What is the best course of action for an 18-year-old patient with Attention Deficit Hyperactivity Disorder (ADHD) experiencing intense chewing behaviors while taking Jornay (methylphenidate) 60mg and Zoloft (sertraline) 25mg?

Management of Intense Chewing Behaviors in an 18-Year-Old with ADHD

Immediate Assessment and Optimization

Your first priority is to optimize the methylphenidate dose, as the current 60mg Jornay may be insufficient or the chewing behavior may represent a stimulant-induced side effect requiring adjustment. 1

The chewing behavior in this patient likely represents one of three possibilities:

• Suboptimal ADHD control leading to fidgeting/oral motor stereotypy as a self-regulatory mechanism
• Stimulant-induced bruxism or jaw clenching (a known adverse effect of methylphenidate)
• Anxiety manifestation that may be exacerbated by stimulants or undertreated by the low-dose sertraline 1

Medication Optimization Strategy

Step 1: Evaluate Methylphenidate Efficacy and Dosing

Assess whether ADHD core symptoms are adequately controlled at the current 60mg Jornay dose. 1 Methylphenidate demonstrates response rates of 78% versus 4% with placebo when dosed appropriately at approximately 1 mg/kg total daily dose 2. For an 18-year-old, this typically translates to 54-72mg daily depending on weight 3.

• If ADHD symptoms remain poorly controlled (inattention, hyperactivity, impulsivity), titrate methylphenidate upward to a maximum of 72mg daily while monitoring for worsening jaw clenching or anxiety 4, 1
• If chewing intensifies with dose increases, this suggests stimulant-induced bruxism rather than inadequate ADHD control 4

Step 2: Address the Sertraline Dose

The current 25mg sertraline dose is subtherapeutic for anxiety disorders. 3 If anxiety is contributing to the chewing behavior:

• Increase sertraline to 50-100mg daily (therapeutic range for anxiety) over 2-4 weeks 1, 3
• Escitalopram demonstrates efficacy for anxiety with response rates of 66-78% in clinical series, and SSRIs can be safely combined with stimulants without significant drug-drug interactions 1, 3

Step 3: Consider Adjunctive Medication if Chewing Persists

If the chewing behavior represents stimulant-induced bruxism or residual hyperactivity despite optimized methylphenidate:

Add extended-release guanfacine (1-4mg daily) or clonidine as adjunctive therapy. 1, 2 These alpha-2 agonists:

• Have effect sizes around 0.7 for ADHD symptoms 1, 2
• Can reduce stimulant-related side effects including motor restlessness 3
• Should be dosed in the evening due to sedation 1
• Are FDA-approved as adjunctive therapy to stimulants 1

Critical Monitoring Parameters

Monitor the following every 2 weeks during titration 3:

• Blood pressure and pulse (stimulants and alpha-2 agonists affect cardiovascular parameters) 4, 3
• Sleep quality and appetite (common stimulant adverse effects) 4, 3
• Severity and frequency of chewing behavior (use a simple 0-10 scale)
• ADHD symptom control using standardized rating scales with feedback from family or close contacts 2
• Anxiety symptoms to ensure sertraline optimization is effective 3

Common Pitfalls to Avoid

Do not assume the chewing is purely behavioral without first optimizing pharmacotherapy. 1 Oral motor behaviors in ADHD often improve dramatically with adequate stimulant dosing when they represent self-regulatory fidgeting 5.

Do not add benzodiazepines for anxiety in this population, as they may reduce self-control and have disinhibiting effects in adolescents with ADHD 1, 3.

Do not discontinue the stimulant prematurely if chewing worsens slightly with dose increases—this may be transient and resolve within 1-2 weeks 4. However, if bruxism becomes severe or causes dental damage, consider switching to atomoxetine (60-100mg daily), which has a 2-4 week onset but demonstrates superior anxiety reduction compared to methylphenidate (effect size 0.7) 1, 3.

Screen for substance use given the patient's age, as prescribing psychostimulants to young adults with comorbid substance abuse requires special consideration of long-acting formulations with lower diversion potential 1, 2.

Alternative Approach if Stimulants Are Contraindicated

If the chewing behavior represents severe bruxism causing dental damage or if stimulants are otherwise contraindicated:

Switch to atomoxetine 60-100mg daily as monotherapy, allowing 6-12 weeks for full therapeutic effect 2. Atomoxetine is an uncontrolled substance with lower abuse potential and may be particularly appropriate given the patient's age and transition to adulthood 1, 2.