Pharmacological Treatment of Child & Adolescent ADHD

2 Baseline Measurement Complete blood count  Complete blood count (CBC)  Height; Weight; Blood Pressure; Pulse Rate  SNAP-IV 18 Items Rating Scale  WFIRS-P  WFIRS-P (Weiss Functional Impairment Rating Scale- Parent Report)  CFA  CFA (Child Functional Assessment)  KSES-A  KSES-A (Kutcher Side Effects Scale for ADHD Meds) Family history of heart disease  Family history of heart disease CBC Ht Wt BP Pulse Ht Wt BP Pulse SNAP-IV 18 KSES-A History

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 Stimulants Non-Stimulants For youth… 1. Not responding well to stimulant medications 2. At risk for substance abuse 3. With other conditions with ADHD Short-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 Medication5 - 10mg /bid Placebo Medication5 - 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 armacare/sa/criteria/restricted/ methylphenidate.html

9 CADDRA Medication Tables

10 Methylphenidate Treatment

11 Dextroamphetamine Treatment

12 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 EffectsNeverSomewhatConstant Anorexia01234 Weight Loss01234 Abdominal Pain01234 Dry Mouth01234 Nausea01234 Vomiting01234 Fearful01234 Emotional Lability01234 Irritable01234 Sadness01234 Restlessness01234 Headaches01234 Trouble Sleeping01234 Drowsiness01234 Dry Eyes01234 Suicidal Ideation01234 Rash01234 Acne01234 Dyskinesia01234 Tics01234 Other Movements01234 Sexual Effects01234

16 Tool Bas e- line Day 1* Day 3* Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8 SNAP-IV 18 xxxxxxxx CFA/TeF A WFIRS xxxxx KSES-Axxxxxxxx * 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 Adherence 3 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…