to medicate or not

Children’s Health Council

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Glen R. Elliott, PhD, MD Chief Psychiatrist & Medical Director

To Medicate or Not


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.


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Our Framework for Learning & Life Success

Happy, resilient and

thriving children

Social Emotional Learning

Academic Success

Executive Functioning

Physical Development


The Center at CHC

Sand Hill School

Esther B. Clark School

Community Clinic at CHC

Integrated Learning

Expert interdisciplinary assessments, tr

eatments & programs

Personalized learning for students in K-5, expanding to K-8

Transformative help for

emotionally challenged

children ages 7-16

Nurturing care for families served by Medi-Cal

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Empowering Success through Four Divisions


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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


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• 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

NOT On the Agenda


For many with ADHD, the disorder is

chronic and potentially life-long


Broad Observations about ADHD


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• 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

Good News


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• No existing treatments seem to change the long-term 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

Bad News


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• 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

General Points on Treating ADHD


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Environmental

• Structural

• Programmatic

Psychological

• Cognitive/Behavioral

• Intrapsychic

Possible Points of Intervention

Biological

• Medications

• Nutritional changes


A Model for Using Medications to Treat

ADHD


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• Meet regularly, especially early in treatment

• Talk about:

– Likely side effects

– Agreed-upon useful positive targets

– How best dose will be determined

– Monitoring

Working with Your Doctor


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• 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

Selecting Medication


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Determine who should have input on benefits and adverse effects:

• Parent(s)

• Child

• Teacher(s)

• Others?

It Takes A Village


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• 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

It Takes A Village (cont.)


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• 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

Best Practices


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• 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)

Best Practices (cont.)


Medication Options


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• 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

General Observations


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• Stimulants

– methylphenidate

– amphetamine

• Non-Stimulants

– atomoxetine (Strattera)

– guanfacine (Tenex, Intuniv)

– clonidine (Kapvay, Catapres patch)

• Others less well-established or less used

Medication Options


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• 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

Stimulants: Advantages


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• 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

Stimulants: Disadvantages


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Methylphenidate

Brand Name Type Dose Forms (mg)Estimated Duration

Generic IR* 5, 10, 20 2.5-3 hrs

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

MetadzateCD**ER*

10, 20, 30, 40, 50, 60

10, 20

8-10 hrs

6-8 hrs

*tablet **capsule


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Methylphenidate (cont.)


Methylin

IR*

Chewtabs

SolutionER

5, 10, 20

2.5, 5, 10

5/5ml; 10/5ml10, 20

2.5-3 hrs

2.5-3 hrs

2.5-3 hrs6-8 hrs

RitalinIR*LA**

5, 10, 2010, 20, 30, 40

2.5-3 hrs 8-10 hrs

*tablet **capsule


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Methylphenidate (cont.)


Datrana Patch 10, 20, 30 10+ hrs

Methylin

IR*

Chewtabs

IR†

ER

5, 10, 20

2.5, 5, 10

5/5ml; 10/5ml10, 20

2.5-3 hrs

2.5-3 hrs

2.5-3 hrs6-8 hrs

Quillivant XR ER† 10, 20, 30, 40, 50, 60 mg 10-12 hrs

*tablet **capsule †solution or suspension


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Brand Name Form Release pattern Duration

ConcertaInsoluble 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 CDCapsule with

beads30% IR, 70% at 4

hours6-8 hrs

Metadate ER Wax matrix Steady release 8-10 hrs

Differences in Long-Acting Forms of Methylphenidate


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Other Stimulants

Name/ Brand Type Dose Forms (mg)EstimatedDuration

amphetamineDextrostat IR** 5, 10 4-6 hrs

DexedrineDexedrine Spansule

IR*ER**

55, 10, 15

4-6 hrs10-12 hrs

AdderallAdderall XR

IR*XR**

5, 7.5, 10, 12.5, 15, 20, 3010, 20, 30

4-6 hrs10-12 hrs

ProCentra IR† 5 mg/5ml 3-4 hrs

lisdexamfetamine

Vyvanse

Pro-drug**

20, 30, 40, 50, 60, 70 12-24 hrs

*pills **capsules †solution


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• 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

Non-Stimulants: Advantages


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• 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”

Non-Stimulants: Disadvantages


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• 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

Atomoxetine (Strattera)


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• 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

Atomoxetine (cont.)


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• 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 guanfacineor 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

Guanfacine (Tenex, Intuniv)


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• Common side effects are daytime sedation but sometimes disrupts sleep; may lower blood pressure

• NOT thought to carry risk of inducing mania

Guanfacine (cont.)


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• 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

Clonidine (Kapvay, Catapres patch)


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• 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

Clonidine (cont.)


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Other Non-Stimulant Antidepressants

Generic (Brand) Dose Forms (mg)Doses/

DayMaximum Daily Dose

bupropion

(Wellbutrin)

(Wellbutrin SR)

(Wellbutrin XL)

75, 100100, 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

modafinil (Provigil) 100, 200 1 ? 500 mg


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• 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

What’s in the Offing?


Common Patterns


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• 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

Diurnal Stress Points


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• Evening and bedtime issues

– May or may not be medication related

– Stimulants rarely helpful

– May need to consider non-stimulant alternatives or additions

Diurnal Stress Points (cont.)


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• 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

Comorbid Conditions


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• 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

Comorbid Conditions (cont.)


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• 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

Conclusion


Questions?


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• 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)

Resources: Books


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• 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

Resources: Websites

http://chadd.org/

http://add.org/

http://schwablearning.org/

http://cec.sped.org/

http://aacap.org/

http://aap.org/

http://ldanatl.org/

http://help4adhd.org/

http://nichcy.org/

http://addwarehouse.com/

http://gsi.com/

http://guilford.com/

http://russellbarkley.org/


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650.688.3625

[email protected]

Thank You for Coming

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