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Raising the Bar 2008
Medication for ADHD
Presentation to Families with ADHD
Frank W. Gearing, MD
Harrisonburg Pediatrics
March 20, 2008
Medication for ADHD
 Goals
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for this presentation:
To leave the participant aware of the
complexity of successful management of
ADHD.
To familiarize the participant with medication
options and some rationale to therapy
decisions.
To encourage a philosophy of treating the
whole person within their daily context.
To present research about adults who were
treated for ADHD as children.
Principles of Management of ADHD
Medications
 Correct
diagnosis
 Patient profile
 Target symptoms
 Chronic disease management model of
care
 Education of key players
 Communication
Principles of Management of ADHD

Selection of an appropriate medication at an
appropriate dose in combination with behavioral
therapy are the foundation of therapy.
 Adequate behavioral therapy involves intensive
and prolonged parent involvement and
cooperation from the teacher.
 All children with ADHD should be evaluated for
LD and treatment of LD, when present, should
be included in management.
 Individuals with ADHD should get enough to eat,
get enough sleep, and have sufficient exercise.
Why Treat ADHD
 Individuals
with ADHD are impacted over
a lifetime by:
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Parents who do not understand, are frustrated
and feel guilty
Teachers who may label a child as lazy, slow,
bad, or lacking motivation.
Rejection by peers because of poor social
skills.
Spouse or boss who are exasperated by lack
of organization, forgetfulness, and inability to
complete tasks.
Risks of co morbid conditions
Medications for ADHD
 Psychostimulants
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Methylphenidate based (Ritalin)
Dexamphetamine based (Dexedrine)
 Non-stimulants
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Atomoxetine (Strattera)
Guanfacine (Tenex)
 Antidepressants
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Buproprion (Wellbutrin)
ADHD Medication Benefits
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Improve selective and sustained attention
Improve impulse control
Improve regulation of activity and arousal
Improve memory
Improve productivity, accuracy, and organization
Improve reinforceability
Improve emotional control
ADHD Medication Side Effects
Manageable
 Decreased appetite
 Headache
 Stomachache
 Insomnia
 Suicidal thoughts (Strattera)
 Skin rash (Daytrana)
ADHD Medication Side Effects
• Unacceptable
• Personality Change or social withdrawal
• Labile mood/irritability
• Excessive Lethargy (Zombie)
• Liver Injury (Strattera)
• Mania (caution should be taken in treating
individuals with Bipolar disorder)
• Psychosis rarely may develop in individuals
with no prior history
ADHD Medication Side Effects
• Possibly Manageable
• Tics
• Seizures
• Family history of heart disease
Rebound from ADHD Medication
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Irritability, hyperactivity and impulsiveness
exceeding untreated symptoms
Related to psychostimulants “wearing off”
Often coincides with homework time
Increases family stress
May suggest need for increased dose or
change of medication
Often requires short acting stimulant
supplement
Black Box Warnings
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Stimulants
 Risk of sudden death
 25 deaths and 54 cardiovascular problems in adults
and children between 1999 and 2003
 Report does not indicate the drugs were responsible
for the deaths
 Screen all patients for high risk conditions including
structural heart defects.
Strattera
 Increased suicidal thoughts
 No increase in suicide attempts
 Monitoring is recommended.
 Liver injury
Psychostimulants

Methylphenidate products (Ritalin)
 Ritalin (4 hours average duration of effect)
 Ritalin LA (8-10 hours)
 Metadate CD (10 hours)
 Concerta (10-12 hours)
 Focalin (dexmethylphenidate) (4-6
hours)
 Focalin XR (8-10 hours)
 Daytrana (methylphenidate transdermal
system) (2-3hr. after patch removed)
Psychostimulants
 Amphetamine
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products
Dextrostat (4-5 hours)
Mixed amphetamine salts
• Adderall (4-6 hours)
• Adderall XR (10-12 hours)
Lisdexamfetamine (Vyvanse)
• 11-13 hours
Vyvanse (lisdexamphetamine)
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Prodrug that must be metabolized to active
ingredient (single dextro isomer of
amphetamine)
Available as 30 mg, 50 mg, 70 mg
No generic
FDA has approved 20 mg, 40 mg, 60 mg that
are not available at this time
Onset in 1-2 hours and reaches peak at 3.5
hours with duration of 11-13 hours
Food prolongs time to peak concentration
Non Stimulant Medications
 Strattera
(atomoxetine)
 Tenex (guanfacine)
 Wellbutrin (buproprion)
Strattera (atomoxetine)
 Strattera
is a selective norepinephrine
reuptake inhibitor
 It is not recommended but it is known to
be stable when capsule contents dissolved
in grape juice for those unable to swallow
capsule
 Absorption unaffected by food
Tenex (guanfacine)

Tenex is an antihypertensive (alpha adrenergic)
medication that has been used to treat
hyperactive-impulsive and aggressive behaviors
in individuals with ADHD.
