Child & Adolescent Psychiatry and Behavioral Medicine Center Basic Principles in the Pharmacologic Management of ADHD

Overview Therapy may be indicated in ADHD to address organizational skills deficits or oppositional behavior. Nonetheless, medication is a first line treatment for ADHD. It is appropriate to start with either of the two stimulant classes (methylphenidate or amphetamine) or with atomoxetine. Stimulants have been shown to be effective more often than atomoxetine. The decision regarding which medication to start and when to start will need to be made as part of an informed consent discussion with the patient and parent/guardian. A routine physical exam, including blood pressure, pulse, height and weight, should be performed prior to initiating stimulants. Vital signs should then be checked at each visit for potential tachycardia or hypertension. Obtaining a lead level should be considered for exposed children, but is not part of routine assessment. If the child doesn’t respond to the first stimulant tried (at maximum dosage) or has prohibitive side effects, try using another stimulant type or another medication class. “Rebound” in symptoms of ADHD is common in the late afternoon as the stimulant wears off, even with the sustained-release formulations. An immediate release dose may be given late in the afternoon to help avoid this phenomenon. Watch for sleep disturbances when the stimulants are given later in the day. The American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters for ADHD (http://www.aacap.org/galleries/PracticeParameters/JAACAP_ADHD_2007.pdf) note the following contraindications to the use of stimulants: glaucoma, symptomatic cardiovascular disease, hyperthyroidism, hypertension, active psychosis, and concomitant use of an MAO-I (monoamine oxidase inhibitor). Caution should be exercised when there is a history of substance abuse in the home. In this case Atomoxetine or Vyvanse might be considered. Baseline EKG’s are not recommended for otherwise healthy individuals (see N.B. “2)” below). The Food and Drug Administration has added other contraindications including motor tics, severe anxiety, and a family history or diagnosis of Tourette’s Disorder, although these are relative contraindications and these conditions may not be worsened by stimulants. In the presence of seizure disorder, it is best to initiate stimulant treatment following adequate seizure control with anticonvulsants. Consider referring to a child psychiatrist if two adequate trials of stimulants or Strattera have failed.