior to initiating medication document:Prior to initiating medication document: Family history of response to medicationFamily history of response to medication Prioritized “Target Symptoms”Prioritized “Target Symptoms” Compliance and Follow-up requirementsCompliance and Follow-up requirements Plan for coordination of care (counselors, Plan for coordination of care (counselors,

teachers, care providers, parents)teachers, care providers, parents)

Monitoring ADHD MedicationsMonitoring ADHD Medications Monthly weight, height, and blood Monthly weight, height, and blood

pressure until on stable dose followed by pressure until on stable dose followed by routine 3 month interval checksroutine 3 month interval checks

Appetite, sleep, energy, mood changes, Appetite, sleep, energy, mood changes, academic performance, behavior academic performance, behavior concerns, social relations, family relationsconcerns, social relations, family relations

Worries, rituals, depression, thoughts of Worries, rituals, depression, thoughts of suicidesuicide

Be specific and detailed (number of hours Be specific and detailed (number of hours of sleep/night, specific grades per subject, of sleep/night, specific grades per subject, extracurricular activities, etc.)extracurricular activities, etc.)

Risks of Not Treating ADHDRisks of Not Treating ADHD

Untreated ADHD has twice the risk for Untreated ADHD has twice the risk for substance abuse, with earlier onset, and substance abuse, with earlier onset, and less likelihood to recover as an adultless likelihood to recover as an adult Effective management of ADHD with Effective management of ADHD with

stimulants does not increase substance stimulants does not increase substance abuseabuse

Effective management of ADHD Effective management of ADHD significantly decreasessignificantly decreases risk for risk for substance abusesubstance abuse

Risks of Not Treating ADHDRisks of Not Treating ADHD Employment stabilityEmployment stability

Parents of children with ADHD have greater Parents of children with ADHD have greater absenteeism from workabsenteeism from work

Parents of children with ADHD are less productive in Parents of children with ADHD are less productive in the work placethe work place

Interpersonal relationshipsInterpersonal relationships Marriage/divorce- 3-5 times greater parental divorce Marriage/divorce- 3-5 times greater parental divorce

or separation in families with a child with ADHDor separation in families with a child with ADHD• Possibly related to untreated ADHD in parentPossibly related to untreated ADHD in parent

Untreated adults with ADHD have poor employment Untreated adults with ADHD have poor employment recordsrecords

• Vocational aptitude testing beneficial for teens with Vocational aptitude testing beneficial for teens with ADHD seeking areas of likely successADHD seeking areas of likely success

ADHD Treatment of Preschool ADHD Treatment of Preschool ChildrenChildren

Preschool children have higher incidence of side effects Preschool children have higher incidence of side effects from stimulants, especially abdominal pain, decreased from stimulants, especially abdominal pain, decreased appetite, and insomnia, but recent PATS study shows appetite, and insomnia, but recent PATS study shows stimulants clearly of benefitstimulants clearly of benefit

Factors associated with lower response to stimulants Factors associated with lower response to stimulants include lower IQ, greater severity of symptoms, co- include lower IQ, greater severity of symptoms, co- morbid conditions, family dysfunction, confidence in morbid conditions, family dysfunction, confidence in diagnosisdiagnosis

Preliminary evidence of efficacy of Tenex without side Preliminary evidence of efficacy of Tenex without side effects of stimulants and greater hyperactive/impulsive effects of stimulants and greater hyperactive/impulsive symptoms may suggest Tenex a better first medication symptoms may suggest Tenex a better first medication trial, along with behavioral interventionstrial, along with behavioral interventions

Most frequent co morbid condition was ODD, followed by Most frequent co morbid condition was ODD, followed by communication/language disorder and anxietycommunication/language disorder and anxiety

Choosing ADHD MedicationChoosing ADHD Medication ConsiderConsider

Child’s profile- affinities, personality traits, Child’s profile- affinities, personality traits, social skills, emotional stability social skills, emotional stability