 Tenex has been used for insomnia in ADHD
patients and to suppress Tics in Tourettes
patients
 Recent research has shown that with continued
use, inattention shows continuous improvement
 A sustained release and a patch are currently in
clinical trials with the sustained release showing
greater benefit and flexibility than the immediate
release formulation
Wellbutrin (buproprion)
 Wellbutrin
is an atypical antidepressant
that is a dopamine and norepinephrine
reuptake inhibitor that has been shown to
be effective for ADHD
 Wellbutrin has been advocated in ADHD
patients with substance abuse disorder
 Zyban is also buproprion marketed under
another name as a smoking cessation aid.
 It is recommended for ADHD with unstable
mood disorder, and seasonal affective
disorder.
Management of ADHD
Prior to initiating medication document:
 Family history of response to medication
 Prioritized “Target Symptoms”
 Compliance and Follow-up requirements
 Plan for coordination of care (counselors,
teachers, care providers, parents)
Monitoring ADHD Medications
 Monthly
weight, height, and blood
pressure until on stable dose followed by
routine 3 month interval checks
 Appetite, sleep, energy, mood changes,
academic performance, behavior
concerns, social relations, family relations
 Worries, rituals, depression, thoughts of
suicide
 Be specific and detailed (number of hours
of sleep/night, specific grades per subject,
extracurricular activities, etc.)
Risks of Not Treating ADHD
 Untreated
ADHD has twice the risk for
substance abuse, with earlier onset, and
less likelihood to recover as an adult
 Effective management of ADHD with
stimulants does not increase substance
abuse
 Effective management of ADHD
significantly decreases risk for
substance abuse
Risks of Not Treating ADHD
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Employment stability
 Parents of children with ADHD have greater
absenteeism from work
 Parents of children with ADHD are less productive in
the work place
Interpersonal relationships
 Marriage/divorce- 3-5 times greater parental divorce
or separation in families with a child with ADHD
• Possibly related to untreated ADHD in parent
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Untreated adults with ADHD have poor employment
records
• Vocational aptitude testing beneficial for teens with
ADHD seeking areas of likely success
ADHD Treatment of Preschool
Children
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Preschool children have higher incidence of side effects
from stimulants, especially abdominal pain, decreased
appetite, and insomnia, but recent PATS study shows
stimulants clearly of benefit
Factors associated with lower response to stimulants
include lower IQ, greater severity of symptoms, comorbid conditions, family dysfunction, confidence in
diagnosis
Preliminary evidence of efficacy of Tenex without side
effects of stimulants and greater hyperactive/impulsive
symptoms may suggest Tenex a better first medication
trial, along with behavioral interventions
Most frequent co morbid condition was ODD, followed by
communication/language disorder and anxiety
Choosing ADHD Medication
 Consider
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Child’s profile- affinities, personality traits,
social skills, emotional stability
Anxiety or depression symptoms
Aggressive behavior
Other medical diagnosis
Sleep patterns
Tics
Seizures
Family dynamics
Choosing ADHD Medications
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Morning person (runs out of mental energy in
afternoon)
• Avoid difficult classes in afternoon
• Encourage afternoon physical activity
• Homework may require supplemental
medication after school
• Rebound symptoms may be more likely
without supplemental medication
• Consider Concerta, Metadate CD, Adderall
XR, Daytrana, Vyvanse, Strattera
Choosing ADHD Medications
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Afternoon person (hard to get started in
morning)
• Schedule difficult classes in mid day
• Encourage morning physical activity
• Evaluate sleep hygiene at each visit
• May require short acting stimulant in
morning in addition to sustained release
preparation
• Consider Ritalin LA, Focalin XR, Vyvanse,
Strattera
Choosing ADHD Medication
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ADHD with depressive or anxious symptoms
may respond best to Strattera
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Strattera less effective for hyperactivity
Strattera can be used in conjunction with stimulants
SSRI’s are well tolerated and can be used in
conjunction with stimulants for more depressed
or anxious patients
 Aggressive behaviors, tics, and disturbed sleep
may respond to Clonidine or Guanfacine
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Controversy about safety of stimulants with Clonidine
Insomnia may respond to Melatonin
Medications for ADHD
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Reasons for treatment failure
 Child with ADHD has parent with
undiagnosed/untreated ADHD
 Lack of family and patient education about
ADHD
 Failure to consistently follow management
plan
 Undiagnosed co morbid condition
 Lack of recognition for success
• 80% of interactions for children with ADHD
who are not stabilized are negative.
