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Choosing Medications for ADHD
Anne Buchanan, DO
Child psychiatrist at Maimonides Medical Center in Brooklyn, NY
Dr. Buchanan has disclosed that she has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
CCPR: Can you tell us about your current practice?
Dr. Buchanan: I am responsible for pediatric ER and floor consults, I supervise the school crisis walk-in clinic, and I am responsible for high-risk intakes in the clinic.
CCPR: We hear a lot about overdiagnosis of ADHD. What are your thoughts?
Dr. Buchanan: We all hear that the problem is that every child with bad behavior is given a stimulant. In actuality, the saddest cases are the children who have not been identified despite chronic academic underperformance and behavioral problems. By the time they get to middle school, they have anxiety and depression. They come to clinic for, say, suicidal ideation, and as we peel back the history, we find untreated ADHD. So, while overdiagnosis and overmedication is a huge problem, so is underdiagnosis. If children come in before they end up repeating first grade for the third time, then maybe we can change their paths. But there is, I think, a pretty significant minority of children who may not have as much of the disruptive behavior, and they kind of get just moved along—and in those cases, we really end up with a lot more problems down the line.
CCPR: So how do you do assessments?
Dr. Buchanan: We get history from the parent, from the child, and from the school. We have parents and teachers fill out rating scales, with another teacher form about the student’s strengths and weaknesses. Academic records, IEPs, special education plans, and previous testing are really helpful. If we have concerns about learning issues or developmental problems, we then refer for additional assessment.
CCPR: How do you sort out learning disabilities and ADHD?
Dr. Buchanan: Teachers may describe ADHD symptoms in certain settings, such as during testing or during certain subjects, or parents might not see symptoms at home. A child might also tell me that concentration is not the problem, but rather that the material is simply “too hard.” If I am suspicious of other psychiatric issues, we can do psychological testing. However, ADHD is often apparent with a proper history, collateral information, and observation of the child in the office.
CCPR: We hear from some pediatricians that they don’t think the kids they are referring to us actually have ADHD. Is this a common problem at that level of care?
Dr. Buchanan: Yes, and it is also something we sometimes see in our clinic. ADHD is a catchphrase that teachers and guidance counselors know, and they will often use it as a label as part of a referral. But larger issues are often evident during the initial consultation, things that the school may not know about. Many children we see have ADHD, but many do not.
CCPR: Does your evaluation change depending whether it’s a younger or older patient?
Dr. Buchanan: I find that younger children are often not as reliable as older kids in terms of self-reporting symptoms; however, we are still gathering the same records and the same information from parents and schools no matter the child’s age.
CCPR: We’ve also read that poor sleep can play a role with kids. Can you tell us more about that?
Dr. Buchanan: Lack of sleep/poor sleep hygiene is a huge factor in worsening existing ADHD symptoms and making any kid more inattentive during the day. Although getting kids to sleep is by no means a new issue, the overall increase in screen time over the years certainly has contributed to this, and we always ask and counsel about sleep.
CCPR: Moving on to treatment, what is your approach to choosing medications?
Dr. Buchanan: Most child psychiatrists, including myself, consider stimulants first-line. I view alpha-agonists as second-line, or sometimes I use them as augmenters to a stimulant, such as when we see only a partial response from a stimulant or when we are limited in dosing due to side effects. Agents such as Strattera (atomoxetine) and Wellbutrin (bupropion) are generally third-line. I deviate from that depending on contraindications or comorbidities, but most kids do well on stimulants. Ultimately, the recommendations that we land on depend on individual tolerability.
CCPR: Which medications do you tend to start with?
Dr. Buchanan: Keeping in mind that insurance formularies often dictate medication choices, especially when initiating treatment, it’s rare that I use newer formulations. I tend to start with a methylphenidate product, and I try a second one before going to an amphetamine product, because amphetamines can often be more potent, with more appetite suppression, irritability, and withdrawal symptoms. I generally start with any of the long-acting methylphenidate products—this would include medications such as Concerta, Metadate CD, Ritalin LA, and Focalin XR. For younger kids, I may consider starting with a short-acting, such as generic Ritalin (methylphenidate), as younger children may experience more side effects with stimulant medications and may not need as much coverage due to having fewer academic demands. The newer liquid, chewable, and dissolvable meds seem great for kids who struggle to swallow pills. However, insurance often doesn’t cover them initially. With some generics and Adderall XR, Metadate CD, Focalin XR, and Ritalin LA, it works well to snip the capsule and pour the beads into a spoonful of something with decent consistency—not a liquid—to ensure the child gets all the beads. Parents can use yogurt, oatmeal, or peanut butter, for example.
