Initial decision making with Stimulants in adolescents and youth
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Josh Stein, MD
As a practitioner in a partial hospital and inpatient setting the most common reason for adverse reaction to stimulants is incorrect diagnosis. In these support rich settings the ability to gain psychological testing helps to clarify the differential for hyperactivity and/or inattention. Often, learning disabilities (i.e. reading disorder, math disorder, auditory processing disorder), anxiety or sensory concerns were missed. This is a common dilemma and a point of profound difficulty for the outpatient prescriber who doesn't have the assistance of formal testing in clinic. Despite these limitations, remembering that impairment must occur in two settings (most commonly home and school) to meet diagnostic criteria, is a helpful tool. Commonly, the absence of symptoms at home or school helps to clarify a need to deepen the differential. Additionally keep in mind that obstructive sleep apnea commonly can masquerade as ADHD. Questions about sleep are necessary as part of the initial workup.
Once the diagnosis of ADHD is made stimulants remain the most effective treatment for ADHD in children. Stimulant use remains the primary step in treatment, and non stimulants are deferred in common cases until both classes of stimulants are failed. The vast majority of children will respond to either the methylphenidate class or amphetamine class. It is appropriate to build comfort with one or two medications in each class to support treatment. As a provider it is appropriate to choose either class first. If the initial class is failed then switching to the other class is warranted prior to a non-stimulant trial.
Commonly, a provider will start with a short acting stimulant such as Ritalin SA or Adderrall to test tolerance. Once tolerated, a long acting stimulant is preferred to avoid need for additional dosing. If trials in one class (i.e. methylphenidate) are not tolerated it is appropriate to switch to the alternate class (i.e amphetamine). There is significant individual details in finding dose and toleration. Stimulants have weight based indications but overall appear to be more individual based. It is appropriate to move to higher doses if tolerated to achieve symptomatic relief. Regular input from school is often needed as well.
Keep in mind cost and delivery methods when choosing medications. For example, Concerta (a long acting methylphenidate stimulant) is a pill that must be swallowed, while its analog Quillichew/Quillivent can be chewed or drank in liquid form. In small children delivery is often a concern.
Vyvanse, a long acting amphetamine based stimulant, has the option of opening the tab and dissolving in liquid. Additionally it is a pro-drug, requiring digestion to promote action, decreasing the risk of diversion. For these reasons many providers prefer it to Adderall XR when it is affordable.
Some youth will require a second dose of a stimulant despite being on a long acting formulation. Short acting doses of Ritalin, Focalin, Metadate, Dexedrine or Adderall should be considered. This is where the regular check-ins become important. There is an art to prescribing these meds which includes determining how to cover a child for the duration needed with medication, while decreasing side effect risk. Over time, dosing needs and patterns will change. Clinic visits three times per year at the least are needed.
Stimulant breaks are appropriate and often needed due to appetite suppression. At times, this can be on weekends, school breaks or summer break. For the hyperactive child this may not be a tolerable option for the family. Appetite suppression is often an issue for younger children as eating is related to hunger, while in teenagers it has gained social value similar to adults. If suppression is severe with a long acting stimulant consider returning to a short acting dosed after breakfast and lunch to support appetite.
There are numerous other considerations with stimulant use. Further blogs will provide additional information. I hope you find this initial dosing guide beneficial.
