Assessing and Treating Patients With ADHD


Attention Deficit Hyperactivity Disorder A Young Girl With ADHD

A Young Girl With ADHD

Decision Point One

· Begin Intuniv extended release 1 mg orally at BEDTIME


·  Client returns to clinic in four weeks

·  Katie’s teacher reports no change in her classroom behaviors

·  Katie's parents are reporting that Katie has become “impossible” to wake in the morning and that for the first few hours of the day, she seems “sluggish”

Decision Point Two

Discontinue Intuniv and begin Focalin (dexmethylphenidate) XR 10 mg orally daily


·  Client returns to clinic in four weeks

·  Katie’s parents report that they spoke with Katie’s teacher who notices that her symptoms are much better, and that her academic performance has improved considerably

·  Katie’s parents are very concerned, however, about Katie’s decreased appetite. They say that Katie was never a “big eater” but have become concerned that her appetite has worsened

Decision Point Three

Maintain current dose of Focalin XR and re-evaluate at next clinic visit in 4 weeks

Guidance to Student

Focalin XR [Methylphenidate (d)] is a first line agent with strong evidence of efficacy in ADHD. Side effects such as decreased appetite are not unusual with stimulant medications. The side effect may not have been as pronounced with a starting dose of 5 mg daily, but since she was started on 10 mg daily, the most prudent course of action from the available choices would be to maintain the current dose of Focalin XR until the next visit in 4 weeks. At that time, appetite should be assessed. No action will be required if it stabilizes or improves. However, worsening of appetite may herald the need to decrease to 5 mg orally daily.

Increasing the dose to 20 mg orally daily would not be appropriate as it may increase the side effects- and since there is evidence of good efficacy at the 10 mg, there is no clinical indication to increase the dose (recall that with stimulants, you always want to use the smallest effective dose).

Common side effects are not an indication to discontinue the drug and begin a different medication, therefore, it would not be appropriate to discontinue Focalin XR and begin Strattera at this time.