Questions often come up about how to manage ADHD in kids or adults when a stimulant (methylphenidate, etc) isn't enough.
About 30% of patients still have symptoms while on a stimulant.
Consider these approaches to optimize management.
Recommend behavior therapies at home and school. Combining meds and behavior therapy often results in better outcomes than meds alone.
Recommend switching stimulants or increasing the dose if needed.
The max labeled dose is enough for most kids...but not for some teens and adults. If needed, suggest up to 100 mg/day methylphenidate... 108 mg/day Concerta...or 60 mg/day Adderall XR.
If the stimulant doesn't last long enough, consider suggesting a long-acting in the morning and a short-acting in the afternoon.
Suggest switching to or adding a NONstimulant...atomoxetine (Strattera), guanfacine, or clonidine.
Suggest a nonstimulant if stimulant response is inadequate, patients have stimulant side effects, or substance abuse is a concern.
Be aware of other conditions that can mimic or coexist with ADHD...learning disabilities, depression, anxiety, conduct disorder, etc.
About 70% of ADHD patients have at least one comorbidity.
Expect an antidepressant to sometimes be added for concomitant depression or anxiety. Explain that bupropion or SNRIs might also improve ADHD symptoms...but SSRIs probably don't.
Keep in mind that stimulants can sometimes worsen anxiety. In this case, back off on the stimulant dose or switch to a nonstimulant.
Caution about using atypical antipsychotics due to safety concerns.
Suggest saving them for special circumstances such as ADHD with SEVERE concomitant aggression when other options aren't enough.
See our PL Chart, Comparison of ADHD Medications, for dosing, titration, duration of action, and more.
J Am Acad Child Adolesc Psychiatry 2014;53:948. N Engl J Med 2014;370:838. Pediatrics 2011;128:1007.