Screening, Referral and Treatment for

Attention Deficit and Hyperactivity

Disorder (ADHD) – Adult – Ambulatory
Clinical Practice Guideline
Table of Contents
EXECUTIVE SUMMARY ........................................................................................................... 2
SCOPE ...................................................................................................................................... 2
METHODOLOGY ...................................................................................................................... 2
INTRODUCTION ....................................................................................................................... 3
RECOMMENDATIONS .............................................................................................................. 4
1. PRESENTATION AND SCREENING .......................................................................... 5
2. CLINICAL ASSESSMENT ........................................................................................... 5
3. ESTABLISH DIAGNOSIS ............................................................................................ 7
4. PROVIDE TREATMENT .............................................................................................. 9
5. COMPLETE FOLLOW-UP CARE ...............................................................................10
REFERENCES .........................................................................................................................11
APPENDIX A ............................................................................................................................13
APPENDIX B ............................................................................................................................14
APPENDIX C ............................................................................................................................15

Note: Active Table of Contents -- Click to follow link

Release Date: October 2014

Next Review Date: October 2016

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Executive Summary
Guideline Overview
This document has been developed to assist in identifying, treating, and monitoring
adult patients with potential or diagnosed ADHD.

Key Practice Recommendations

1. Assess symptoms and functional impairment
2. Complete physical exam and consider comorbid or alternative diagnoses
3. Establish ADHD diagnosis using DSM-5 diagnostic criteria
4. Provide behavioral and/or pharmacotherapy
5. Perform periodic follow-up to confirm treatment efficacy and absence of side effects

Companion Documents
1. Adult ADHD Algorithm
2. Adult ADHD Medication Algorithm
3. Adult Medication Charts

External Resources
1. Wisconsin Prescription Drug Monitoring Program (PDMP)
2. Wisconsin Uniform Controlled Substances Act

Scope
Disease/Condition(s):
Attention deficit and hyperactivity disorder (ADHD)

Clinical Specialty:
Family Medicine, Neurology, Pediatrics, Psychiatry, and Psychology

Intended Users:
Primary Care Physicians, Advanced Practice Providers, Psychiatrists, Psychologists

CPG objective(s):
To provide evidence-based recommendations for the effective diagnosis and treatment
of adult patients with ADHD.

Target Population:
Adult patients (age 18 years or older).

Methodology
Methods Used to Collect/Select the Evidence: Evidence was selected using
hand searches of published literature and electronic databases.

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Methods Used to Assess the Quality and Strength of the Evidence
and Recommendations: Recommendations developed during the workgroup
meetings used the modified Grading of Recommendations Assessment, Development
and Evaluation (GRADE) developed by the American Heart Association and American
College of Cardiology (Figure 1) to establish evidence grades for each piece of
literature and/or recommendation.

Rating Scheme for the Strength of the Evidence and

Recommendations: See Appendix A.

Methods Used to Formulate the Recommendations: Recommendations

developed by external organizations were adopted while others were developed via
group consensus through discussion of the literature evidence and expert experiences.

Introduction
Attention Deficit Hyperactivity Disorder, originally thought to occur just in childhood, is
now widely understood as persisting into adulthood. Between 50 to 65 percent of adults
diagnosed with childhood ADHD will continue to have symptoms of inattention,
distractibility and impulsivity causing functional impairment as adults. In addition, adults
who were never diagnosed as children may present with a complicated array of
behavioral, legal and functional problems requesting diagnosis and treatment.

This guideline is designed to provide primary care clinicians with a structure, tools and
referral criteria for diagnosis and treatment of adults 18 and over with symptoms typical
of ADHD.

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Recommendations
Adult ADHD Algorithm (ages 18 years or older)
Suspect ADHD
Self-referral, suggestion of family , friend, employer, or therapist, or previous child or adult diagnosis
Symptoms include: inattention, restlessness, forgetfulness, poor executive functioning, disorganization,
impulsive behaviors, poor planning, increased risk of driving and other accidents, family and relationship
difficulties

