Components of a Comprehensive ADHD Treatment Plan Jennifer A. Ganem MS, APRN Londonderry Square 50...

Components of a Comprehensive ADHD

Treatment PlanJennifer A. Ganem MS, APRN

Londonderry Square

50 Nashua Road, Suite 208

Londonderry, NH 03053-3221

(603) 432-3399

Jennifer A. Ganem MS, APRN

Educational/

Workplace

Accommodations

Community Support

MedicationBehavioral Intervention

Coaching

ADHD

Community Support

•CHADD Support Groups • Local• Regional• National• Virtual

•Parent Support Groups • Hospitals/ Behavioral Health Center

•Parent/ School Collaborative Groups

Jennifer A. Ganem MS, APRN

Educational / Workplace Accommodations

• Individuals with Disabilities Education Act (IDEA)• Section 504 of the Rehabilitation Act of 1973 • A child's disability must "substantially limit" the child’s ability to learn requiring the

need for specialized services or accommodations• All determinations of “substantial limitation” must be made without regard to the

"ameliorative effects of mitigating measures“• This means that the question of whether a "substantial limitation" exists must be

determine before any intervention for that limitation is implemented• "Mitigating measures" includes such things as medication, assistive technology,

learned behavioral modifications, psychotherapy, and/or reasonable accommodations

• Parent Information Center provides workshops on the special education process and have trained advocates for a nominal fee http://www.parentinformationcenter.org

Jennifer A. Ganem MS, APRN

Coaching• Coaches assist ADHDers with • identifying their personal strengths and weaknesses• developing concrete strategies to manage their symptoms in all areas of life

• Coaches are supportive and hold ADHDers accountable

• Coaching can be done in-person, via the phone and/or virtually

• Coaching can be individual, couples and/or group

• Resources to locate an ADHD Coach:• www.CHADD.org• www.adhdcoaches.org• www.addresources.org

Jennifer A. Ganem MS, APRN

Behavioral Interventions

• Incentive charts, token systems…

• Social Skills Groups

• “Therapy” learn to manage symptoms of co-morbid mental health disorders, such as depression, anxiety, oppositional behavior, tic disorders, OCD…• Can be individual, family and/or group

Jennifer A. Ganem MS, APRN

Medication

• A prescriber should:• Explain all of your medication options• Inform you of the potential side effects and how to manage them• Inform you how long it will take before the effect of the medication

is observed • Inform you of what time of day to take the medication and how

long the medication will last (duration) • Discuss how the medication’s effectiveness will be evaluated over

time• Inform you how often you’ll need to be seen• Instruct you to lock all medication• Address ALL OF YOUR CONCERNS

Jennifer A. Ganem MS, APRN

Jennifer A. Ganem MS, APRN

Long Acting

ADHD Meds

(amphetamine)

Adderall XR

(methylphenidate)

Concerta Metadate CD Ritalin LA

Focalin XR

Daytrana Quillivant XR

atomoxetine

(Strattera)

lisdexamphetamine

(Vyvanse)

Guanfacine XR

(Intuniv)

How the Long-Acting Stimulants Differ:

1. Mechanism of Action:• Methylphenidate is believed to be primarily a dopamine

reuptake inhibitor with some mild norepinephrine reuptake inhibition.• Amphetamine is believed to be a dopamine reuptake inhibitor

and a strong norepinephrine reuptake inhibitor. It’s also thought to block the dopamine pump - increasing dopamine secretion.

2. How they are released

3. The duration of efficacyJennifer A. Ganem MS, APRN

•Both methylphenidate and amphetamine have been shown to have similar side effect profile and response rates of 70-75%.

• If there is a trial of each type of stimulant, the response rate increases to 80-90%.

Jennifer A. Ganem MS, APRN

Concerta

• Delivers methylphenidate using an immediate-release coating and a delayed-release osmotic mechanism

• 22% immediate, 78% delayed release

• Designed for 12-hour effect

• Available dosages: 18mg, 27mg, 36mg, 54mg

• Approved up to 72mg/day (Adolescents commonly need daily doses of 1-1.5mg/kg)

• Approved 6-65yo

• To be effective the tablet can not be broken, crushed or chewed

Jennifer A. Ganem MS, APRN

Metadate CD

• Biphasic delivery of methylphenidate using immediate and delayed-release beads within a capsule

• 30% immediate, 70% delayed

• Designed for 8-hour effect

• Available dosages: 10mg, 20mg, 30mg, 40mg, 50mg, 60mg

• Capsules can be opened and contents mixed with applesauce

• Approved 6-15yo

Jennifer A. Ganem MS, APRN

Ritalin LA

• Biphasic delivery of methylphenidate using immediate and delayed-release beads within a capsule

• 50% immediate release, 50% delayed

• Designed for 8-hour effect

• Available dosages: 10mg, 20mg, 30mg, 40mg

• Approved 6-12yo

Jennifer A. Ganem MS, APRN

Daytrana

• Continuous delivery of methylphenidate through DOT Matrix transdermal patch

• Efficacy from 2 hours* through 12 hours

• Approved for a 9 hour wear time (12 hour duration)

• Available dosages: 10mg, 15mg, 20mg, 30mg

• Approved 6-12yo

* first time point measured in studies

Jennifer A. Ganem MS, APRN

Quillivant XR

• Liquid form of extended release methylphenidate (25mg/5ml)

• 20% immediate release, 80% delayed release

• 12 hour duration with peak plasma concentration at 5 hours

• Starting dose is 20mg (4ml) given orally once daily in the morning with or without food. Dosage can be increased 10-20mg per day to a maximum dose of 60mg daily.

