Adults with ADHD may need to modify their school or work settings to function well. College students should be encouraged to use their school’s study center, and may require accommodations for taking examinations.
Focused cognitive behavioral therapies have shown benefit in children, adolescents, and adults with ADHD.14 Training children and their parents in behavioral modification can help control the child’s disruptive behaviors, inflexibility, anxiety, or outbursts. Other useful adjuncts to treatment include remediation to improve interpersonal skills and coaching to address organization and study skills.
Pharmacotherapy
Medications are fundamental in treating ADHD1 (Table 2). In fact, a 14-month, multisite study demonstrated that medication management of ADHD was the most important variable in outcome when patients received combined pharmacologic and nonpharmacologic therapies.15 Stimulants, antihypertensives, and antidepressants are used to treat ADHD symptoms. Children, adolescents, and adults with ADHD respond similarly to pharmacotherapy.16
Psychostimulants: First-line agents
Psychostimulants are first-line agents for ADHD, based in part on extensive data showing efficacy (>250 controlled trials) and safety.17,18 Stimulants are sympathomimetic drugs that increase intrasynaptic catecholamines (mainly dopamine) by inhibiting the presynaptic reuptake mechanism (amphetamine, methylphenidate, and pemoline) and releasing presynaptic catecholamines (amphetamine).19 Methylphenidate, dextroamphetamine, amphetamine compounds, and magnesium pemoline are among the most commonly used compounds in this class.
New approaches Prescribing stimulants for ADHD has changed in two fundamental ways. Frist, in the past we covered a child’s ADHD symptoms only during school hours, but we now include time after school and weekends and holidays. Second, we also are using longer-acting stimulant preparations, which recently became available. Extended-release preparations are usually preferred for lack of in-school dosing requirements, improved compliance, reduced stigma and wear-off, and lower risk of abuse or diversion—i.e., the medication being given or sold by an individual with ADHD to someone who is using it recreationally.
Short-acting compounds such as methylphenidate, D-methylphenidate, and D-amphetamine begin working within 30 to 60 minutes. Their clinical effect usually peaks 1 and 2 hours after administration and lasts 2 to 5 hours. The amphetamine compounds (e.g., Adderall) and older sustained-release methylphenidate begin working within 60 minutes, with a clinical effect that usually peaks between 1 and 3 hours and is maintained for 5 to 8 hours).
Table 2
RECOMMENDED DOSING OF PSYCHOSTIMULANTS FOR ADHD
| Medication | Starting dosage | Maximum dosage | Usual dosing (hr) |
|---|---|---|---|
| Methylphenidate (short-acting) | |||
| Ritalin | 5 mg bid | 2 mg/kg/day | tid (4 hr) |
| Dexmethylphenidate (short-acting) | |||
| Focalin | 2.5 mg bid | 1 mg/kg/day | bid (5 hr) |
| Methylphenidate (extended-release) | |||
| Concerta | 18 mg once daily | 2 mg/kg/day | Once (12 hr) |
| Metadate CD | 20 mg once daily | Once (8-9 hr) | |
| Ritalin LA | 10 mg once daily | Once (8-9 hr) | |
| Amphetamine compounds | |||
| Adderall | 2.5 to 5 mg once daily | 1.5 mg/kg/day | bid (6 hr) |
| Adderall XR | 10 mg | Once (12 hr) | |
| Dextroamphetamine | |||
| Dexedrine | 2.5 to 5 mg once daily | 1.5 mg/kg/day | bid/tid (4 hr) |
| Dex Spansule | 5 mg | bid (6 hr) | |
| Magnesium pemoline | |||
| Cylert | 37.5 mg once in the morning | 3 mg/kg/day | Once |
Newer extended-release methylphenidate products (e.g., Ritalin LA and Metadate CD), with 8 to 9 hours’ duration of action, were developed to approximate twice-daily short-acting methylphenidate. The Concerta brand of methylphenidate, with 10 to 12 hours’ duration of action, approximates short-acting methylphenidate given three times daily. The extended-release Adderall XR brand of amphetamine compound, with a 10- to 12-hour duration of action, is similar to twice-daily Adderall.
Methylphenidate is the most studied, but among the available stimulants the literature suggests more similarities than differences in patient response.17,18 Because of the agents’ marginally different mechanisms of action, however, some patients who do not respond satisfactorily to one stimulant or manifest adverse effects may respond more favorably to another agent of this type.
Start stimulants at the lowest available dose and increase every 3 to 4 days until a response is noted or adverse effects emerge. Dose-response data indicate more robust response at higher dosages of stimulants; therefore, efficacy—rather than onset of side effects—should guide titration to an optimal dose.
Predictable short-term adverse effects include reduced appetite, insomnia, edginess, and GI upset.20 To manage these effects, consider when they occur:
- Within 2 hours after administration may signal the need to reduce the dose or change to another preparation.
- Within 4 to 6 hours after administration (e.g., moodiness) suggests the need for a longer-acting preparation or low dosing prior to the anticipated wear-off.
For insomnia, strategies include using a shorter-acting stimulant preparation, reducing the stimulant load in the afternoon, or providing adjunct treatment for the insomnia (i.e., clonidine, imipramine, mirtazapine).17 Edginess and headaches—more common in adolescents and adults—can be reduced with low-dose beta blockers. For diminished appetite in youths, caloric intake can be enhanced with a hearty breakfast, late-afternoon and evening snacks, and caloric supplements. Appetite enhancers such as cyproheptadine given nightly may be considered. Pemoline may rarely cause hepatitis and requires liver function monitoring.