RISK FACTORS: Family history, Co-morbid conditions (associated with, but not caused by)
. Learning disabilities, Mood disorders, Oppositional defiant disorder, Conduct disorder
GENERAL MEASURES:
β’ Parent/school/patient education
β’ Work closely with teacher
β’ Avoid unproved therapies
PATIENT EDUCATION:
. Key points for parents:
. 50% of ADHD children have one parent with ADHD; modify education sessions with parents accordingly
. Behavior therapy (token systems, etc.) is recommended
. Reinforce good behavior (with rewards and attention)
. Address behavior before it escalates
. Set goals and monitor their achievement
. Some families benefit from anger training, social training and family therapy
. Refer to advocacy and support groups
. Help family and child deal with negative feelings
. Key points for school:
. Evaluate need for IEP (individualized education plan)
. Use behavioral techniques (tokens, reinforcement)
. Coordinate homework with parents using daily assignment notebook
. Have second set of books at home
DRUG(S) OF CHOICE:
ADHD is a chronic disease and is managed, not cured. Stimulants are the drug of choice and have high
efficacy. Methylphenidate (Concerta, Metadate, Ritalin) is the most studied and should be tried fi rst. Short
and long acting versions are preferred to intermediate preparations. If stimulants fail, another stimulant family
should be tried before using nonstimulant medication. Most preparations are not approved under age 6, but
short acting Adderall can be used at age 3 (if necessary). Dosing is not by weight. Start at the lowest dose and titrate upward as needed to meet treatment goals.
. STIMULANTS:
. Methylphenidate (Ritalin, Concerta, Metadate CD, Ritalin LA)
- Short-acting - Ritalin 5-20 mg q am, noon and 4 pm; maximum dose 60 mg/day
- Long-acting - Concerta 18, 36, 54 mg qd; Metadate CD 10-30 mg qd; Ritalin LA 10-40mg qd
. Amphetamine (Adderall XR: has been withdrawn from the Canadian market due to reports of sudden death in children using it)
- Short-acting - Adderall 2.5-10 mg bid
- Long-acting - Adderall XR 5-25 mg qd
. NONSTIMULANT:
. Atomoxetine (Strattera); selective norepinephrine reuptake inhibitor; 0.5-2 mg/kg/d every AM. Slower onset of effi cacy; GI side effects and sedation. FDA issued warning concerning the potential for severe liver toxicity using atomoxetine.
PRECAUTIONS:
β’ If not responding, check compliance and consider another diagnosis
β’ Methylphenidate has become a drug of abuse and should be monitored carefully - 20 mg nongeneric have
highest street value
β’ Drug holidays should only be given if family/peer relationships arenβt harmed
β’ Some children experience withdrawal (tearfulness, agitation) after a missed dose
PATIENT MONITORING:
. Parent/teacher rating scales initially, in 2 weeks, and regularly
. Office visits to monitor side effects and efficacy. End point is - improved grades, improved rating scales,
acceptable family interactions, and improved peer interactions.
. Monitor growth and BP
. Dexmethylphenidate (Focalin), monitor CBC
PREVENTION/AVOIDANCE:
. Children are at risk for: abuse, depression, social isolation
. Parents need regular support and advice
. Establish contact with teacher each school year
POSSIBLE COMPLICATIONS:
. Untreated ADHD can lead to: failing school, parental abuse, social isolation, poor self esteem
. If appetite poor, offer food morning and evening (when medication has worn off)
. Some children experience withdrawal (tearfulness, agitation) after a missed dose
. Sudden death has been reported, rarely, with stimulant use, not clearly linked to the stimulant
EXPECTED COURSE/PROGNOSIS:
. May last through school years and into adulthood . It becomes easier to control with increasing age
. Encourage career choices which allow autonomy and mobility
. There is no increased incidence of delinquency unless other co-morbid features exist (eg, conduct disorder)
. Encourage parents to subtract 2 years from their childs chronological age when allowing privileges (eg, treat
a 16 year old like a 14 year old; delay driving until age 18)