First Visit
1. Assess current symptoms using brief validated tool
2. Establish a childhood history of ADHD symptoms and impact on historical childhood functioning
(especially academic difficulty)
3. Assess for functional impairment at home, work, or school and in relationships
4. Assess for mimicking and coexisting psychiatric disorders (especially anxiety and depression)
5. Preform thorough screening for substance abuse
6. Evaluate for medical cause of symptoms
Consider Referral
1. Extreme dysfunction
Gather Information 2. Suicidal or homicidal
1.Request past medical records, report cards, complete family history 3. Substance abuse or
2. Request missing childhood and developmental history
dependence
3. Encourage scheduling of second visit with informant who can provide corroboration for symptoms and
dysfunction 4. Psychosis
4. Request informant information behavioral checklist 5. Extreme psychosocial
stressors
6. Previous treatment
failures
Second Visit 7. Atypical presentation
1. Review/interview for corroboration of childhood symptoms and dysfunction (parent, relative, report cards,
medical history)
2. Reviw childhood history including medical, psychiatric, developmental, and academics
3. Review family psychiatric history
4. Interview for corroboration of current symptoms and dysfunction (spouse/partner, employer, reliable friend) and/or review
completed behavioral checklist

Corroborate Diagnosis
1. Confirmation of childhood symptoms and impairment
2. Evidence of current dysfunction
3. Meets DSM-5 criteria

Treatment
1.Education of patient and family See Medication
2. Psychological support (support groups, counseling, coaching for time management and task organization) Algorithm and Chart(s)
3. Medications
4. Consider vocational and/or educational accomodation

Follow-up
1. Review target symptoms and occupational/academic behavior/performance
2. Review impressions of informants
3. Monitor for drug adverse effects/toxicity or signs of abuse/diversion
4. Adjust therapy as needed
5. Follow-up monthly until functionality improved, then every 3-6 months

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1. PRESENTATION AND SCREENING
Adults with potential ADHD may present with a self-diagnosis, at the suggestion of a
family member, friend, employer or therapist or with other behavioral or psychological
problems. (Class I, LOE B) There may or may not be a previous childhood or adult
diagnosis of ADHD.

Adult ADHD is commonly characterized by poor executive functioning. Indicators of

ADHD and screening symptoms include:
 Inattention
 Restlessness
 Forgetfulness
 Disorganization
 Impulsive behaviors/often impatient
 Poor planning
 Increased risk of driving and other accidents
 Family and relationship difficulties
 Difficulties with parenting

High risk behaviors, failed relationships, legal difficulties, substance abuse and
recurrent job loss are common. Physical hyperactivity diminishes in severity with age,
but inattentive symptoms become more prominent and may be perceived as
incompetence. Some adults compensate by finding a spouse / partner who organizes
them or a job which is very active, highly absorbing or stimulating.

2. CLINICAL ASSESSMENT
Evaluation of adults presenting with ADHD symptoms typically requires at least two
visits. As well as allowing for a thorough evaluation, two visits allows the clinician to
assess motivation for follow up, persistence of symptoms and dysfunction and likelihood
for alternative diagnoses. The following components of a complete evaluation are
considered during both visits (Class I, LOE C):
 review and corroboration of current symptoms and dysfunction
 determination of a childhood onset
 evaluation for comorbid and /or mimicking psychiatric problems, medical
disorders or substance abuse.

First Visit
A. Review Current Symptoms and Functional Impairment (Class I, LOE C)
 DSM-5 diagnostic criteria for ADHD should be used and followed. A
validated adult ADHD assessment tool (such as the Adult ADHD Self-
Report Scale (ASRS-v1.1) Symptom Checklist) may be used to adjunctively
evaluate an adult patient.
 Adults may present with distractibility, impulsiveness and poor executive
functioning. A variety of psychiatric or lifestyle conditions need to be
considered when these symptoms are present.

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 B. Establish Onset (Class I, LOE C)
 ADHD is a neurodevelopmental disorder that may persist into adulthood.
 In order to meet diagnostic criteria, symptoms and functional impairment
need to have been present in patients prior to age 12.