Anxiety or depression symptomsAnxiety or depression symptoms Aggressive behaviorAggressive behavior Other medical diagnosisOther medical diagnosis Sleep patternsSleep patterns Tics Tics SeizuresSeizures Family dynamicsFamily dynamics

Choosing ADHD MedicationsChoosing ADHD Medications Morning person (runs out of mental energy in Morning person (runs out of mental energy in

afternoon)afternoon)• Avoid difficult classes in afternoonAvoid difficult classes in afternoon• Encourage afternoon physical activityEncourage afternoon physical activity• Homework may require supplemental Homework may require supplemental

medication after school medication after school • Rebound symptoms may be more likely Rebound symptoms may be more likely

without supplemental medicationwithout supplemental medication• Consider Concerta, Metadate CD, Adderall Consider Concerta, Metadate CD, Adderall

XR, Daytrana, Vyvanse, StratteraXR, Daytrana, Vyvanse, Strattera

Choosing ADHD MedicationsChoosing ADHD Medications Afternoon person (hard to get started in Afternoon person (hard to get started in

morning)morning)• Schedule difficult classes in mid daySchedule difficult classes in mid day• Encourage morning physical activityEncourage morning physical activity• Evaluate sleep hygiene at each visitEvaluate sleep hygiene at each visit• May require short acting stimulant in May require short acting stimulant in

morning in addition to sustained release morning in addition to sustained release preparationpreparation

• Consider Ritalin LA, Focalin XR, Vyvanse, Consider Ritalin LA, Focalin XR, Vyvanse, StratteraStrattera

Choosing ADHD MedicationChoosing ADHD Medication

ADHD with depressive or anxious symptoms ADHD with depressive or anxious symptoms may respond best to Stratteramay respond best to Strattera Strattera less effective for hyperactivityStrattera less effective for hyperactivity Strattera can be used in conjunction with stimulantsStrattera can be used in conjunction with stimulants

SSRI’s are well tolerated and can be used in SSRI’s are well tolerated and can be used in conjunction with stimulants for more depressed conjunction with stimulants for more depressed or anxious patientsor anxious patients

Aggressive behaviors, tics, and disturbed sleep Aggressive behaviors, tics, and disturbed sleep may respond to Clonidine or Guanfacinemay respond to Clonidine or Guanfacine Controversy about safety of stimulants with ClonidineControversy about safety of stimulants with Clonidine

Insomnia may respond to MelatoninInsomnia may respond to Melatonin

Medications for ADHDMedications for ADHD Reasons for treatment failureReasons for treatment failure

Child with ADHD has parent with Child with ADHD has parent with undiagnosed/untreated ADHDundiagnosed/untreated ADHD

Lack of family and patient education about Lack of family and patient education about ADHDADHD

Failure to consistently follow management Failure to consistently follow management planplan

Undiagnosed co morbid conditionUndiagnosed co morbid condition Lack of recognition for successLack of recognition for success

• 80% of interactions for children with ADHD 80% of interactions for children with ADHD who are not stabilized are negative.who are not stabilized are negative.

• Reinforce the positive. Catch them doing Reinforce the positive. Catch them doing well.well.

Medications for ADHDMedications for ADHD

When there is a sudden deterioration in When there is a sudden deterioration in daily functioning after a long period of daily functioning after a long period of stability it is most often not an issue of stability it is most often not an issue of medication failure. Consider other medication failure. Consider other explanations such as changes in family explanations such as changes in family dynamics, changes in peer relations, dynamics, changes in peer relations, pregnancy, drug use, etc.pregnancy, drug use, etc.

ADHD in AdultsADHD in Adults

ADHD in AdultsADHD in Adults 80-90% of individuals diagnosed and 80-90% of individuals diagnosed and

treated as children for ADHD have areas treated as children for ADHD have areas of impairment as adults.of impairment as adults.

