78. ADHD Meds Simplified: How to Choose the Right Stimulant

It’s back-to-school season—and that often means a surge of ADHD concerns as academic demands ramp up, especially around key school transitions like 3rd, 6th, and 9th grade. 

In this episode of ADHD, Anxiety, and More, Dr. Elise Fallucco  shares a practical, confidence-building approach to picking stimulant treatment for children and teens, answering questions like:

Which ADHD medication should I start first?

When should you use methylphenidate medications like Ritalin or Concerta?

When should you use amphetamine-salt medications like Adderall or Vyvanse?

How does family history help direct treatment choices?

When does it make sense to try a d-methylphenidate medication like Focalin?

 00:00 Podcast Rebrand Update

00:30 Back to School ADHD Surge

01:09 ADHD Evaluation Basics

02:36 Case Introduction Third Grader

03:04 Rule of Three Transitions

04:09 Parents Nervous About Meds

04:45 Family History Medication Clues

06:06 Step One Start Methylphenidate

06:33 Short Acting First Rationale

08:05 When to Use Long Acting

08:30 Long Acting Coverage Limits

09:27 Step Two Try Amphetamines

10:59 Step Three Consider Focalin

11:52 Wrap Up Simple Stimulant Toolkit

12:43 Bonus Algorithm and Course

14:00 Closing and Next Week Preview

Check out our website PsychEd4Peds.com for more resources!
Follow us on Instagram @psyched4peds

Check out our NEW CME Audio-based, on-demand CME Course online at:

Pediatric Mental Health CME Toolkit - Cracking the ADHD Code: Essentials for Pediatric Clinicians. 

https://ce.nemours.org/content/podcast-series-cracking-adhd-code-essential-skills-pediatric-clinicians#group-tabs-node-course-default1