• Reinforce the positive. Catch them doing
well.
Medications for ADHD
 When
there is a sudden deterioration in
daily functioning after a long period of
stability it is most often not an issue of
medication failure. Consider other
explanations such as changes in family
dynamics, changes in peer relations,
pregnancy, drug use, etc.
ADHD in Adults
ADHD in Adults
 80-90%
of individuals diagnosed and
treated as children for ADHD have areas
of impairment as adults.
 Education: higher drop out rate, lower
GPA, fewer college graduates
 Employment: unskilled level jobs, greater
periods of unemployment, higher
likelihood of being fired, lower work
performance ratings, lower job status
ADHD in Adults
 Poorer
driving skills
 More auto accidents with more at faults (23 times risk)
 Worse accidents (3 times more cost and
injuries)
 More citations (speeding 4-5 times risk)
 3 times more license suspensions
 Alcohol has greater adverse impact on
driving
ADHD in Adults
 Begin
sexual activity earlier
 More lifetime sexual partners with less
time per partner
 Higher risks for STDs
 Less likely to use contraception
 6-7 times more teen pregnancies
 54% do not have custody of their children
ADHD in Adults
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Higher incidence of co morbid disorders
(anxiety, substance use/abuse, personality
disorders, depression, suicide attempts)
Greater frequency of antisocial acts: stealing,
assault, illegal drug possession, breaking and
entering, setting fires, runaway
Fewer close friends
Watch more TV, play more video games
Less time reading, exercising, getting education
More sleep disturbances
ADHD in Adults
 Higher
incidence of medical and dental
problems
 Money management problems
 Greater likelihood of smoking and excess
alcohol use
 Higher risk of cardiovascular disease
 ? Greater risk of cancer
ADHD in Adults
 Adults
not diagnosed with ADHD as
children who present with ADHD:
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Have greater awareness of symptoms and
impairments
Have higher education, salaries, higher SES,
higher IQ’s
Less antisocial, less drug use
More co morbid depression, anxiety
Impaired executive functions (sustained
attention, task completion)
Similar impairments in risky sexual behavior,
marriage, child rearing, money management,
driving and health care
Treatment of ADHD in Adults
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Adults often respond well to Strattera.
Wellbutrin and Effexor are used more frequently
in adults than children for ADHD
Caution is required to address preexisting health
conditions and use of other medication in adults.
Counseling is important for improving self
awareness and addressing co morbid
conditions.
Accommodations can often be implemented with
the cooperation of employers, spouses, and
coworkers.
The medications we discussed in this
presentation are used in adults as well as
children.
Summary
 Children
with ADHD need to understand
themselves to work toward independence.
 Compliance with routine should be closely
monitored with associated consequences.
 Teacher involvement is crucial to include
daily communication with the focus on
making the child responsible, and teaching
the child to monitor his own work. Training
these behaviors takes a long time and a
lot of persistence on the part of parents.
Summary

ADHD is a complex disorder beginning in
childhood that may impact as many as 90% of
affected children as they grow to adulthood.