Education: higher drop out rate, lower Education: higher drop out rate, lower GPA, fewer college graduatesGPA, fewer college graduates

Employment: unskilled level jobs, greater Employment: unskilled level jobs, greater periods of unemployment, higher periods of unemployment, higher likelihood of being fired, lower work likelihood of being fired, lower work performance ratings, lower job statusperformance ratings, lower job status

ADHD in AdultsADHD in Adults Poorer driving skills Poorer driving skills More auto accidents with more at faults (2-More auto accidents with more at faults (2-

3 times risk)3 times risk) Worse accidents (3 times more cost and Worse accidents (3 times more cost and

injuries)injuries) More citations (speeding 4-5 times risk)More citations (speeding 4-5 times risk) 3 times more license suspensions3 times more license suspensions Alcohol has greater adverse impact on Alcohol has greater adverse impact on

drivingdriving

ADHD in AdultsADHD in Adults Begin sexual activity earlierBegin sexual activity earlier More lifetime sexual partners with less More lifetime sexual partners with less

time per partnertime per partner Higher risks for STDsHigher risks for STDs Less likely to use contraceptionLess likely to use contraception 6-7 times more teen pregnancies6-7 times more teen pregnancies 54% do not have custody of their children54% do not have custody of their children

ADHD in AdultsADHD in Adults Higher incidence of co morbid disorders Higher incidence of co morbid disorders

(anxiety, substance use/abuse, personality (anxiety, substance use/abuse, personality disorders, depression, suicide attempts)disorders, depression, suicide attempts)

Greater frequency of antisocial acts: stealing, Greater frequency of antisocial acts: stealing, assault, illegal drug possession, breaking and assault, illegal drug possession, breaking and entering, setting fires, runawayentering, setting fires, runaway

Fewer close friendsFewer close friends Watch more TV, play more video gamesWatch more TV, play more video games Less time reading, exercising, getting educationLess time reading, exercising, getting education More sleep disturbancesMore sleep disturbances

ADHD in AdultsADHD in Adults Higher incidence of medical and dental Higher incidence of medical and dental

problemsproblems Money management problemsMoney management problems Greater likelihood of smoking and excess Greater likelihood of smoking and excess

alcohol usealcohol use Higher risk of cardiovascular diseaseHigher risk of cardiovascular disease ? Greater risk of cancer? Greater risk of cancer

ADHD in AdultsADHD in Adults Adults not diagnosed with ADHD as Adults not diagnosed with ADHD as

children who present with ADHD:children who present with ADHD: Have greater awareness of symptoms and Have greater awareness of symptoms and

impairmentsimpairments Have higher education, salaries, higher SES, Have higher education, salaries, higher SES,

higher IQ’shigher IQ’s Less antisocial, less drug useLess antisocial, less drug use More co morbid depression, anxietyMore co morbid depression, anxiety Impaired executive functions (sustained Impaired executive functions (sustained

attention, task completion)attention, task completion) Similar impairments in risky sexual behavior, Similar impairments in risky sexual behavior,

marriage, child rearing, money management, marriage, child rearing, money management, driving and health caredriving and health care

Treatment of ADHD in AdultsTreatment of ADHD in Adults Adults often respond well to Strattera.Adults often respond well to Strattera. Wellbutrin and Effexor are used more frequently in Wellbutrin and Effexor are used more frequently in

adults than children for ADHDadults than children for ADHD Caution is required to address preexisting health Caution is required to address preexisting health

conditions and use of other medication in adults.conditions and use of other medication in adults. Counseling is important for improving self Counseling is important for improving self

awareness and addressing co morbid conditions.awareness and addressing co morbid conditions. Accommodations can often be implemented with the Accommodations can often be implemented with the

cooperation of employers, spouses, and coworkers.cooperation of employers, spouses, and coworkers. The medications we discussed in this presentation The medications we discussed in this presentation

are used in adults as well as children.are used in adults as well as children.

