What are the treatment guidelines for a 6-year-old male patient with Attention Deficit Hyperactivity Disorder (ADHD) starting on Adderall (amphetamine and dextroamphetamine), who has not tolerated Focalin (dexmethylphenidate) and Ritalin (methylphenidate) and has a poor response to Concerta (methylphenidate)?

Treatment Guidelines for a 6-Year-Old Male Patient with ADHD Starting on Adderall

For a 6-year-old male patient with ADHD who has not tolerated Focalin and Ritalin and has poor response to Concerta, switching to Adderall (amphetamine and dextroamphetamine) is appropriate as patients may respond differently to amphetamine versus methylphenidate-based stimulants. 1

Medication Selection Rationale

• Patients with ADHD often respond to either amphetamine or methylphenidate with an overall high response rate when both types are tried 1
• Since this patient has failed multiple methylphenidate-based medications (Focalin, Ritalin, Concerta), switching to an amphetamine-based medication like Adderall is the logical next step
• Dextroamphetamine is the only medication FDA-approved for children younger than 6 years of age, making Adderall (which contains dextroamphetamine) an appropriate choice 1

Dosing Guidelines for Adderall in 6-Year-Old Patients

• Start with a low dose: 2.5-5 mg once daily 2
• Titrate gradually: Increase by 2.5-5 mg weekly based on response and tolerability 2
• Maximum daily dose: Should generally not exceed 40 mg daily 2
• Timing: Administer in the morning to minimize sleep disturbances
• Consider twice-daily dosing if coverage throughout the day is needed

Monitoring Parameters

• Baseline assessment before starting:

  • Height, weight, blood pressure, pulse
  • Appetite and sleep patterns
  • Severity of ADHD symptoms using standardized rating scales

• Regular follow-up:

  • Weekly during initial titration
  • At least monthly until symptoms stabilize 2
  • Monitor vital signs, growth parameters, appetite, sleep, and mood

• Watch for common side effects:

  • Decreased appetite
  • Sleep disturbances
  • Irritability
  • Headache
  • Potential effects on growth 1

Special Considerations for Young Children

• Evidence suggests that the rate of metabolizing stimulant medication is slower in young children, so they should be given a lower starting dose with smaller incremental increases 1
• Careful monitoring of height and weight is particularly important as effects on growth may be dose-related 1
• Reduced appetite is a frequent side effect that may contribute to growth concerns 1

Behavioral Interventions

• Behavioral therapy should be continued alongside medication
• Parent Training Behavioral Management (PTBM) is particularly important for this age group 2
• Classroom accommodations should be implemented through school

Treatment Pitfalls to Avoid

• Inadequate dose titration - ensure proper titration to find optimal dose
• Premature discontinuation - ADHD is a chronic condition requiring ongoing management
• Neglecting to monitor for side effects - regular monitoring is essential
• Failing to address potential comorbid conditions 2

Alternative Options if Adderall is Not Tolerated

If Adderall is not tolerated, consider:

1. Other amphetamine formulations like Vyvanse (lisdexamfetamine) 2
2. Non-stimulant medications:
   • Atomoxetine (Strattera) - a norepinephrine reuptake inhibitor 1, 2
   • Extended-release guanfacine (Intuniv) 2
   • Extended-release clonidine (Kapvay) 2

These non-stimulant options have less abuse potential but may take longer to show full therapeutic effects.

Medication Safety

• Amphetamine overdose can cause significant neurological and cardiovascular effects 3
• Proper storage and supervision of medication administration is essential
• Educate parents about keeping medication secure and out of reach of children

Remember that ADHD is a chronic condition requiring ongoing management with a comprehensive approach including FDA-approved medications, behavioral therapy, and educational interventions.