2. STIMLUANTS FOR ADHD Part I Stephen Soltys MD Professor and Chair SIU Department of Psychiatry Double click speaker on subsequent slides

3. MEDICATIONS Stimulants and atomoxetine are the first line of treatment Behavioral intervention alone ineffective in ADHD as first line treatment Medication not likely to impact behaviors resulting from other co-morbid disorders or conduct and oppositional-defiant disorder need behavioral interventions Clonidine, guanfacine, buproprion, imipramine are second-line or augmenting treatments

4. MEDICATIONS FOR HOW LONG? Summer and long holiday’s can be utilized to assess if meds still needed All meds have side effects, key lowest dose that has benefit without adverse effects Monitor height and weight

5. STIMULANTS Effects mainly on dopamine (DA), very weak impact on norepinephrine if any Amphetamines increase intersynaptic concentration of DA via indirect mechanisms Methylphenidate with a radioisotope marker occupies the DA transporter the striatal area of the brain

6. STIMULANTS Preparations of methylphenidate and amphetamines have been the mainstay of treatment for ADHD Regular preparations are quickly absorbed, low plasma binding and quickly metabolized extracellularly and hepatically: Onset of action 30 minutes, peak 1-3 hours, duration 4-6 hours Generics may have fast absorption and peak sooner Class II Controlled non-narcotic substance Problems with break-through symptoms between doses, non-compliance with multiple doses

7. STIMULANT TOLERANCE Little evidence for tolerance to ADHD symptoms No evidence to suggest behavioral sensitization to long-term stimulants as used in children Can occur if drug is intermittently administered in high parenteral doses that are then allowed to fall to zero Use as prescribed is low oral intake

8. STIMULANT EFFECTS Can see a rebound in the activity level with stimulants when they wear off Equal general efficacy for MPH, DEX, AMP 70% respond when single stimulant is tried, placebo response of ADHD ranges 3-30% Produce improvement in day to day functioning, retain behavioral problems, no consistent long-term academic achievement or improvement in social skills Positive response does not mean ADHD

9. STIMULANTS AND COMORBIDITY ADHD and anxiety: increased placebo response rates, more side effects, less cognitive improvement ADHD and Tourette’s: generally worsening but a few reports of improvement ADHD and DBH: Generally decreases rate of behaviors

10. STIMULANTS Mixed amphetamine salts and dextro- amphetamine: Maximum 40 mg/day Methylphenidate similar dosing with maximum of 60 mg/day Dexmethylphenidate dosing up to 20 mg/day Maximum dosing should be guided by size of child (mg/kg/day) but not exceed published maximums Behavior /education benefit trade off may be in the 0.3 to 0.8 mg/kg/day range depending on the medication