Transcript

SPEAKER_00 0:21

Welcome back to the pod. For those of you who have noticed, we have slightly changed our name. We are now called simply ADHD, Anxiety and More, Child Mental Health for Pediatrics. And since the podcast has been around for over three years, we decided it was time for a fresh new rebrand, new logo, slightly new title, but still lots of the same fun educational content to help you in your practice take care of kids. All right. So let's get started. So for many of us, this is back to school season. And as kids head back to school, we know what that means in the child mental health world. It means lots more conversations about ADHD. So maybe the kid that did just fine last year and has had tons of fun with an unstructured summer now goes back to the increased academic demands of the new school year, new teacher. And usually about a month or so after starting school is when we begin to notice some teacher reports or frustrated parents saying, I think something's not right and we're struggling a little bit at school. And that's when they come to you. And when you're evaluating them, of course you're thinking about ruling out possible learning differences, checking their vision, their hearing, making sure that they're medically healthy. And also knowing ADHD is the most common neurodevelopmental disorder in childhood, affecting one out of 10 kids. Of course, you're thinking about ADHD. And side note, if we've got a parent who has ADHD, then their kid is much, much more likely to also experience it themselves. So knowing the family history of mom andor dad andor a sibling having ADHD, you've got your eyes peeled out for this. You know how to evaluate for ADHD. As part of the evaluation, you send home a Vanderbilt or a Connors rating scale to the parents, to the teachers, to any adults who are working with this child. And in fact, let's say they come back all pan positive, concerning for ADHD, and notably no comorbid anxiety. So what do you do? Now many of us have our favorite ADHD go-to meds that we like to use. But my hope for all of us is that you have at least one medication from each of the three stimulant subcategories that you feel solidly comfortable with and you know when to use them and how to use them. So what we're going to do today is talk through a clinical case, and I'm going to share the framework that I use when determining which med to use or which med to start for a child with ADHD. So let's get into a case. We've got an eight-year-old boy who has just started third grade, and about a month in, the teachers are giving feedback. There's a lot of rushed assignments. And basically, the teacher and the parents are getting the impression that this little boy knows a lot more than he's able to demonstrate. And his performance is much lower than what they would expect it to be, given his capacity. Now, a little note for those of you who listened to episode 72, where we talked with Dr. James Waxmanski, one of the things that we highlighted is that there are three major times in a kid's life where we're most likely to see problems related to ADHD. And these have to do with big school transitions. So think of the rule of three, because all these numbers are divisible by three. So we've got third grade, which is the time where we begin to see a lot more independent work for kids. The other two times, unsurprisingly, are sixth grade and ninth grade, which are respectively the transition to middle school and high school. And so at all of these developmental times and transitions, we see a jump up in terms of increased academic pressure, increased demand for executive functioning. And that is when we see kids who were bright enough to get by up until this point begin to stumble. And this is our opportunity to go and evaluate and see is there ADHD that's causing this? And can we help address those underlying symptoms so that they can perform their best? But back to this case. So, eight-year-old boy on your evaluation, you diagnose him with ADHD, no comorbid anxiety, no other major medical problems, not currently on any meds. And the parents are very nervous about starting any medication for ADHD. He eats well, he sleeps well, pretty straightforward. So the question is which med would you choose? And I know you're gonna say whichever your favorite med happens to be. And we we all have our favorites, and that's fine. But I'm gonna go through the questions I ask and my three-step approach for determining medication treatment for ADHD. Before we start, this is a question I want to ask all families to determine what medication may be beneficial for the patient. What I'm gonna say to the family is you know, anytime we diagnose a child with ADHD, we often have parents or siblings who also have had ADHD symptoms or have been treated for ADHD because it's highly heritable. It tends to run in families, just like eye color and hair color. Has anyone else in the family been treated for ADHD? If so, which medication worked well and which one didn't? And while that's not necessarily going to get you the perfect med for the child immediately, it can give you some ideas as to what meds were well tolerated, what problems have they had, and what meds tend to work well. So let's say, for example, his big brother or his big sister takes vivance, and that's tend to work well. So that will give you a clue. Okay, vivance is one of the amphetamine salt class medications, so maybe you'll start with that class of medication. Or you might hear the opposite, like, oh, Adderall made my daughter feel miserable. And then you know, okay, we're not going to start with the amphetamine salts. We'll maybe think about methylphenidates. So find out about family history of treatment to guide your selection of meds for the patient. Okay, if you don't have a clear answer from that, then we go into the three-step approach to determine the best medication for the patient. Step one, you have to figure out do you choose methylphenidate or amphetamine salt meds? And I'm gonna tell you more often than not, I start with methylphenidate products, mainly because we know they tend to be much better tolerated in kids and teens than the amphetamine salt. There's less appetite suppression, less irritability, and less anxiety as a whole with the methylphenidates. So this is where I like to start with those. Since the child's eight years old, so definitely solidly pre-pubertal, I'm gonna go ahead and start with a short-acting medication. And I know a lot of clinicians start everyone on the long-acting medication for reasons that make total sense, many of which have to do with it's easier to give one pill in the morning than to try to have to do a pill in the morning and then maybe take a pill at school, in the nurse's office if the kid remembers to go. But here's why I don't start with long-acting meds for pre-pubertal