 Severe symptoms of ADHD in childhood are
associated with risk of impairment in academics,
social relations, family relations, work success,
and healthy lifestyle choices.
 Effective management involves a closely
monitored, comprehensive approach that
involves physicians, counselors, teachers, and
especially parents. As affected individuals age,
spouses, bosses, counselors, and friends will be
part of successful management.
 Medication is a major component of managing
ADHD in children and adults.
Summary
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Recognition and treatment of co morbid
conditions, especially learning disorders in
children and mood disorders in adults is crucial
to success.
 Attention to diet, sleep, exercise and
establishing routines are points of emphasis.
 Building on the strengths identified in the
individuals profile while working to improve
areas in need of improvement will be important
goals for the individual as they grow in their own
self awareness.
Addendum
Medications for ADHD
Methylphenidate products
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Effects attributed to blocking Dopamine (DA) reuptake at
the neuron synapse
 DA is involved in frontal and prefrontal cortex mediating
suppression of distractions and inhibiting
inappropriate behaviors related to tangential
thoughts and ideas (mesocortex pathway).
 DA is involved in mediating working memory required
for reasoning, planning, and problem solving
(mesodorsolateral pathway).
 DA is involved in mediating interpersonal decisions
and inhibiting impulsive social responses.
Ritalin (methylphenidate)
 Available
as tablet 5 mg, 10 mg, 20 mg
 Available as liquid 10 mg/5 ml
 Available as generic
 Onset within 30-60 minutes with peak at 1
hour and duration average of 4 hours
Ritalin LA
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Available as 10 mg., 20 mg., 30 mg.
Bead filled capsule that can be swallowed or
sprinkled on applesauce
Uses SODAS absorption technology and
replicates twice daily dosing 4 hours apart of
equal amounts of methylphenidate (50-50)
Onset within 1 hour and peak serum levels at
3 and 6 hours after ingestion
Absorption affected by food, especially fatty
meals slowing absorption
Metadate CD
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Extended release formulation of
methylphenidate
Available as 10 mg, 20 mg, 30 mg bead filled
capsule that can be sprinkled on apple sauce
No generic
30% of dose available as immediate release
with onset in 30-60 minutes and 70% of dose
extended slow release
Dual peak concentrations at 1.5 hours and 4.5
hours that are delayed by fatty meals
Duration of effect 8-10 hours
Concerta
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Available as 18 mg, 27 mg, 36 mg, 54mg tablet
No generic
Exterior coating of tablet dissolves in water and
provides immediate release of 22% of dose
Uses OROS technology for osmotic release of
78% of dose in slow consistent manner over 5-9
hours
Onset of immediate release within 30-60 min
with initial peak at 1 hour and secondary peak at
6-10 hours and duration of 10-12 hours
Absorption unaffected by food
Focalin XR (dexmethylphenidate)
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Extended release formulation
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Available as 5 mg, 10 mg, 15 mg, and 20 mg
Bead filled capsule that can be swallowed or
sprinkled on applesauce
Uses SODAS absorption technology and replicates
twice daily dosing 4 hours apart of equal amounts of
dexmethylphenidate (50-50)
Onset within 1 hour and peak serum levels at 3 and 6
hours after ingestion
Absorption effected by food, especially fatty meals
slowing absorption
Duration of effect 8-10 hours
Focalin (dexmethylphenidate)
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Single isomer formulation of Ritalin
Available as tablet 2.5 mg, 5 mg, 10 mg
Available as generic
Onset in 1 hour with peak at 3 hours and
duration of effect of 4-6 hours
Absorption slowed by food, especially fat
Theory of single isomer
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Single isomer active ingredient
Inactive isomer (levomethylphenidate) may:
• Block receptor site
• Cause side effects
Dexedrine Products
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Dexedrine products increase levels of dopamine
(DA) and norepinephrine(NE) at the synapse by
stimulating release and blocking reuptake of the
neurotransmitters
NE has wide, diffuse projections throughout the brain
suggesting a role as a neuromodulator.