CCPR: What dose do you tend to shoot for?
Dr. Buchanan: I always start with the lowest dose, as some kids will respond to it. I will go up to and over the maximum recommended dose if needed, as long as we see improvement and as long as there are no side effects. For Metadate, the first dose is 10 mg, and if by 30 mg we have side effects and no improvement, I would switch to something else. Otherwise, I go to a maximum of 60 mg. For Concerta, I start at 18 mg. I’ve gone up to the max of 72 mg and even higher in certain patients, as long as the medicine is tolerated and the symptoms are improving.
CCPR: Are you typically going up by a pill a week?
Dr. Buchanan: In an ideal setting, I would raise the dose each week. In busier clinics, seeing kids that often is difficult, so frequently the dose gets raised every other week.
CCPR: So you won’t just tell parents to figure it out and come back in a month?
Dr. Buchanan: No, we don’t do that. Families need education. For us, it’s often a slow ramp up to get a parent to agree to medication. Private practice may be a different story because parents may come in already understanding the diagnosis, and if so, they might be more reliable in increasing the dose on their own and coming back in several weeks.
CCPR: What side effects do you see?
Dr. Buchanan: Mostly appetite suppression. We try to make sure kids eat their breakfast before taking medicine; we also educate the parents that children may not be hungry at lunch, so packing snacks for school is recommended if they get hungry later. We find that a lot of kids eat their traditional lunch after school and then are hungry again for dinner. As long as they get enough calories in 24 hours, I don’t worry about timing. I recommend parents be flexible so that children are eating what they need to gain weight and grow. Another option is to lower the stimulant dose until appetite improves, and augment with an alpha-agonist to target residual ADHD symptoms. [EIC Note: When clinically appropriate, I use Periactin 4–12 mg or Remeron 7.5–30 mg, both dosed at night, to help with appetite and sleep. —JDF].
CCPR: What are your thoughts about the Daytrana patch?
Dr. Buchanan: Many kids have skin reactions with the patch, but it is as efficacious as other stimulants. The nice thing is that you can peel the patch and control when the effect is gone, depending on the child’s schedule that day.
CCPR: When do you switch to an amphetamine?
Dr. Buchanan: If after two methylphenidates we are not seeing symptom control, I try an amphetamine. Some kids respond better to them. One reason to go with an amphetamine product from the beginning of treatment might be because a sibling is doing well on one.
CCPR: Out of, say, 100 patients in your practice, what percentage are on methylphenidates vs. amphetamines?
Dr. Buchanan: I would guess the ratio is 70%/30%.
CCPR: Is Vyvanse better in some way?
Dr. Buchanan: Both work well, but for some kids Vyvanse is better tolerated. But all amphetamines suppress appetite and have withdrawal irritability.
CCPR: Do you prescribe much Adderall?
Dr. Buchanan: We prescribe Adderall XR, but we avoid short-acting Adderall because it may have higher diversion and abuse potential. I see red flags whenever there are prescriptions lost or when there are requests for refills sooner than necessary. In New York, we are required to electronically prescribe everything, and we check the state monitoring program before prescribing any controlled substance, so this has cut down on funny business. As more states do this, diversion will be less of a problem. We can have parents or patients sign a contract that if they need to fill a script early, we will do so one time, but then after that we won’t prescribe anymore.
CCPR: Tell me about alpha-agonists.
Dr. Buchanan: Guanfacine comes in short-acting Tenex and long-acting Intuniv. Clonidine is more sedating and has a long-acting formulation, Kapvay, as well as a long-acting Catapres patch. Alpha-agonists have the FDA indications to treat core symptoms of ADHD. They are not quite as good as stimulants for inattention and concentration, but they help hyperactivity and disruptive behaviors. ADHD kids often have issues with sleep from the ADHD and from stimulants, and alpha-agonists can help them settle down for bed.
CCPR: Do alpha agonists cause sedation the next day?
Dr. Buchanan: Clonidine is more sedating, so I will have parents split the lowest dose of Tenex (1 mg) into 0.5 mg for a bedtime dose, and if the kid is not sedated in the morning we will go with BID dosing, which seems to work well for many.