• Approved 6 and up, but age 65+ have not been studied

Jennifer A. Ganem MS, APRN

Focalin XR

• Delivers dexmethylphenidate (active enantiomer of racemic methylphenidate) using immediate and delayed-release beads within a capsule

• 50% immediate release, 50% delayed

• 10 to 12-hour effect

• Available dosages: 5mg, 10mg, 15mg, 20mg, 30mg

• Capsules can be opened and contents mixed with applesauce

• Approved 6yo-adult

Jennifer A. Ganem MS, APRN

Adderall XR

• Delivers mixed salts of amphetamine using immediate and delayed-release beads within a capsule

• 50% immediate release, 50% delayed release

• Designed for 12-hour effect

• Available dosages: 5mg, 10mg, 15mg, 20mg, 25mg, 30mg

• Approved 6yo-adult

Jennifer A. Ganem MS, APRN

Vyvanse

• It’s a pro-drug, meaning it doesn’t become active until various processes occur in the body.

• It’s the most consistently released stimulant from person to person.

• 13 to 14-hour effect

• Available dosages: 20mg, 30mg, 40mg, 50mg, 60mg, and 70mg

• Capsules can be opened and contents mixed with 4 ounces of water

• Approved 6yo-adults

Jennifer A. Ganem MS, APRN

Strattera

• Non-stimulant medication (NE reuptake inhibitor)

• Designed for 24-hour effect

• Available dosages: 10mg, 18mg, 25mg, 40mg, 60mg, 80mg

• Recommended starting dose is 0.3mg/kg/day, which is titrated over 1-3 weeks to a dosage of 1.8mg/kg/day or 80mg

• Approved 6yo-adults

Jennifer A. Ganem MS, APRN

Intuniv• Non-stimulant medication (long-acting* alpha-2 agonist)

• Designed for 24-hour effect

• Starting dose is 1mg with dosage increases of 1mg per week with a final dosage of 0.05-0.12mg/kg

• Available dosages: 1mg, 2mg, 3mg, 4mg

• To be effective as a long-acting agent, the tablet can not be broken, crushed or chewed.

• Approved 6yo-18yo

* The short-acting agent (guanfacine/Tenex) is NOT interchangeable

Jennifer A. Ganem MS, APRN

Common Side Effects• Stimulants:• headache, lack of appetite, insomnia, mood instability*, stomach pain,

increased BP/pulse, exacerbation of tics • With Daytrana only – irritant contact dermatitis*

Side effects typically decrease with continued use. * = Exceptions. If you these side effects, stop the medication and call your provider ASAP!

• Strattera:• headache, lack of appetite, sedation, mood instability*, stomach pain,

increased BP/pulse, exacerbation of tics

• Intuniv:• NO impact on appetite• headache, sedation, lack of appetite, decreased BP/pulse

Jennifer A. Ganem MS, APRN

Managing Decreased Appetite• Maximize the hungry times of day by having additional (healthy)

food • Yogurt smoothies at night

• Have small protein-based snacks throughout the day• Nuts• Peanut butter crackers• Cheese sticks• Greek yogurt

Jennifer A. Jennifer A. Ganem MS, APRN APRN – Nov 2013

Managing Insomnia – Good Sleep Hygiene

• Use the bed only for sleeping so that the bed is positively associated with sleeping • This means no reading, eating, watching TV, etc…

• Set and maintain a regular sleep schedule and keep as close to it as possible on weekends

• Do not take naps during the day

• Get exposure to sunlight in the morning

• Get some daytime exercise and avoid exercise 2 hours before bedtime

• Reduce the use of computers and television within two hours of bedtime, because it can alter natural body rhythms • If doing either, wear amber lensed safety glasses for a couple of hours before

bedtime to help block the blue light emissions. This allows the brain to produce melatonin.

Jennifer A. Ganem MS, APRN

• Keep the bedroom at a comfortable temperature; keep it dark and free of distractions • Mute the cell phone or keep it out of the room!

• Use a sound machine or fan for white noise•  

• Reduce stress and/or try relaxation techniques before bed•  

• Take a hot bath or have decaffeinated tea as a drop in body temperature helps increase drowsiness

•  

• Move the clock so you can’t clock-watch

• Use nightlights in the bathrooms and hallways •  

• Avoid caffeine after 2pm

• Avoid alcohol before bedJennifer A. Ganem MS, APRN