SummarySummary Children with ADHD need to understand Children with ADHD need to understand

themselves to work toward independence.themselves to work toward independence. Compliance with routine should be closely Compliance with routine should be closely

monitored with associated consequences.monitored with associated consequences. Teacher involvement is crucial to include Teacher involvement is crucial to include

daily communication with the focus on daily communication with the focus on making the child responsible, and teaching making the child responsible, and teaching the child to monitor his own work. Training the child to monitor his own work. Training these behaviors takes a long time and a these behaviors takes a long time and a lot of persistence on the part of parents.lot of persistence on the part of parents.

SummarySummary ADHD is a complex disorder beginning in ADHD is a complex disorder beginning in

childhood that may impact as many as 90% of childhood that may impact as many as 90% of affected children as they grow to adulthood.affected children as they grow to adulthood.

Severe symptoms of ADHD in childhood are Severe symptoms of ADHD in childhood are associated with risk of impairment in academics, associated with risk of impairment in academics, social relations, family relations, work success, social relations, family relations, work success, and healthy lifestyle choices.and healthy lifestyle choices.

Effective management involves a closely Effective management involves a closely monitored, comprehensive approach that monitored, comprehensive approach that involves physicians, counselors, teachers, and involves physicians, counselors, teachers, and especially parents. As affected individuals age, especially parents. As affected individuals age, spouses, bosses, counselors, and friends will be spouses, bosses, counselors, and friends will be part of successful management. part of successful management.

Medication is a major component of managing Medication is a major component of managing ADHD in children and adults.ADHD in children and adults.

SummarySummary Recognition and treatment of co morbid Recognition and treatment of co morbid

conditions, especially learning disorders in conditions, especially learning disorders in children and mood disorders in adults is crucial children and mood disorders in adults is crucial to success.to success.

Attention to diet, sleep, exercise and Attention to diet, sleep, exercise and establishing routines are points of emphasis.establishing routines are points of emphasis.

Building on the strengths identified in the Building on the strengths identified in the individuals profile while working to improve individuals profile while working to improve areas in need of improvement will be important areas in need of improvement will be important goals for the individual as they grow in their own goals for the individual as they grow in their own self awareness.self awareness.

AddendumAddendum

Medications for ADHDMedications for ADHD

Methylphenidate productsMethylphenidate products Effects attributed to blocking Dopamine (DA) reuptake at Effects attributed to blocking Dopamine (DA) reuptake at

the neuron synapsethe neuron synapse DA is involved in frontal and prefrontal cortex mediating DA is involved in frontal and prefrontal cortex mediating

suppression of distractions and inhibiting suppression of distractions and inhibiting inappropriate behaviors related to tangential inappropriate behaviors related to tangential thoughts and ideasthoughts and ideas (mesocortex pathway). (mesocortex pathway).

DA is involved in mediating DA is involved in mediating working memoryworking memory required required for for reasoning, planning, and problem solvingreasoning, planning, and problem solving (mesodorsolateral pathway).(mesodorsolateral pathway).

DA is involved in mediating DA is involved in mediating interpersonal decisions interpersonal decisions and inhibiting impulsive social responsesand inhibiting impulsive social responses..

Ritalin (methylphenidate)Ritalin (methylphenidate) Available as tablet 5 mg, 10 mg, 20 mgAvailable as tablet 5 mg, 10 mg, 20 mg Available as liquid 10 mg/5 mlAvailable as liquid 10 mg/5 ml Available as genericAvailable as generic Onset within 30-60 minutes with peak at 1 Onset within 30-60 minutes with peak at 1

hour and duration average of 4 hourshour and duration average of 4 hours

Ritalin LARitalin LA Available as 10 mg., 20 mg., 30 mg.Available as 10 mg., 20 mg., 30 mg. Bead filled capsule that can be swallowed or Bead filled capsule that can be swallowed or

sprinkled on applesaucesprinkled on applesauce Uses SODAS absorption technology and Uses SODAS absorption technology and

replicates twice daily dosing 4 hours apart of replicates twice daily dosing 4 hours apart of equal amounts of methylphenidate (50-50)equal amounts of methylphenidate (50-50)