CCPR: When would you use an alpha-agonist as monotherapy?
Dr. Buchanan: Kids with cardiac histories may have a murmur or arrhythmia, and in those cases we are hesitant to use a stimulant. Or if a stimulant causes side effects like palpitations or high blood pressure or irritability, we might switch to an alpha-agonist.
CCPR: What do you tell families who ask about risk of sudden death with stimulants?
Dr. Buchanan: If the child does not have a personal history of any cardiac issues and there is no family history of sudden cardiac death, we reassure families that the risk of sudden death is low. We check blood pressure when starting or increasing a dose, and we wouldn’t continue a child on something that made the parents feel uncomfortable, even if the vitals are OK. We don’t send every kid for EKGs or cardiac clearance, but if there is something in the history that makes us concerned, then we will do that first.
CCPR: What about Provigil or Nuvigil?
Dr. Buchanan: I don’t have experience with Provigil and Nuvigil, as they are generally not covered by managed Medicaid. I use Strattera or Wellbutrin. They are not as efficacious as the stimulants, but for kids who can’t be on stimulants, they may help.
CCPR: What about psychotherapy or non-medication treatments?
Dr. Buchanan: We have group therapy for every child for difficult behaviors, impulse control, and frustration tolerance. If a child is unmanageable in group, we have the child undergo individual therapy. We have groups for parenting and psychoeducation. Our psychiatrists collaborate closely with the group and individual therapists. A few kids are stable on medication only.
CCPR: How does therapy add to care?
Dr. Buchanan: The psychotherapeutic modalities won’t fix the core symptoms of ADHD: focus, distractibility, and inattention. But kids with mild symptoms can learn cognitive strategies that mitigate their symptoms, helping with frustration tolerance, coping, resilience, and social skills. More importantly, kids with ADHD are often difficult to parent, and effective parenting can help so the child doesn’t feel constantly punished, as punishment can lead to more acting out. The psychoeducation that the parents get is invaluable. The MTA study demonstrated that the combined treatment tends to be as good or better than medication alone, whereas psychosocial treatments alone tend to be not as good (Arch Gen Psychiatry 1999;56(12):1073–1086). We push for combined treatment for the best outcome.
CCPR: Thank you for your time, Dr. Buchanan.
Child PsychiatryDr. Buchanan: I am responsible for pediatric ER and floor consults, I supervise the school crisis walk-in clinic, and I am responsible for high-risk intakes in the clinic.
CCPR: We hear a lot about overdiagnosis of ADHD. What are your thoughts?
Dr. Buchanan: We all hear that the problem is that every child with bad behavior is given a stimulant. In actuality, the saddest cases are the children who have not been identified despite chronic academic underperformance and behavioral problems. By the time they get to middle school, they have anxiety and depression. They come to clinic for, say, suicidal ideation, and as we peel back the history, we find untreated ADHD. So, while overdiagnosis and overmedication is a huge problem, so is underdiagnosis. If children come in before they end up repeating first grade for the third time, then maybe we can change their paths. But there is, I think, a pretty significant minority of children who may not have as much of the disruptive behavior, and they kind of get just moved along—and in those cases, we really end up with a lot more problems down the line.
CCPR: So how do you do assessments?
Dr. Buchanan: We get history from the parent, from the child, and from the school. We have parents and teachers fill out rating scales, with another teacher form about the student’s strengths and weaknesses. Academic records, IEPs, special education plans, and previous testing are really helpful. If we have concerns about learning issues or developmental problems, we then refer for additional assessment.
CCPR: How do you sort out learning disabilities and ADHD?
Dr. Buchanan: Teachers may describe ADHD symptoms in certain settings, such as during testing or during certain subjects, or parents might not see symptoms at home. A child might also tell me that concentration is not the problem, but rather that the material is simply “too hard.” If I am suspicious of other psychiatric issues, we can do psychological testing. However, ADHD is often apparent with a proper history, collateral information, and observation of the child in the office.
CCPR: We hear from some pediatricians that they don’t think the kids they are referring to us actually have ADHD. Is this a common problem at that level of care?
Dr. Buchanan: Yes, and it is also something we sometimes see in our clinic. ADHD is a catchphrase that teachers and guidance counselors know, and they will often use it as a label as part of a referral. But larger issues are often evident during the initial consultation, things that the school may not know about. Many children we see have ADHD, but many do not.