NE is critical to reasoning, learning, problem
solving, priority setting, organizational thought
NE functions in maintaining arousal, regulating
excitability related to danger (fright/flight),
contributes to memory storage and retrieval
DA is involved in suppressing distractions,
inhibiting inappropriate behavior, reasoning,
planning, problem solving, inhibiting impulsive
social responses.
Dextrostat (dextroamphetamine)
 Single
d-isomer of amphetamine
 Available as 5 mg, 10 mg scored tablets
 Approved from age 3 years
 Peak level at 2 hours Dose
recommendation of once daily
Adderall (mixed amphetamine
salts)
 d,l
amphetamine sulfate,
dextroamphetamine saccharate,
d,l amphetamine aspartate
 Available as 5 mg, 7.5 mg, 10 mg, 12.5
mg, 15 mg, 20 mg, 30 mg
 Generic available
 Duration of effect 4-6 hours
Adderall XR
 Two
different beads in each capsule to
give double pulsed delivery of medication
 Available as 5 mg, 10 mg, 15 mg, 20 mg,
25 mg, 30 mg.
 No generic
 Peak serum levels at 7 hours
 Fatty meal prolongs the time to peak
levels
 Contents of capsule can be opened and
spread on apple sauce
Strattera
 Onset
of benefit in 1-2 weeks with
maximal benefit reached in 4-6 weeks
 Not recommended for crisis intervention
 Initial dosing recommended at 0.5 mg/kg
for 3-5 days with gradual increase to FDA
recommended dose of 1.2-1.4 mg/kg
 Dose can be split BID to avoid side effects
 Literature supports continued benefits for
select patients with dose up to 1.8 mg/kg
 Warnings related to suicide ideation and
liver toxicity
Strattera
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Side effect profile includes headache, nausea,
stomachache, decreased appetite, drowsiness,
aggression, priapism, mania, psychosis
Adult trials have reported erectile dysfunction,
urinary retention, dysmenorrhea, hot flush
Dosage adjustment may be needed when used
in conjunction with SSRI
Sudden death has been reported in individuals
with underlying structural heart disease or other
serious heart disease (not felt to be related to
drug)
Caution when treating co morbid Bipolar
disorder
Tenex
 Often
used in conjunction with stimulants
 Discontinuation should be tapered to avoid
blood pressure changes
 Side effects: somnolence, initial decrease
in blood pressure, depression, rebound
hypertension
 Catapres (clonidine) is a similar
antihypertensive that has been used for
similar reasons in ADHD but has
significantly more sedation than Tenex
Wellbutrin
 Side
effects: agitation/activation,
irritability, aggression, insomnia, suicidal
ideation, panic attacks, anorexia, dry
mouth, stomachache
 Contraindicated in individuals with
seizures, and for use with Tagamet
 Onset of benefit in 10-14 days with
maximal benefit at 3-6 weeks
 Often used in conjunction with stimulants
Addendum
Evaluation for ADHD
Correct Diagnosis and Patient
Profile
 Presenting
problems
 Comprehensive evaluation
 Assessment of specific components of
attention and behavior
 Evaluation of cognitive and academic
functioning
 Assessment of secondary vulnerabilities
Presenting Problems
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Poor Concentration
Inattention/Distractibility
Impulsivity
Hyperactivity
Academic problems
Behavior problems
Does this child have an attention disorder?
Or associated disorders?
What are this individual’s strengths and
weaknesses?
Comprehensive Evaluation
 Medical
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History, physical, neurological examination,
fine and gross motor assessment
Neurodevelopmental assessment
Vision and hearing screening
 Emotional
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History and interview
 Family-Environmental
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Family/School milieus and extracurricular
activities
Family mental health history
Assessment of Specific Components of
Attention and Behavior
 Rating
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scales
Parents, teachers, self report
 Interviews
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Parent, patient
 Direct
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observations
Classroom
During testing
 Objective
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measures
Computerized (controversial)
Evaluation of Cognitive and Academic
Function
 Processing
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abilities
Verbal/language, visual, sequential
 Memory
 Fine
motor abilities, especially
graphomotor skills
 Problems solving abilities
 Intelligence
 Academic achievement
Assessment of Secondary Vulnerabilities
 Self
esteem
 Social abilities
 Family interactions
 Classroom behaviors