Onset within 1 hour and peak serum levels at Onset within 1 hour and peak serum levels at 3 and 6 hours after ingestion3 and 6 hours after ingestion

Absorption affected by food, especially fatty Absorption affected by food, especially fatty meals slowing absorptionmeals slowing absorption

Metadate CDMetadate CD Extended release formulation of Extended release formulation of

methylphenidatemethylphenidate Available as 10 mg, 20 mg, 30 mg bead filled Available as 10 mg, 20 mg, 30 mg bead filled

capsule that can be sprinkled on apple saucecapsule that can be sprinkled on apple sauce No genericNo generic 30% of dose available as immediate release with 30% of dose available as immediate release with

onset in 30-60 minutes and 70% of dose onset in 30-60 minutes and 70% of dose extended slow releaseextended slow release

Dual peak concentrations at 1.5 hours and 4.5 Dual peak concentrations at 1.5 hours and 4.5 hours that are delayed by fatty mealshours that are delayed by fatty meals

Duration of effect 8-10 hoursDuration of effect 8-10 hours

ConcertaConcerta Available as 18 mg, 27 mg, 36 mg, 54mg tabletAvailable as 18 mg, 27 mg, 36 mg, 54mg tablet No genericNo generic Exterior coating of tablet dissolves in water and Exterior coating of tablet dissolves in water and

provides immediate release of 22% of doseprovides immediate release of 22% of dose Uses OROS technology for osmotic release of Uses OROS technology for osmotic release of

78% of dose in slow consistent manner over 5-9 78% of dose in slow consistent manner over 5-9 hours hours

Onset of immediate release within 30-60 min Onset of immediate release within 30-60 min with initial peak at 1 hour and secondary peak at with initial peak at 1 hour and secondary peak at 6-10 hours and duration of 10-12 hours6-10 hours and duration of 10-12 hours

Absorption unaffected by foodAbsorption unaffected by food

Focalin XR (dexmethylphenidate)Focalin XR (dexmethylphenidate) Extended release formulation Extended release formulation

Available as 5 mg, 10 mg, 15 mg, and 20 mgAvailable as 5 mg, 10 mg, 15 mg, and 20 mg Bead filled capsule that can be swallowed or sprinkled Bead filled capsule that can be swallowed or sprinkled

on applesauceon applesauce Uses SODAS absorption technology and replicates Uses SODAS absorption technology and replicates

twice daily dosing 4 hours apart of equal amounts of twice daily dosing 4 hours apart of equal amounts of dexmethylphenidate (50-50)dexmethylphenidate (50-50)

Onset within 1 hour and peak serum levels at 3 and 6 Onset within 1 hour and peak serum levels at 3 and 6 hours after ingestionhours after ingestion

Absorption effected by food, especially fatty meals Absorption effected by food, especially fatty meals slowing absorptionslowing absorption

Duration of effect 8-10 hoursDuration of effect 8-10 hours

Focalin (dexmethylphenidate)Focalin (dexmethylphenidate) Single isomer formulation of RitalinSingle isomer formulation of Ritalin Available as tablet 2.5 mg, 5 mg, 10 mgAvailable as tablet 2.5 mg, 5 mg, 10 mg Available as genericAvailable as generic Onset in 1 hour with peak at 3 hours and Onset in 1 hour with peak at 3 hours and

duration of effect of 4-6 hoursduration of effect of 4-6 hours Absorption slowed by food, especially fatAbsorption slowed by food, especially fat Theory of single isomerTheory of single isomer

Single isomer active ingredientSingle isomer active ingredient Inactive isomer (levomethylphenidate) may:Inactive isomer (levomethylphenidate) may:

• Block receptor siteBlock receptor site• Cause side effectsCause side effects

Dexedrine ProductsDexedrine Products Dexedrine products increase levels of dopamine Dexedrine products increase levels of dopamine

(DA) and norepinephrine(NE) at the synapse by (DA) and norepinephrine(NE) at the synapse by stimulating release and blocking reuptake of the stimulating release and blocking reuptake of the neurotransmittersneurotransmitters

NE has wide, diffuse projections throughout the brain NE has wide, diffuse projections throughout the brain suggesting a role as a suggesting a role as a neuromodulator..