CCPR: Does your evaluation change depending whether it’s a younger or older patient?
Dr. Buchanan: I find that younger children are often not as reliable as older kids in terms of self-reporting symptoms; however, we are still gathering the same records and the same information from parents and schools no matter the child’s age.
CCPR: We’ve also read that poor sleep can play a role with kids. Can you tell us more about that?
Dr. Buchanan: Lack of sleep/poor sleep hygiene is a huge factor in worsening existing ADHD symptoms and making any kid more inattentive during the day. Although getting kids to sleep is by no means a new issue, the overall increase in screen time over the years certainly has contributed to this, and we always ask and counsel about sleep.
CCPR: Moving on to treatment, what is your approach to choosing medications?
Dr. Buchanan: Most child psychiatrists, including myself, consider stimulants first-line. I view alpha-agonists as second-line, or sometimes I use them as augmenters to a stimulant, such as when we see only a partial response from a stimulant or when we are limited in dosing due to side effects. Agents such as Strattera (atomoxetine) and Wellbutrin (bupropion) are generally third-line. I deviate from that depending on contraindications or comorbidities, but most kids do well on stimulants. Ultimately, the recommendations that we land on depend on individual tolerability.
CCPR: Which medications do you tend to start with?
Dr. Buchanan: Keeping in mind that insurance formularies often dictate medication choices, especially when initiating treatment, it’s rare that I use newer formulations. I tend to start with a methylphenidate product, and I try a second one before going to an amphetamine product, because amphetamines can often be more potent, with more appetite suppression, irritability, and withdrawal symptoms. I generally start with any of the long-acting methylphenidate products—this would include medications such as Concerta, Metadate CD, Ritalin LA, and Focalin XR. For younger kids, I may consider starting with a short-acting, such as generic Ritalin (methylphenidate), as younger children may experience more side effects with stimulant medications and may not need as much coverage due to having fewer academic demands. The newer liquid, chewable, and dissolvable meds seem great for kids who struggle to swallow pills. However, insurance often doesn’t cover them initially. With some generics and Adderall XR, Metadate CD, Focalin XR, and Ritalin LA, it works well to snip the capsule and pour the beads into a spoonful of something with decent consistency—not a liquid—to ensure the child gets all the beads. Parents can use yogurt, oatmeal, or peanut butter, for example.
CCPR: What dose do you tend to shoot for?
Dr. Buchanan: I always start with the lowest dose, as some kids will respond to it. I will go up to and over the maximum recommended dose if needed, as long as we see improvement and as long as there are no side effects. For Metadate, the first dose is 10 mg, and if by 30 mg we have side effects and no improvement, I would switch to something else. Otherwise, I go to a maximum of 60 mg. For Concerta, I start at 18 mg. I’ve gone up to the max of 72 mg and even higher in certain patients, as long as the medicine is tolerated and the symptoms are improving.
CCPR: Are you typically going up by a pill a week?
Dr. Buchanan: In an ideal setting, I would raise the dose each week. In busier clinics, seeing kids that often is difficult, so frequently the dose gets raised every other week.
CCPR: So you won’t just tell parents to figure it out and come back in a month?
Dr. Buchanan: No, we don’t do that. Families need education. For us, it’s often a slow ramp up to get a parent to agree to medication. Private practice may be a different story because parents may come in already understanding the diagnosis, and if so, they might be more reliable in increasing the dose on their own and coming back in several weeks.
CCPR: What side effects do you see?
Dr. Buchanan: Mostly appetite suppression. We try to make sure kids eat their breakfast before taking medicine; we also educate the parents that children may not be hungry at lunch, so packing snacks for school is recommended if they get hungry later. We find that a lot of kids eat their traditional lunch after school and then are hungry again for dinner. As long as they get enough calories in 24 hours, I don’t worry about timing. I recommend parents be flexible so that children are eating what they need to gain weight and grow. Another option is to lower the stimulant dose until appetite improves, and augment with an alpha-agonist to target residual ADHD symptoms. [EIC Note: When clinically appropriate, I use Periactin 4–12 mg or Remeron 7.5–30 mg, both dosed at night, to help with appetite and sleep. —JDF].
CCPR: What are your thoughts about the Daytrana patch?
Dr. Buchanan: Many kids have skin reactions with the patch, but it is as efficacious as other stimulants. The nice thing is that you can peel the patch and control when the effect is gone, depending on the child’s schedule that day.