kids. Kids tend to be very sensitive to stimulant medications, and we want them ultimately on the lowest dose possible. And the long-acting meds start at pretty high doses, especially for a given prepubertal child's weight. Whereas the short acting meds, especially the methylphenidates, you can start them at 2.5 milligrams or even five milligrams, as opposed to, let's say, long-acting or OS methylphenidate or concerta, the lowest dose is 18, which is gonna be potentially too much for this eight-year-old. Now we may end up on a long-acting med, and that's fine, but we just want to start low, figure out what the child responds best to before we ultimately jump up to a higher med. This helps improve tolerability and the patient and family's experience. We just have to warn the family that we're gonna start at a really low dose because we want to be conservative, but we'll gradually increase the medicine to find the best dose that's the most helpful, causing the fewest side effects. And once we know that, our ideally will try to transition to a long-acting medicine. Now, as kids get older, and we're talking about not pre-perutal kids, but teenagers or even larger tweens, then my thinking changes, then it makes more sense to start with a long-acting med. So let's say you had a 13 or 14-year-old who were just diagnosing with ADHD in middle school. For somebody like that, it'd be more reasonable to start with a longer-acting medication, assuming they're at a pretty healthy height and weight for their age. I also, since we're talking about long-acting meds, I just want to put a little caveat out there that the long-acting meds very rarely give you full coverage throughout the whole day, afternoon, and early evening. That while they say that they're effective for 10 to 12 hours, the reality is, best case scenario is you give a long-acting medication in the morning, like say methylphenidate OROS, 18 milligrams or 27 milligrams in the morning, and that'll get you through till about three o'clock or the end of school. But if we're talking about a child who has after school activities or is doing homework after school, which many of these kids are, then you're often going to need to add on a short-acting medication to kind of get them through the last three to six hours of their day. Okay, so we've talked about my step one, which is a strong preference to start with a methylphenidate type product. And now we go to step two. Let's say we've tried methylphenidate, it's either really poorly tolerated or we bumped up the dose and we're just not seeing a lot of effectiveness, then what do you do? And just a quick word, I think tolerability issues are what hurts us with stimulants. That the reason why we end up switching meds is very often because they cause too much appetite suppression, mood changes, irritability, anxiety, all the things I mentioned before. And so we say we're going to move out of that sub of stimulant medications and try a different one. So when do we not choose methylphenidate? So for kids who have failed or not tolerated methylphenidate, then I think about amphetamine salts, unless, of course, the family history has guided us to believe that somebody else in the family has had a really good response to an amphetamine salt med like Adderall XR, Adderall IR, vivant, something like that, then we might start with it. And while we're talking about the amphetamine salts, what I do want to note is that while I said before that in general they tend to be not as well tolerated as methylphenidate, we do have a lot of kids that for whatever reason feel better on the amphetamine salts than with no treatment at all. So, in other words, very often in clinic, we hear from families like we started the Adderall, and not only did it help with attention and impulse control, but I feel like her mood was better. She just seemed happier on the medicine. And that is a home run if you can do that. So now we're to step three to review. Step one, methylphenidate. Step two, amphetamine stalt. Step three, aye, aye. A lot of people abandon ship after they've tried two meds and they don't work. But because we know stimulants can be very effective when you find the right one, at this point, my preference is to try one of the DEX methylphenidate products like Focalin IR or Focalin. I do think they tend to be better tolerated than even the methylphenidate products, but they're not very long-lasting. And so sometimes you end up having to dose multiple times throughout the day, which insurance may or may not like. Now I know what you're thinking right now. You're thinking, wait a minute, what about the alpha agonists? How come we're only talking about stimulants? And that is an excellent question, which I'm going to talk about in part two of this episode next week. But for now, since we're talking about stimulants, and which one do you choose when and for which person, I just want to wrap up and say, I don't think that you need to know the 28 different forms of stimulant medication with new fancy, more expensive, non-generic versions coming out every day. I think it's most helpful for your patients to have one methylphenidate med that you're comfortable with. For me, it's short-acting Ritalin, long-acting concerta slash methylphenidate OROS. I think you need one amphetamine salt. For me, I'm thinking Adderall IR or XR, and then one dexmethylfenidate, so focalin IR, focalin XR. Get comfortable with these medications, and I think you can take care of 80 to 90% of the ADHD in your office. And as a special bonus for the friends and colleagues of the pod who subscribe to our newsletter, I'm going to share a really helpful resource. And this resource is the ADHD Medication Management Algorithm, which is a one-page simple, straightforward algorithm that summarizes what we talked about and the three steps to choosing stimulant meds for your kids and teens with ADHD. And just to let you know, if you want a deeper dive into ADHD, we have an entire course where you can get CME credit that goes through treatment approaches like this and includes a lot of helpful downloadable resources and tools and algorithms and flowcharts that you can use to figure out what meds do you use, what do you do when you're treating ADHD plus anxiety, when do you use non-stimulants? When do you use alpha agonists? And the goal is to empower you with the tools, tips, strategies, and resources to be able to go to your practice tomorrow and take care of the potentially one out of 10 kids walking through the door with ADHD. So for more information about the course or to just sign up for our newsletter, check out our website, psychedhenum4peeds.com, and sign up to be a friend and colleague. Thank you for listening. Good luck with the back to school ADHD season. And stay tuned next week where we talk about when to use Alpha Agnes. See you next time.