To Medicate or Not

Children’s Health Council

To Medicate or Not
Glen R. Elliott, PhD, MD
Chief Psychiatrist & Medical Director

1


Our Vision
At Children’s Health Council, we
believe there is a world of promise
and potential in every child.
Using a personalized approach, we
help children become happier, more
resilient and more successful.


Our Mission
Our mission is to help children with
ADHD, LD, Anxiety & Depression and ASD thrive
by promoting Social Emotional
Learning, Academics, Executive Functioning and
Physical Development.


Our Framework for Learning & Life
Success
Academic
Success

Social
Emotional
Learning

Executive
Functioning

Happy, resilie
nt and
thriving
children

Physical
Development

4


Empowering Success through Four
Divisions
Expert
interdisciplinary
assessments, tr
eatments &
programs

Transformative
help for
emotionally
challenged
children ages
7-16

The Center at
CHC

Sand Hill
School

Integrated
Learning

Esther B. Clark
School

Community
Clinic at CHC

Personalized
learning for
students in K5, expanding to
K-8

Nurturing care
for families
served by
Medi-Cal

5


On the Agenda
• Broad observations about ADHD and treatment
• A model for working with a prescribing doctor
• Current approaches to treating ADHD with
medications
• Some common patterns and problems parents
encounter
• Q&A

6


NOT On the Agenda
• Non-medication treatment approaches (9.25.13)
• Children with lots of sensory issues (10.2.13)
• Highly complicated situations where ADHD is only a
small part of the problem
• Solving specific problems about specific children

7


For many with
ADHD, the disorder is
chronic and potentially
life-long


Broad Observations
about ADHD


Good News
• On average, over time, symptoms become less
severe
• A variety of interventions clearly can reduce
symptoms, at least in the short run
• Some features of ADHD can be real strengths in the
right setting and context

10


Bad News
• No existing treatments seem to change the longterm course of ADHD
• Inadequately treated ADHD makes other
developmental goals much harder to attain
• When ADHD occurs with another problem (about
2/3 of the time), outcomes tend to be worse
• All treatments have the potential for side effects

11


General Points on Treating ADHD
•
•
•
•

ADHD is a chronic disorder
Impairment takes many forms
Issues change with time
Both medication and non-medication strategies can
be effective—and both may be needed

12


Possible Points of Intervention
Environmental
• Structural
• Programmatic
Psychological
• Cognitive/Behavioral
• Intrapsychic

Biological
• Medications
• Nutritional changes

13


A Model for Using
Medications to Treat
ADHD


Working with Your Doctor
• Meet regularly, especially early in treatment
• Talk about:
– Likely side effects
– Agreed-upon useful positive targets
– How best dose will be determined
– Monitoring

15


Selecting Medication
• Pick a medication
– 65% of ADHD subjects will do well on first stimulant
– 15%-20% will respond well to a second stimulant
• Choose between short- or long-acting
– Short-acting forms out of favor but allow tailoring
of dose
– Long-acting forms have differing durations and
release patterns
16


It Takes A Village
Determine who should have input on benefits and
adverse effects:
• Parent(s)
• Child
• Teacher(s)
• Others?

17


It Takes A Village (cont.)
• Establish communication between key caregivers, for
example, teacher(s)
– Make a tailored, brief checklist of key symptoms
and behaviors
– Ask teacher regularly to indicate how child is
doing and share feedback, preferably in chart
form, at each visit

18


Best Practices
• Keep records!
– Medication form and dose
– Height and weight
– Any other changes you think might be relevant
• Communicate!
– Concerns over possible side effects
– Fading benefits
– Any other worries that interfere with treatment
19


Best Practices (cont.)
• Do not make changes at key transitions, e.g., just as
school is starting or in the middle of finals
– Older, bigger children may need greater daily
dosages and different types of coverage for
optimal benefit
– NB: puberty is apt to change symptom
presentation and possibly dosage needs (higher or
lower)
20


Medication Options


General Observations
• Extensive evidence supports the conclusion that
specific medications can improve the core symptoms
of ADHD: inattention, distractibility, impulsivity and
hyperactivity
• Available medications have little to no direct effect
on executive functioning and social skills
• For better or worse, medication-induced changes are
not permanent
• Research has yet to suggest that medications (or any
other intervention) change the underlying course of
ADHD
22


Medication Options
• Stimulants
– methylphenidate
– amphetamine
• Non-Stimulants
– atomoxetine (Strattera)
– guanfacine (Tenex, Intuniv)
– clonidine (Kapvay, Catapres patch)
• Others less well-established or less used
23


Stimulants: Advantages
•
•
•
•

Highly effective
Act very quickly
Can be used selectively—given only when needed
A variety of different forms are available to tailor the
action during the day

