Management

The clinician should establish a comprehensive management program that recognizes ADHD as a chronic condition and works with the parents, child, and teachers to identify the most important problems as targets of treatment (AHCPR, 1999). Indications for referral to a specialist include (1) children with ADHD plus a comorbid psychiatric disorder and (2) children with ADHD who do not respond to initial treatment. More specific guidance in assessment and management may be obtained by consulting practice guidelines or parameters (AAP, 2000; McDonagh et al., 2009;

Pliszka et al., 2007) and health care guidelines (Moore, 2007; O'Brien, 2005). An initial effort must be made to educate the parents and child about ADHD (see Web Resources).

Psychosocial Therapy

The physician or staff should review techniques of parent behavioral management to assess how well they are understood and effectively implemented. This includes the proper use of positive reinforcers and punishment. A structured and standardized system, called the "token economy," can be very effective but requires considerable time and effort by the parents. Common mistakes made by parents include too much punishment versus positive reinforcement, too long a delay in receiving a reward, making the system too difficult initially so that the child never achieves success, inconsistent implementation, and poor supervision.

Assessing for proper educational placement is important. At a minimum, the parents should consult with the child's classroom teacher and confirm close supervision of the child, a structured classroom, good behavioral management, and good communication with parents. If this effort is not sufficient, the parents can request educational accommodations under Section 504 of the 1973 Rehabilitation Act. This federal law provides for special accommodations and services in a person with a chronic handicapping condition, including psychiatric disorder. The request must be accompanied by a physician statement documenting the handicapping condition and directed to the building principal or school district "Section 504 compliance officer." If this is not enough and the child is failing in one or more subjects, the parents can request a comprehensive evaluation by the Child Study Team for possible Special Education placement ("Other Health Impaired" eligibility condition—Federal Public Law 94-142, currently the Individuals with Disabilities Education Act, IDEA). The request should be in writing and directed to the building principal. The evaluation may take up to 85 school days but could result in an individualized education program (IEP), a description and contract of what special services the school will provide.

For children with ADHD alone, other psychosocial treatments have not been shown to be more effective than aggressive use of stimulant medication, or even to provide an additional benefit (MTA Cooperative Group, 1999). However, psychosocial treatments are beneficial in children with ADHD and other comorbid disorders or those from families with chaotic functioning.

Pharmacotherapy

The stimulants are the medications of first choice at any age (AHCPR, 1999); they do not have a paradoxical reverse effect at puberty. Methylphenidate was also shown to be beneficial for very young children with ADHD through the National Institutes of Mental Health (NIMH) Preschoolers with ADHD Treatment Study (PATS); however, the benefit was not as robust as in older children, and adverse effects were more prominent (Abikoff et al., 2007; Gleason et al., 2007). Table 24-2 provides measures for successful stimulant administration, and Table 24-3 lists specific dosing recommendations. Of ADHD children, 70% show significant

Table 24-2 Keys to Successful Pediatric Stimulant Administration

Recommendation

Comment

Be aggressive with titration of medication.

Increase dose until benefit clearly seen or side effects prevent further dose increases.

Frequency of doses: cover the day as much as possible and normalize functioning as much as possible.

Give doses at breakfast, lunch, and after school, depending on duration of benefit of the specific stimulant.

Monitor closely the beneficial and adverse effects of medication.

Obtain information from both parents and teachers.

Use standardized behavior report."

See patients at least every 3 months for maintenance treatment.

Try to head off problems before they develop into serious ones.

Consider annual discontinuation of medication to see if it is still needed.

However, this is unnecessary if parents still see a clear worsening when medication wears off.

*For example, NICHQ Vanderbilt Assessment Follow-up forms.

improvement on the first trial of a stimulant, and 85% to 90% improve significantly taking at least one of the listed stimulants. When the medication is in effect, motor activity decreases, certain cognitive processes improve, motivation improves, academic performance improves, and oppositional and aggressive behaviors decrease. However, the medication works only for as long as it is given, with no long-lasting or curative effect.

The physician should use a systematic approach. If the first stimulant is not effective after an adequate trial of maximum doses, a sequential trial of each available stimulant is appropriate before moving to another class of medication. At a minimum, at least one methylphenidate preparation and one amphetamine preparation should be tried. Follow-up appointments should be regular and scheduled and should include information from the parents, teachers, and child (AHCPR, 1999). Adverse effects are similar for all stimulants and can affect up to 20% of children. Important side effects include anorexia, weight loss, irritability (more likely in younger children), abdominal pain, insomnia (only if given after 5 pm), dysphoria (more likely in younger children), "behavioral rebound" after wearing off, impaired cognitive performance on laboratory tests (methylphenidate at single doses >1 mg/kg), tachycardia, and increased tic symptoms (if patient has tic disorder). In general, growth suppression is not a concern, except in children with dramatic anorexia. There is no evidence that the legitimate prescribed use of stimulants by ADHD children and adolescents lead to future drug abuse, and proper use may actually have a protective effect. Sudden death in children taking stimulant medication was recently a concern (Gould 2009). The U.S. Food and Drug Administration (FDA) issued a 2009 communication recommending caution but not stopping the use of stimulants for ADHD. A more definitive study involving 500,000 stimulant medication users is expected soon.

