Components of a
Comprehensive ADHD
Treatment Plan
Jennifer A. Ganem MS, APRN
Londonderry Square
50 Nashua Road, Suite 208
Londonderry, NH 03053-3221
(603) 432-3399
Jennifer A. Ganem MS, APRN
Educational/
Workplace
Accommodations
Community
Support
Coaching
ADHD
Behavioral
Intervention
Medication
Jennifer A. Ganem MS, APRN
Community Support
• CHADD Support Groups
• Local
• Regional
• National
• Virtual
• Parent Support Groups
• Hospitals/ Behavioral Health Center
• Parent/ School Collaborative Groups
Jennifer A. Ganem MS, APRN
Educational / Workplace Accommodations
• Individuals with Disabilities Education Act (IDEA)
• Section 504 of the Rehabilitation Act of 1973
• A child's disability must "substantially limit" the child’s ability to learn requiring
the need for specialized services or accommodations
• All determinations of “substantial limitation” must be made without regard to the
"ameliorative effects of mitigating measures“
• This means that the question of whether a "substantial limitation" exists must
be determine before any intervention for that limitation is implemented
• "Mitigating measures" includes such things as medication, assistive
technology, learned behavioral modifications, psychotherapy, and/or reasonable
accommodations
• Parent Information Center provides workshops on the
special education process and have trained advocates for a
nominal fee http://www.parentinformationcenter.org
Jennifer A. Ganem MS, APRN
Coaching
• Coaches assist ADHDers with
• identifying their personal strengths and weaknesses
• developing concrete strategies to manage their symptoms in all areas of life
• Coaches are supportive and hold ADHDers accountable
• Coaching can be done in-person, via the phone and/or virtually
• Coaching can be individual, couples and/or group
• Resources to locate an ADHD Coach:
• www.CHADD.org
• www.adhdcoaches.org
• www.addresources.org
Jennifer A. Ganem MS, APRN
Behavioral Interventions
• Incentive charts, token systems…
• Social Skills Groups
• “Therapy” learn to manage symptoms of co-morbid mental
health disorders, such as depression, anxiety, oppositional
behavior, tic disorders, OCD…
• Can be individual, family and/or group
Jennifer A. Ganem MS, APRN
Medication
• A prescriber should:
• Explain all of your medication options
• Inform you of the potential side effects and how to manage them
• Inform you how long it will take before the effect of the medication
•
•
•
•
•
is observed
Inform you of what time of day to take the medication and how
long the medication will last (duration)
Discuss how the medication’s effectiveness will be evaluated over
time
Inform you how often you’ll need to be seen
Instruct you to lock all medication
Address ALL OF YOUR CONCERNS
Jennifer A. Ganem MS, APRN
Long Acting
ADHD Meds
(amphetamine)
Adderall XR
(methylphenidate)
Concerta
Metadate CD
Ritalin LA
Focalin XR
atomoxetine
(Strattera)
Daytrana
lisdexamphetamine
(Vyvanse)
Quillivant XR
Guanfacine XR
(Intuniv)
How the Long-Acting Stimulants Differ:
1. Mechanism of Action:
• Methylphenidate is believed to be primarily a dopamine
reuptake inhibitor with some mild norepinephrine reuptake
inhibition.
• Amphetamine is believed to be a dopamine reuptake inhibitor
and a strong norepinephrine reuptake inhibitor. It’s also
thought to block the dopamine pump - increasing dopamine
secretion.
2. How they are released
3. The duration of efficacy
Jennifer A. Ganem MS, APRN
• Both methylphenidate and amphetamine have
been shown to have similar side effect profile
and response rates of 70-75%.
• If there is a trial of each type of stimulant, the
response rate increases to 80-90%.
Jennifer A. Ganem MS, APRN
Concerta
• Delivers methylphenidate using an immediate-release coating
and a delayed-release osmotic mechanism
• 22% immediate, 78% delayed release
• Designed for 12-hour effect
• Available dosages: 18mg, 27mg, 36mg, 54mg
• Approved up to 72mg/day (Adolescents commonly need daily
doses of 1-1.5mg/kg)
• Approved 6-65yo
• To be effective the tablet can not be broken, crushed or
chewed
Jennifer A. Ganem MS, APRN
Metadate CD
• Biphasic delivery of methylphenidate using immediate and
delayed-release beads within a capsule
• 30% immediate, 70% delayed
• Designed for 8-hour effect
• Available dosages: 10mg, 20mg, 30mg, 40mg, 50mg, 60mg
• Capsules can be opened and contents mixed with applesauce
• Approved 6-15yo
Jennifer A. Ganem MS, APRN
Ritalin LA
• Biphasic delivery of methylphenidate using immediate and
delayed-release beads within a capsule
• 50% immediate release, 50% delayed
• Designed for 8-hour effect
• Available dosages: 10mg, 20mg, 30mg, 40mg
• Approved 6-12yo
Jennifer A. Ganem MS, APRN
Daytrana
• Continuous delivery of methylphenidate through DOT Matrix
transdermal patch
• Efficacy from 2 hours* through 12 hours
• Approved for a 9 hour wear time (12 hour duration)
• Available dosages: 10mg, 15mg, 20mg, 30mg
• Approved 6-12yo
* first time point measured in studies
Jennifer A. Ganem MS, APRN
Quillivant XR
• Liquid form of extended release methylphenidate (25mg/5ml)
• 20% immediate release, 80% delayed release
• 12 hour duration with peak plasma concentration at 5 hours
• Starting dose is 20mg (4ml) given orally once daily in the
morning with or without food. Dosage can be increased 1020mg per day to a maximum dose of 60mg daily.