24


Stimulants: Disadvantages
•
•
•
•

Only cover part of the day
Not especially useful early and late in the day
Prescribing is restricted
Have well-known side effects:
–
–
–
–

Depressed appetite with weight loss
Possible effect on decreased height
Insomnia
Uncover or worsen tics
25


Methylphenidate
Brand Name

Type

Dose Forms (mg)

Estimated
Duration

5, 10, 20

2.5-3 hrs

Generic

IR*

Concerta

ER**

18, 27, 36, 54

10-12 hrs

Focalin
(dexmethylphenidate)

IR*
XR**

2.5, 5, 10
5, 10, 15, 20

3-4 hrs
8-12 hrs

Metadzate

CD**
ER*

10, 20, 30, 40, 50, 60
10, 20

8-10 hrs
6-8 hrs

*tablet **capsule

26


Methylphenidate (cont.)
Brand Name

Type

Dose Forms (mg)

Estimated
Duration

Methylin

IR*
Chewtabs
Solution
ER

5, 10, 20
2.5, 5, 10
5/5ml; 10/5ml
10, 20

2.5-3 hrs
2.5-3 hrs
2.5-3 hrs
6-8 hrs

IR*
LA**

5, 10, 20
10, 20, 30, 40

2.5-3 hrs
8-10 hrs

Ritalin
*tablet **capsule

27


Methylphenidate (cont.)
Brand Name

Type

Datrana

Patch

Methylin

IR*
Chewtabs
IR†
ER

Quillivant XR

ER†

Dose Forms (mg)

Estimated
Duration

10, 20, 30

10+ hrs

5, 10, 20
2.5, 5, 10
5/5ml; 10/5ml
10, 20

2.5-3 hrs
2.5-3 hrs
2.5-3 hrs
6-8 hrs

10, 20, 30, 40, 50, 60 mg

10-12 hrs

*tablet **capsule †solution or suspension

28


Differences in Long-Acting Forms of
Methylphenidate
Brand Name

Form

Release pattern

Duration

Concerta

Insoluble
capsule

28% IR, then
ascending curve

10-12 hrs

Ritalin LA
Focalin XR

Capsule with
beads

50% IR, 50% at 4
hours

6-8 hrs
8-10 hrs

Metadate CD

Capsule with
beads

30% IR, 70% at 4
hours

6-8 hrs

Metadate ER

Wax matrix

Steady release

8-10 hrs

29


Other Stimulants
Dose Forms (mg)

Estimated
Duration

IR**

5, 10

4-6 hrs

Dexedrine
Dexedrine Spansule

IR*
ER**

5
5, 10, 15

4-6 hrs
10-12 hrs

Adderall
Adderall XR

IR*
XR**

5, 7.5, 10, 12.5, 15, 20, 30
10, 20, 30

4-6 hrs
10-12 hrs

ProCentra

IR†

5 mg/5ml

3-4 hrs

20, 30, 40, 50, 60, 70

12-24 hrs

Name/ Brand
amphetamine
Dextrostat

lisdexamfetamine
Vyvanse

Type

Prodrug**

*pills **capsules †solution
30


Non-Stimulants: Advantages
• Can provide 24-hour coverage
• When effective, have benefits quite comparable to
those of stimulants
• Tend to have side effects quite different from
stimulants (e.g., sedating, less effect on appetite)
• Easier to prescribe

31


Non-Stimulants: Disadvantages
• Often take weeks to work
• Do not work for as many individuals (40% vs. 65%)
• Side effects may be unacceptable, especially daytime
tiredness and sedation
• Seem less likely to provide “cognitive boost”

32


Atomoxetine (Strattera)
• Nonstimulant
• Mechanism of action thought to be selective
noradrenergic reuptake inhibition
• Available as 10, 18, 25, 40 & 60 mg capsules
• Dosing is once or twice daily, continuous
• Recommended dose formally up to 1.2 mg/kg/d;
some suggesting up to 1.8

33


Atomoxetine (cont.)
• Some delay in action, with continued accrual of
benefits over weeks to months
• Common side effects: nausea (sometimes vomiting)
and daytime sedation
• Has black-box warning for suicidal ideation;
theoretical risk of inducing mania
• Estimated efficacy is 40-45% of patients
• Compatible with concurrent use of stimulants
34


Guanfacine (Tenex, Intuniv)
• Nonstimulant
• Mechanism of action thought to be pre-synaptic
noradrenergic receptor activation
• Available as 1 or 2 mg tablets for guanfacine (Tenex)
or as 1, 2, 3 or 4 mg tablets for Intuniv
• Dosing is continuous, 1-2 times daily, for guanfacine
or once daily usually in AM for Intuniv
• Usual dose range is 2 to 4 mg per day
• NB: Only Intuniv has FDA endorsement for ADHD
35


Guanfacine (cont.)
• Common side effects are daytime sedation but
sometimes disrupts sleep; may lower blood pressure
• NOT thought to carry risk of inducing mania

