Pharmacological Treatment of Child & Adolescent

ADHD

2

Baseline Measurement

Complete blood count (CBC)

Height; Weight; Blood Pressure; Pulse Rate

SNAP-IV 18 Items Rating Scale

WFIRS-P (Weiss Functional Impairment Rating Scale- Parent Report)

CFA (Child Functional Assessment)

KSES-A (Kutcher Side Effects Scale for ADHD Meds)

Family history of heart disease

CBCHtWtBP

Pulse

SNAP-IV 18

WFIR

S\P

CFA

KSES-AHistory

3

Do not cause addiction in ADHD treatment

› Tolerance develops occasionally Decreases rates of future substance abuse Improves outcomes in functioning “Drug holidays” are not needed Long acting, once per day dose easiest

Facts About Stimulants

4

Stimulants & Non-Stimulants

Available in two different forms

Highly effective

Available for decades

Well studied

Safe prescribed to healthy patients

under medical supervision

StimulantsNon-Stimulants

For youth…

1. Not responding well to

stimulant medications

2. At risk for substance abuse

3. With other conditions with

ADHDShort-Intermediate

Release Preparations

 

Repeated doses/day

More adverse effects

Stigma associated with

taking at school.

Methylphenidate’s 

Ritalin®

Ritalin® SR

PMS or Ratio

Methylphenidate

Dextroamphetamine Sulphate’s

Dexedrine

Extended Release Preparations

Preferred over short-acting medications,

Better compliance; less diversion.

More expensive, not all Canadian

medication insurance plans cover.

Mixed Salts Amphetamine

*Adderall XR

Methylphenidate

*Biphentin

*Concerta

*Novo-Methylphenidate ER-C

Lisdexamfetamine Dimesylate

*Vyvanse

Atomoxetine

*Strattera

 

Is the only non-stimulant

medication that is approved to

treat children / adolescents

with ADHD.

5

Tricyclic antidepressants (not recommended)

› Imipramine or Desipramine Bupropion

› Wellbutrin Clonidine

Reserve these medications for specialty mental health services

Additional ADHD Medications

6

Evaluating response to Methylphenidate

› 3-day baseline assessment SNAP-IV 18

Alternate every 3 days for 12 days:

› Dose of methylphenidate (standard release) 5 mg/BID or 10 mg/BID depending on weight

› Dose of placebo Daily measurement

› Symptoms (SNAP-IV 18)

› Side Effects (KSES-A)

“N of 1” Model

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Day 8

Day 9

Day 10

Day 11

Day 12

No Medication 5 -10mg/bid

5 -10mg/bid

5 - 10mg/bid

Placebo Medication

5 -10mg/bid

5 -10mg/bid

5-10mg/bid

7

Concerning with

alcohol/drug abuse

> Careful evaluation and

monitoring

> Avoiding drug diversion

> Sustained-release preparations

> Non-stimulants

> Consider using Atomoxetine

> Studying for exams

Stimulants Misuse

8

Collaborative Prescribing Agreement for ADHD Medications

http://www.health.gov.bc.ca/pharmacare/sa/criteria/restricted/methylphenidate.html

9

CADDRA Medication Tables

10

START LOW & GO SLOW

Begin: 2.5mg – 5mg; morning and noon; 30 – 45 minutes before meals. Maintain for 1 wk.

If insufficient effect, tolerable and no significant side effects increase to 5mg - 10mg in morning and 2.5mg - 5mg at noon and maintain for a week

If needed, increase: to 5 mg – 10mg in the morning and 5mg – 10mg at noon. Maintain for 1 wk.

If insufficient effect, tolerable and no significant side effects increase: to 5 mg – 10mg in the morning, 5mg – 10 mg at noon and 2.5 – 5mg at 4pm. Maintain for 1 wk.

Continue stepped titration by 2.5mg - 5mg weekly to a maximum total daily dose of 2mg/kg/d not to exceed 60 mg, measuring outcomes every week following the step increase.

After beginning dose and increases: Measure outcomes using SNAP-IV 18 items (aiming for a score of less than or equal to 18) and the KSES-A

If Side Effects… …become a problem, while no substantial improvement, increase time between increases from 1 wk to 2 wks; continue steps.…limit dose increases to optimize symptom control, refer to specialty services or change to Dextroamphetamine .

Discontinuation: Taper gradually over several months at low stress times

Methylphenidate Treatment

11

START LOW & GO SLOW

Begin: 2.5 mg – 5mg in the morning and 2.5mg – 5mg at noon; 30 – 45 minutes before meals. Maintain for 1 wk.

If insufficient effect, tolerable and no significant side effects increase to 5 mg - 10mg in morning and 2.5mg - 5mg at noon and maintain for a week

If insufficient effect, tolerable and no significant side effects increase to 5 mg - 10mg in morning and 5mg - 10mg at noon and maintain for a week

If insufficient effect, tolerable and no significant side effects increase: to 5mg - 10mg in the morning and 5mg – 10mg at noon and 2.5mg – 5mg at 4pm. Maintain for 1 wk.