Table 24-3 Stimulant Medications Used in Treatment of Attention-Deficit/Hyperactivity Disorder (ADHD)

Drug

Brand Name

Dosage Forms

Duration of Behavioral Effects

Suggested Dosage

Methylphenidate

Ritalin regulär Methylin

5-, 10-, 20- mg tablet Methylin also in chewable tablet and solution

1-4 hours

0.6-2.0 mg/kg/day in divided doses FDA approved for use in children age >6 years

PDR: 60 mg max dose

Ritalin SR

20-mg tablet

3-9 hours

Titrate quickly up to 0.5 mg/kg in a single dose.

Observe for benefit and titrate to max dose if necessary.

Methylin ER

10-, 20-mg tablet

Ritalin LA

10-, 20-, 30-, 40- mg tablet

10-12 hours

Metadate ER

10-, 20-mg tablet

Metadate CD

10-, 20-, 30-, 40-, 50-, 60-mg capsule

8-12 hours

Concerta

18-, 27-, 36-, 54-mg tablet

12 hours

Child: up to 54 mg daily Adolescent and adult: 72 mg daily

Daytrana skin patch

10-, 15-, 20-, 30-mg patch

9 hours while patch applied

Dexmethyl-phenidate

Focalin

2.5-, 5-, 10-mg tablet

0.3-1.0 mg/kg/day

Focalin XR

5-, 10-, 15-, 20-, 30-mg capsule

PDR: 30 mg max daily dose

Amphetamine salts

Adderall

5-, 7.5-, 10-, 12.5-, 15-, 20-, 30-mg scored tablet

6-8 hours

0.3-1.0 mg/kg/day

Adderall XR

5-, 10-, 1-, 20-, 25-, 30-mg capsule

10-12 hours

PDR: Max daily dose — child: 30 mg; adolescent/adult: 40 mg

Dextro-amphetamine

Dexedrine

5-mg tablet

FDA approved for use in children age >3 years

Dexedrine SR

5-, 10-, 15-mg Spansule

8-9 hours

PDR: 40 mg max dose

Lisdexamfetamine

Vyvanse

20-, 30-, 40-, 50-, 60-, 70-mg capsule

Up to 70 mg daily

Methamphetamine

Desoxyn

5-mg tablet

0.3-1.0 mg/kg/day, typically 20-25 mg daily

CR tablets are no longer available.

Up to 40 mg in morning

FDA, U.S. Food and Drug Administration; PDR, Physicians' Desk Reference; CR, controlled-release.

The third line of treatment (after two trials of stimulants) is atomoxetine, which has an FDA indication for the treatment of ADHD. It is initially given at 0.5 mg/kg/day, either in the early morning or as a divided dose (morning and late afternoon). It is titrated up to a maximum dose of 1.4 mg/kg/day (or 100 mg maximum). The full benefit may not be seen for 4 weeks (ICSI, 2005). Common adverse effects include nausea, vomiting, gastrointestinal pain, anorexia, headache, fatigue, and sleepiness. Atomoxetine is not a U.S. Drug Enforcement Administration (DEA) scheduled medication, has no potential for abuse, and therefore can be written with refills.

Bupropion, tricyclicantidepressants (TCAs, e.g., imipramine, nortriptyline), and the alpha-adrenergic agent clonidine do not have an official FDA indication for the treatment of ADHD. The evidence for their benefit is based on randomized controlled trials (RCTs) and nonrandomized trials with controls (ICSI, 2007). Two alpha agents, guanfacine and clonidine, in extended-release forms, have received FDA approval for treatment of ADHD. Further information can be found by referring to the Texas Children's Medication Algorithm Project (most recent algorithms, May 2006; see Web Resources), developed by expert consensus (Pliszka 2000). Atypical antipsychotic medication (i.e., risperidone), mood stabilizers (lithium,

KEY TREATMENT

The stimulants are the medications of first choice for ADHD at any age (AHCPR, 1999) (SOR: A)

Although not a first-line drug, atomoxetine is effective for treatment of ADHD (Hammerness et al., 2009) (SOR: A). Behavioral treatments for children with ADHD are effective adjuncts to pharmacologic therapy (Fabiano et al., 2009) (SOR: A).

valproic acid), or clonidine can be used in children with comorbid severe aggression or suspected bipolar disorder after an adequate trial of a standard ADHD medication (Barzman and Sorter, 2009).

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