NE is critical to NE is critical to reasoning, learning, problem solving, priority setting, organizational thought

NE functions in maintaining NE functions in maintaining arousal, regulating arousal, regulating excitability related to dangerexcitability related to danger (fright/flight), (fright/flight), contributes to contributes to memory storage and retrievalmemory storage and retrieval

DA is involved in DA is involved in suppressing distractions, suppressing distractions, inhibiting inappropriate behavior, reasoning, inhibiting inappropriate behavior, reasoning, planning, problem solving, inhibiting impulsive planning, problem solving, inhibiting impulsive social responsessocial responses..

Dextrostat (dextroamphetamine)Dextrostat (dextroamphetamine) Single d-isomer of amphetamineSingle d-isomer of amphetamine Available as 5 mg, 10 mg scored tabletsAvailable as 5 mg, 10 mg scored tablets Approved from age 3 yearsApproved from age 3 years Peak level at 2 hours Dose Peak level at 2 hours Dose

recommendation of once dailyrecommendation of once daily

Adderall (mixed amphetamine Adderall (mixed amphetamine salts)salts)

d,ld,l amphetamine sulfate, amphetamine sulfate, dextroamphetamine saccharate, dextroamphetamine saccharate, d,l d,l amphetamine aspartateamphetamine aspartate

Available as 5 mg, 7.5 mg, 10 mg, 12.5 Available as 5 mg, 7.5 mg, 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mgmg, 15 mg, 20 mg, 30 mg

Generic availableGeneric available Duration of effect 4-6 hoursDuration of effect 4-6 hours

Adderall XRAdderall XR Two different beads in each capsule to Two different beads in each capsule to

give double pulsed delivery of medicationgive double pulsed delivery of medication Available as 5 mg, 10 mg, 15 mg, 20 mg, Available as 5 mg, 10 mg, 15 mg, 20 mg,

25 mg, 30 mg.25 mg, 30 mg. No genericNo generic Peak serum levels at 7 hoursPeak serum levels at 7 hours Fatty meal prolongs the time to peak Fatty meal prolongs the time to peak

levelslevels Contents of capsule can be opened and Contents of capsule can be opened and

spread on apple saucespread on apple sauce

StratteraStrattera Onset of benefit in 1-2 weeks with Onset of benefit in 1-2 weeks with

maximal benefit reached in 4-6 weeksmaximal benefit reached in 4-6 weeks Not recommended for crisis interventionNot recommended for crisis intervention Initial dosing recommended at 0.5 mg/kg Initial dosing recommended at 0.5 mg/kg

for 3-5 days with gradual increase to FDA for 3-5 days with gradual increase to FDA recommended dose of 1.2-1.4 mg/kgrecommended dose of 1.2-1.4 mg/kg

Dose can be split BID to avoid side effectsDose can be split BID to avoid side effects Literature supports continued benefits for Literature supports continued benefits for

select patients with dose up to 1.8 mg/kgselect patients with dose up to 1.8 mg/kg Warnings related to suicide ideation and Warnings related to suicide ideation and

liver toxicityliver toxicity

StratteraStrattera Side effect profile includes headache, nausea, Side effect profile includes headache, nausea,

stomachache, decreased appetite, drowsiness, stomachache, decreased appetite, drowsiness, aggression, priapism, mania, psychosisaggression, priapism, mania, psychosis

Adult trials have reported erectile dysfunction, Adult trials have reported erectile dysfunction, urinary retention, dysmenorrhea, hot flushurinary retention, dysmenorrhea, hot flush

Dosage adjustment may be needed when used Dosage adjustment may be needed when used in conjunction with SSRI in conjunction with SSRI

Sudden death has been reported in individuals Sudden death has been reported in individuals with underlying structural heart disease or other with underlying structural heart disease or other serious heart disease (not felt to be related to serious heart disease (not felt to be related to drug)drug)