Continue stepped titration by 2.5mg – 5mg weekly to a maximum total daily dose of 20 mg, - 40mg measuring outcomes every week following the step increase.

After beginning dose and increases: Measure outcomes using SNAP-IV 18 items (aiming for a score of less than or equal to 18) and the KSES-A

If Side Effects… …become a problem, while no substantial improvement, increase time between increases from 1 wk to 2 wks; continue steps.…limit dose increases to optimize symptom control, refer to specialty services or change to Methylphenidate if not tried yet or consider Atomoxetine .

Discontinuation: Taper gradually over several months at low stress times

Dextroamphetamine Treatment

12

START LOW & GO SLOW

Begin: 0.5 mg/kg/d in the morning for 2 wks

Increase: to 0.8 mg/kg/d in the morning for 2 wks

Increase: to 1.0 mg/kg/d in the morning for 2 wks

After beginning dose and increases: Measure outcomes using SNAP-IV 18 items (aiming for a score of less than or equal to 18) and the KSES-A

If Side Effects… …become a problem, while no substantial improvement, increase time between increases to 4 wks…limit dose increases to optimize symptom control, refer to specialty services.…and symptoms are not under optimal control, increase to 1.2mg/kg/d in the morning; maintain for a period of 2 wks.

Measure outcomes using SNAP-IV 18 items and the KSES-A.

Discontinuation: Taper gradually over several months at low stress times

Non-Stimulant Atomoxetine Treatment

NOTE:

If symptoms

are not

under

optimal

control with

1.2mg after

maintaining

it for at least

6 weeks

refer to

speciality

service.

13

When total daily dose is determined…

› Switch to long acting form Biphentin Concerta Nova-Methylphenidate ER-C

› Single daily morning dose Equivalent of initial Ritalin dose

Long acting Methylphenidate

› Start at lowest dose; increase weekly

› Essential to evaluate twice/wk SNAP-IV Side Effects Scale

Switching to Long Acting Forms …

14

If switching for reasons other than side effects

› Add Atomexetine until ADHD symptoms improve

› Then stop Methylphenidate

Use PST Based Supportive Rapport

Switching to Atomoxetine

15

Kutcher Side

Effects Scale

for ADHD Meds

Subjective Side Effects Never Somewhat Constant

Anorexia 0 1 2 3 4

Weight Loss 0 1 2 3 4

Abdominal Pain 0 1 2 3 4

Dry Mouth 0 1 2 3 4

Nausea 0 1 2 3 4

Vomiting 0 1 2 3 4

Fearful 0 1 2 3 4

Emotional Lability 0 1 2 3 4

Irritable 0 1 2 3 4

Sadness 0 1 2 3 4

Restlessness 0 1 2 3 4

Headaches 0 1 2 3 4

Trouble Sleeping 0 1 2 3 4

Drowsiness 0 1 2 3 4

Dry Eyes 0 1 2 3 4

Suicidal Ideation 0 1 2 3 4

Rash 0 1 2 3 4

Acne 0 1 2 3 4

Dyskinesia 0 1 2 3 4

Tics 0 1 2 3 4

Other Movements 0 1 2 3 4

Sexual Effects 0 1 2 3 4

16

ToolBase-

line

Day 1*

Day 3*

Wk 1

Wk 2

Wk 3

Wk 4

Wk 5

Wk 6

Wk 7

Wk 8

SNAP-IV 18

x x x x x x x x

CFA/TeFAWFIRS

x x x x x

KSES-A x x x x x x x x

* For Stimulants Only

Monitoring Treatment of Attention Deficit Hyper-Activity Disorder

17

Allow for further improvements in symptoms Allow for additional therapeutic interventions to occur

(e.g. CBT or parent training) Decrease risk of relapse Decrease risk of a co-morbid mental disorder

Duration of Treatment

Maintain treatment for defined length of time to:

Medication Adherence

19

Predict non-compliance

› Openly recognize probability Missing one or more doses of medication

› No need to feel guilty

Occasional misses…

…a little change in fluoxetine

(long half-life)

…a difference in missing

sertraline (shorter half life)

Checking Adherence to Treatment

20

1. Enquire about medication use from child

2. Enquire about medication use from parent

3. Pill counts are sometimes useful

Assessing Treatment Adherence3 Methods

21

…evaluate the following

Compliance with treatment Medical illness Onset of stressors that challenge patient Onset of substance abuse Alternative diagnostic possibility

Depression, anxiety disorder, bipolar disorder

Refer to mental health specialist if relapse occurs despite adequate ongoing treatment

If Relapse Occurs…