36


Clonidine (Kapvay, Catapres patch)
• Nonstimulant
• Mechanism of action thought to be pre-synaptic
noradrenergic receptor activation
• Available as 0.1 mg tablets for Kapvay or as TTS
0.1, 0.2 and 0.3 mg patches that last 5-7 days
• Dosing is continuous, 2x daily for Kapvay, once every
4-7 days for patch
• Usual dose range is 0.2 to 0.4 mg per day
• NB: Only Kapvay has FDA endorsement for ADHD
37


Clonidine (cont.)
• Absorption of Intuniv is only about 60%
• Common side effects are daytime sedation but
sometimes disrupts sleep; may lower blood pressure
• Abrupt discontinuation can lead to potentially
dangerous sudden spike in blood pressure
• NOT thought to carry risk of inducing mania
38


Other Non-Stimulant Antidepressants
Dose Forms (mg)

Doses/
Day

Maximum
Daily Dose

bupropion
(Wellbutrin)
(Wellbutrin SR)
(Wellbutrin XL)

75, 100
100, 150
150, 300

2
2
1

450 mg/d

imipramine (Tofranil)

10, 25, 50

2

3.5 mg/kg/d

nortriptyline (Pamelor)

10, 25, 50, 75

2

3 mg/kg/d

venlafaxine (Effexor)
(Effexor XR)

37.5. 75
37.5, 75, 150

2
1

225-300
mg/d

100, 200

1

? 500 mg

Generic (Brand)

modafinil

(Provigil)

39


What’s in the Offing?
• No major breakthroughs readily obvious
• Improved executive functioning is a highly desirable
target, but no evidence to date of a medication that
is directly helpful
• Some focus on other brain systems—nicotinic,
NMDA—but data equivocal

40


Common Patterns


Diurnal Stress Points
• Early morning issues
– Cannot complete morning routines
– May need 24-hour coverage
• School day issues
– Nearly universal
– Excellent coverage with most medications
• After-school issues
– Increase with older children/adolescents
– May need supplemental treatment
42


Diurnal Stress Points (cont.)
• Evening and bedtime issues
– May or may not be medication related
– Stimulants rarely helpful
– May need to consider non-stimulant alternatives
or additions

43


Comorbid Conditions
• Anxiety
– May get better with ADHD treatment
– If not, consider either broader coverage
(atomoxetine or guanfacine) or addition of second
medication (antidepressant)
• Tic Disorders
– Try medicine that works for both (alpha agonist)
– Try medicine neutral to tics (antidepressant)
– Use stimulant and tic-suppressing medication
44


Comorbid Conditions (cont.)
• Oppositional Defiant Disorder
– May respond to effective ADHD treatment
– No strong studies show good medication response
specific to ODD
• Sleep Problems
– Some (15%) may sleep better with stimulants
– Non-stimulant medications usually sedating

45


Conclusion
• ADHD is a disorder that is chronic but responsive to
treatment
• Optimal treatment requires ongoing, regular contact
with client, family and school
• Complicated cases demand persistent reassessment
and systematic approaches

46


Questions?


Resources: Books
• Maybe you know my kid: A parents guide to identifying,
understanding, and helping your child with ADHD (2nd ed.).
• Maybe you know my teen: A parents guide to adolescents with
ADHD. Fowler, Mary Cahill (2001).
• Medicating Young Minds: How to Know if Psychiatric Drugs will
Help or Hurt Your Child. Elliott, G. R., and Kelley, K. (2006)
• Taking Charge of ADHD: The complete authoritative guide for
parents. Barkley, R. A. (2005).
• The CHADD Information and Resource Guide to AD/HD. CHADD
(2001).
• Straight Talk About Psychiatric Medications for Kids. Wilens, T. E.
(2008)
48


Resources: Websites
•
•
•
•
•
•
•
•
•
•
•
•
•

CHADD Organization: chadd.org
ADD Organization: add.org
Charles Schwab Foundation (for LD): SchwabLearning.org
Council for Exceptional Education (CEC): cec.sped.org
American Academy of Child & Adolescent Psychiatry: aacap.org
American Academy of Pediatrics: aap.org
Learning Disabilities Association of America (LDA): ldanatl.org
National Institute of Mental Health: help4adhd.org
National Information Center for Children and Youth with Disabilities:
nichcy.org
ADD Warehouse: addwarehouse.com
GSI Publications: gsi.com
Guilford Publications: guilford.com
Dr. Barkley: russellbarkley.org
49


Thank You for Coming
650.688.3625
care@chconline.org

50

To Medicate or Not

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Viewers also liked

Viewers also liked (20)

Similar to To Medicate or Not

Similar to To Medicate or Not (20)

Recently uploaded

Recently uploaded (20)

To Medicate or Not