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Initial therapy in children diagnosed with uncomplicated ADD always consists of one the psychostimulants: methylphenidate, dextroamphetamine, or a combination of dextroamphetamine and levoamphetamine (Adderall). These medications are extremely safe and require no serologic or hematologic monitoring. Patients may respond better to one or the other of these psychostimulants, and patients who do not respond to the initial choice can be treated with either remaining alternative. Interestingly, parent-rating scales favored dextroamphetamine over methylphenidate, probably secondary to the longer half-life of dextroamphetamine so that effects were observed at home and school.
A reasonable lower dose for each medication is initiated, as suggested by actual weight.
Children 5 to 14 Years of AgeAlthough selecting with which medication to initiate therapy may be somewhat arbitrary, in children 5 to 14 years old, either Dextroamphetamine Spansules or Adderall (mixture of amphetamine salts) may be preferred because of the longer, smoother duration of effects, reduced likelihood of midday school dosing with its subsequent stigmatization and teasing by classmates, ease of titration, and relatively lower costs. According to Pelham, Dextroamphetamine Spansules.
Compared with methylphenidate, sustained-release Dextroamphetamine Spansules (and possibly Adderall) is a significantly more reliable and effective long-acting form of amphetamines. Furthermore, sustained-release preparations are preferred by the children themselves.
Stimulant therapy is often avoided in children aged 3 to 4 years because of lower efficacy; the increased rate of problematic AEs, especially moodiness, irritability, and appetite suppression; and because of the lack of availability of a liquid formulation. Only highly aggressive and pervasively, behaviorally disruptive or defiant children in this group warrant therapy.
Prescribing psychostimulants for the adolescent population creates a significant dilemma for pediatricians, who must now choose between the standard stimulants, which demonstrate no evidence of lethality when used appropriately and singly but that are associated with the potential for being abused in this population versus pemoline, which has been associated with an exceptionally rare.
In adolescents who may abuse or sell the medicine, the number of pills dispensed and purportedly taken when using either amphetamines or methylphenidate should be monitored carefully. Consequently, pediatricians may want to consider pemoline therapy for male adolescents initially, unless the family and adolescent are deemed trustworthy and reliable (which is possible with established patients). Patients previously managed with the other psychostimulants who are approaching age 13 or 14 years, particularly male adolescents who are impulsive, defiant, or have conduct problems, are urged to switch to pemoline. Female adolescents are rarely treated with pemoline.
Adolescents and their parents may prefer pemoline for any of five reasons: (1) it usually requires only a single daily dose, removing in-school dosing, a significant source of embarrassment for self-conscious teens; (2) it sustains positive effects into the evening, improving homework productivity; (3) it reduces pharmacologic peaks and troughs.
Pemoline may be indicated for other problem groups of patients with ADD, including those living in households with a high risk for or history of substance abuse; history of parental incarceration.
In patients who seem to have school-related, situational ADD or children or adolescents with ADD-I or milder ADD-H, drug-free holidays on weekends, holidays, and summer vacations.
Less than 1% of children with ADD develop tics. Previously, stimulants were believed to be contraindicated in children with Tourette's syndrome; however, current literature suggests that tics are not caused by stimulants but rather that stimulants exacerbate the underlying propensity.