ADHD Primer for Medications

Tips on prescribing:

Stimulants are frequently prescribed for ADHD, with up to 85% effectiveness. Symptoms of inattention respond slightly better than behavioral symptoms.  Begin with the lowest dose of short-acting drug and increase until an acceptable balance is found between maximum benefit and minimum side effects.  Then switch to a long-acting form in equivalent dosage and desired duration. (Use available pill size, not per kilogram calculations, to determine dosage. Liquid formulations are not available and long-acting pills may not be cut or chewed.)  Avoid medication under age 6 without emotional/behavioral intervention as a first line treatment.  Reducing total cumulative dose may reduce side effects so treat for adequate control, not total elimination of symptoms and consider drug holidays when children are not in school if families can tolerate it.  Excessive doses can cause sleepiness.

Side effects (dose dependent):

Common side effects include anorexia, abdominal unease and poor weight gain.  Insomnia is common with long acting formulations. Irritability may be seen as the blood levels drop after the drug’s peak. Sad affect and social isolation, more common in younger children, is an unacceptable side effect.  Less common but serious side effects include tics, cardiovascular stimulation and lowered seizure threshold.  Recently poor growth in height has re-emerged as a concern, with reports of significant stature reduction in the first one to two years of stimulant use and presumed reduction in eventual adult height.  Rare side effects include acute psychosis, dyskinesia and sudden death, attributed to cardiac arrhythmia. 

Follow-up:
Pediatricians can manage simple ADHD but should seek specialty support for associated emotional and/or learning problems.  Monitor weight, height, pulse and blood pressure, and use the SNAP or the Vanderbilt (NICH-Q) not just for diagnosis but to monitor status during drug treatment.  If no improvement is seen or if significant side effects occur, try a different dose, a different drug, or discontinue medication.

Sprinkle = capsule can be opened and contents sprinkled on food

See Pediatrics In Review article on managing stimulant medication for ADHD:

http://pedsinreview.aappublications.org.arugula.cc.columbia.edu:2048/cgi/content/full/23/7/234