CCPR: When do you switch to an amphetamine?
Dr. Buchanan: If after two methylphenidates we are not seeing symptom control, I try an amphetamine. Some kids respond better to them. One reason to go with an amphetamine product from the beginning of treatment might be because a sibling is doing well on one.
CCPR: Out of, say, 100 patients in your practice, what percentage are on methylphenidates vs. amphetamines?
Dr. Buchanan: I would guess the ratio is 70%/30%.
CCPR: Is Vyvanse better in some way?
Dr. Buchanan: Both work well, but for some kids Vyvanse is better tolerated. But all amphetamines suppress appetite and have withdrawal irritability.
CCPR: Do you prescribe much Adderall?
Dr. Buchanan: We prescribe Adderall XR, but we avoid short-acting Adderall because it may have higher diversion and abuse potential. I see red flags whenever there are prescriptions lost or when there are requests for refills sooner than necessary. In New York, we are required to electronically prescribe everything, and we check the state monitoring program before prescribing any controlled substance, so this has cut down on funny business. As more states do this, diversion will be less of a problem. We can have parents or patients sign a contract that if they need to fill a script early, we will do so one time, but then after that we won’t prescribe anymore.
CCPR: Tell me about alpha-agonists.
Dr. Buchanan: Guanfacine comes in short-acting Tenex and long-acting Intuniv. Clonidine is more sedating and has a long-acting formulation, Kapvay, as well as a long-acting Catapres patch. Alpha-agonists have the FDA indications to treat core symptoms of ADHD. They are not quite as good as stimulants for inattention and concentration, but they help hyperactivity and disruptive behaviors. ADHD kids often have issues with sleep from the ADHD and from stimulants, and alpha-agonists can help them settle down for bed.
CCPR: Do alpha agonists cause sedation the next day?
Dr. Buchanan: Clonidine is more sedating, so I will have parents split the lowest dose of Tenex (1 mg) into 0.5 mg for a bedtime dose, and if the kid is not sedated in the morning we will go with BID dosing, which seems to work well for many.
CCPR: When would you use an alpha-agonist as monotherapy?
Dr. Buchanan: Kids with cardiac histories may have a murmur or arrhythmia, and in those cases we are hesitant to use a stimulant. Or if a stimulant causes side effects like palpitations or high blood pressure or irritability, we might switch to an alpha-agonist.
CCPR: What do you tell families who ask about risk of sudden death with stimulants?
Dr. Buchanan: If the child does not have a personal history of any cardiac issues and there is no family history of sudden cardiac death, we reassure families that the risk of sudden death is low. We check blood pressure when starting or increasing a dose, and we wouldn’t continue a child on something that made the parents feel uncomfortable, even if the vitals are OK. We don’t send every kid for EKGs or cardiac clearance, but if there is something in the history that makes us concerned, then we will do that first.
CCPR: What about Provigil or Nuvigil?
Dr. Buchanan: I don’t have experience with Provigil and Nuvigil, as they are generally not covered by managed Medicaid. I use Strattera or Wellbutrin. They are not as efficacious as the stimulants, but for kids who can’t be on stimulants, they may help.
CCPR: What about psychotherapy or non-medication treatments?
Dr. Buchanan: We have group therapy for every child for difficult behaviors, impulse control, and frustration tolerance. If a child is unmanageable in group, we have the child undergo individual therapy. We have groups for parenting and psychoeducation. Our psychiatrists collaborate closely with the group and individual therapists. A few kids are stable on medication only.
CCPR: How does therapy add to care?
Dr. Buchanan: The psychotherapeutic modalities won’t fix the core symptoms of ADHD: focus, distractibility, and inattention. But kids with mild symptoms can learn cognitive strategies that mitigate their symptoms, helping with frustration tolerance, coping, resilience, and social skills. More importantly, kids with ADHD are often difficult to parent, and effective parenting can help so the child doesn’t feel constantly punished, as punishment can lead to more acting out. The psychoeducation that the parents get is invaluable. The MTA study demonstrated that the combined treatment tends to be as good or better than medication alone, whereas psychosocial treatments alone tend to be not as good (Arch Gen Psychiatry 1999;56(12):1073–1086). We push for combined treatment for the best outcome.
CCPR: Thank you for your time, Dr. Buchanan.
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