Caution when treating co morbid Bipolar Caution when treating co morbid Bipolar disorderdisorder

TenexTenex Often used in conjunction with stimulantsOften used in conjunction with stimulants Discontinuation should be tapered to avoid Discontinuation should be tapered to avoid

blood pressure changesblood pressure changes Side effects: somnolence, initial decrease Side effects: somnolence, initial decrease

in blood pressure, depression, rebound in blood pressure, depression, rebound hypertensionhypertension

Catapres (clonidine) is a similar Catapres (clonidine) is a similar antihypertensive that has been used for antihypertensive that has been used for similar reasons in ADHD but has similar reasons in ADHD but has significantly more sedation than Tenexsignificantly more sedation than Tenex

WellbutrinWellbutrin

Side effects: agitation/activation, Side effects: agitation/activation, irritability, aggression, insomnia, suicidal irritability, aggression, insomnia, suicidal ideation, panic attacks, anorexia, dry ideation, panic attacks, anorexia, dry mouth, stomachachemouth, stomachache

Contraindicated in individuals with Contraindicated in individuals with seizures, and for use with Tagamet seizures, and for use with Tagamet

Onset of benefit in 10-14 days with Onset of benefit in 10-14 days with maximal benefit at 3-6 weeksmaximal benefit at 3-6 weeks

Often used in conjunction with stimulantsOften used in conjunction with stimulants

AddendumAddendumEvaluation for ADHDEvaluation for ADHD

Correct Diagnosis and Patient Correct Diagnosis and Patient ProfileProfile

Presenting problemsPresenting problems Comprehensive evaluationComprehensive evaluation Assessment of specific components of Assessment of specific components of

attention and behaviorattention and behavior Evaluation of cognitive and academic Evaluation of cognitive and academic

functioningfunctioning Assessment of secondary vulnerabilitiesAssessment of secondary vulnerabilities

Presenting ProblemsPresenting Problems Poor ConcentrationPoor Concentration Inattention/DistractibilityInattention/Distractibility ImpulsivityImpulsivity HyperactivityHyperactivity Academic problemsAcademic problems Behavior problemsBehavior problems

Does this child have an attention disorder? Does this child have an attention disorder? Or associated disorders?Or associated disorders?

What are this individual’s strengths and What are this individual’s strengths and weaknesses?weaknesses?

Comprehensive EvaluationComprehensive Evaluation MedicalMedical

History, physical, neurological examination, History, physical, neurological examination, fine and gross motor assessmentfine and gross motor assessment

Neurodevelopmental assessmentNeurodevelopmental assessment Vision and hearing screeningVision and hearing screening

EmotionalEmotional History and interviewHistory and interview

Family-EnvironmentalFamily-Environmental Family/School milieus and extracurricular Family/School milieus and extracurricular

activitiesactivities Family mental health historyFamily mental health history

Assessment of Specific Components of Assessment of Specific Components of Attention and BehaviorAttention and Behavior

Rating scalesRating scales Parents, teachers, self reportParents, teachers, self report

InterviewsInterviews Parent, patientParent, patient

Direct observationsDirect observations ClassroomClassroom During testingDuring testing

Objective measuresObjective measures Computerized (controversial)Computerized (controversial)

Evaluation of Cognitive and Academic Evaluation of Cognitive and Academic FunctionFunction

Processing abilitiesProcessing abilities Verbal/language, visual, sequentialVerbal/language, visual, sequential

MemoryMemory Fine motor abilities, especially Fine motor abilities, especially

graphomotor skillsgraphomotor skills Problems solving abilitiesProblems solving abilities IntelligenceIntelligence Academic achievementAcademic achievement

Assessment of Secondary VulnerabilitiesAssessment of Secondary Vulnerabilities

Self esteemSelf esteem Social abilitiesSocial abilities Family interactionsFamily interactions Classroom behaviorsClassroom behaviors