• Approved 6 and up, but age 65+ have not been studied
Jennifer A. Ganem MS, APRN
Focalin XR
• Delivers dexmethylphenidate (active enantiomer of racemic
methylphenidate) using immediate and delayed-release beads
within a capsule
• 50% immediate release, 50% delayed
• 10 to 12-hour effect
• Available dosages: 5mg, 10mg, 15mg, 20mg, 30mg
• Capsules can be opened and contents mixed with applesauce
• Approved 6yo-adult
Jennifer A. Ganem MS, APRN
Adderall XR
• Delivers mixed salts of amphetamine using immediate and
delayed-release beads within a capsule
• 50% immediate release, 50% delayed release
• Designed for 12-hour effect
• Available dosages: 5mg, 10mg, 15mg, 20mg, 25mg, 30mg
• Approved 6yo-adult
Jennifer A. Ganem MS, APRN
Vyvanse
• It’s a pro-drug, meaning it doesn’t become active until various
processes occur in the body.
• It’s the most consistently released stimulant from person to
person.
• 13 to 14-hour effect
• Available dosages: 20mg, 30mg, 40mg, 50mg, 60mg, and
70mg
• Capsules can be opened and contents mixed with 4 ounces of
water
• Approved 6yo-adults
Jennifer A. Ganem MS, APRN
Strattera
• Non-stimulant medication (NE reuptake inhibitor)
• Designed for 24-hour effect
• Available dosages: 10mg, 18mg, 25mg, 40mg, 60mg, 80mg
• Recommended starting dose is 0.3mg/kg/day, which is titrated
over 1-3 weeks to a dosage of 1.8mg/kg/day or 80mg
• Approved 6yo-adults
Jennifer A. Ganem MS, APRN
Intuniv
• Non-stimulant medication (long-acting* alpha-2 agonist)
• Designed for 24-hour effect
• Starting dose is 1mg with dosage increases of 1mg per week
with a final dosage of 0.05-0.12mg/kg
• Available dosages: 1mg, 2mg, 3mg, 4mg
• To be effective as a long-acting agent, the tablet can not be
broken, crushed or chewed.
• Approved 6yo-18yo
* The short-acting agent (guanfacine/Tenex) is NOT interchangeable
Jennifer A. Ganem MS, APRN
Common Side Effects
• Stimulants:
• headache, lack of appetite, insomnia, mood instability*, stomach pain,
increased BP/pulse, exacerbation of tics
• With Daytrana only – irritant contact dermatitis*
Side effects typically decrease with continued use. * = Exceptions. If you
these side effects, stop the medication and call your provider ASAP!
• Strattera:
• headache, lack of appetite, sedation, mood instability*, stomach pain,
increased BP/pulse, exacerbation of tics
• Intuniv:
• NO impact on appetite
• headache, sedation, lack of appetite, decreased BP/pulse
Jennifer A. Ganem MS, APRN
Managing Decreased Appetite
• Maximize the hungry times of day by having additional (healthy)
food
• Yogurt smoothies at night
• Have small protein-based snacks throughout the day
• Nuts
• Peanut butter crackers
• Cheese sticks
• Greek yogurt
Jennifer A. Jennifer A. Ganem MS, APRN
APRN – Nov 2013
Managing Insomnia – Good Sleep Hygiene
• Use the bed only for sleeping so that the bed is positively associated
with sleeping
• This means no reading, eating, watching TV, etc…
• Set and maintain a regular sleep schedule and keep as close to it as
possible on weekends
• Do not take naps during the day
• Get exposure to sunlight in the morning
• Get some daytime exercise and avoid exercise 2 hours before bedtime
• Reduce the use of computers and television within two hours of
bedtime, because it can alter natural body rhythms
• If doing either, wear amber lensed safety glasses for a couple of hours before
bedtime to help block the blue light emissions. This allows the brain to produce
melatonin.
Jennifer A. Ganem MS, APRN
• Keep the bedroom at a comfortable temperature; keep it dark and free
of distractions
• Mute the cell phone or keep it out of the room!
• Use a sound machine or fan for white noise
•
• Reduce stress and/or try relaxation techniques before bed
•
• Take a hot bath or have decaffeinated tea as a drop in body
temperature helps increase drowsiness
•
• Move the clock so you can’t clock-watch
• Use nightlights in the bathrooms and hallways
•
• Avoid caffeine after 2pm
• Avoid alcohol before bed
Jennifer A. Ganem MS, APRN