C. Perform Medical Evaluation (Class I, LOE C)

 Screen for medical, psychiatric or substance abuse issues which could
explain or exacerbate symptoms of ADHD. (Class I, LOE C)
 Screen for medical and psychological conditions which would influence
choice of medication. When considering a stimulant in an adult with risk
factors for cardiac disease, the provider should consider a cardiovascular
evaluation before initiating therapy. (Class I, LOE C)
 Establish baseline vital signs: weight, blood pressure, pulse. (Class I, LOE C)
 Laboratory testing should be limited to areas of concern. (Class I, LOE C)

D. Evaluate for Psychiatric or Lifestyle Conditions

 Adults may present with distractibility, impulsiveness and poor executive
functioning. A variety of psychiatric or lifestyle conditions need to be
considered when these symptoms are present. (Class I, LOE C)

GATHER ADDITIONAL INFORMATION

A. Corroborate Childhood Onset and Impairment

Childhood history can be gathered by review of medical records, review of report cards
or other academic materials, and interview with parents or close family member either in
person or via a phone call. High activity patterns, difficult temperament, and frequent
accidents or risk taking behavior are common childhood characteristics. Review of
academic background should reveal areas of impairment or concern. Look for drop
outs, failures, learning disability, special evaluations or classes, suspensions /
expulsions, and focused problems in areas such as reading, writing, penmanship or
math. (Class I, LOE C)

Review of report cards often indicates behavior problems, lack of expected

achievement, incomplete work, or inadequate effort. If there is no objective evidence of
childhood symptoms and impairment, the diagnosis of adult ADHD should be
reconsidered.

B. Review Family Psychiatric History

It is common to have a positive family psychiatric history. Inquire particularly about
learning disabilities, behavior problems, legal difficulties, ADHD, and substance abuse.
(Class I, LOE B)

CONSIDER COMORBID OR ALTERNATIVE PSYCHIATRIC DIAGNOSIS

(Class I, LOE B)
Psychiatric disorders can cause inattentive symptoms or can influence the course of
treatment. Presence of another psychiatric diagnosis does not preclude a diagnosis of

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adult ADHD but it does make diagnosis and treatment more confusing. Significant
physical, verbal or emotional abuse / neglect can contribute to symptoms characteristic
of ADHD. Depression, Post-Traumatic Stress Disorder (PTSD), bipolar disorder, anxiety
disorder, personality disorders, substance abuse and other psychiatric disorders should
be considered as a part of the evaluation.

Patients whose psychiatric status is unclear should be referred to a mental health

provider. Patients with active substance abuse should be referred to a substance use
treatment program. Consider evaluation for drug-seeking behavior with multiple
pharmacies or prescribing providers using the Wisconsin Prescription Drug Monitoring
Program.

It is important to identify comorbid disorders because they can mimic ADHD.

a. Comorbid or alternative psychiatric conditions should be addressed prior to
starting treatment for ADHD.
b. Certain medical conditions (liver disease, seizures, hypertension, glaucoma)
are relative contraindications to certain ADHD medications.

CONSIDER REFERRAL (Class I, LOE C)

Referral to psychiatrists and additional providers is always at the discretion of the
provider. There are several presentations and co-conditions for which referral is
recommended:
1. Extreme dysfunction
2. Suicidality or homicidality
3. Substance abuse or dependence
4. Psychosis
5. Extreme psychosocial stressors
6. Previous treatment failures
7. Atypical presentation – if presentation as brand new symptoms this is not
ADHD, even if not diagnosed as a child the symptoms must concur

3. ESTABLISH DIAGNOSIS
To diagnose ADHD, the clinician should determine that DSM-5 criteria have been met.
(Class I, LOE B)

DSM-5 Diagnostic Criteria

A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with

functioning or development, as characterized by (1) and/or (2):

1. Inattention: Six (or more) of the following symptoms have persisted for at least 6
months to a degree that is inconsistent with developmental level and that negatively
impacts directly on social and academic/occupational activities:
Note: The symptoms are not solely a manifestation of oppositional behavior,
defiance, hostility, or failure to understand tasks or instructions. For older

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 adolescents and adults (age 17 and older), at least five symptoms are
required.
a. Often fails to give close attention to details or makes careless mistakes in
schoolwork, at work, or during other activities (e.g., overlooks or misses
details, work is inaccurate).
b. Often has difficulty sustaining attention in tasks or play activities (e.g., has
difficulty remaining focused during lectures, conversations, or lengthy
reading).
c. Often does not seem to listen when spoken to directly (e.g., mind seems
elsewhere, even in the absence of any obvious distraction).
d. Often does not follow through on instructions and fails to finish
schoolwork, chores, or duties in the workplace (e.g., starts tasks but
quickly loses focus and is easily sidetracked).
e. Often has difficulty organizing tasks and activities (e.g., difficulty managing
sequential tasks; difficulty keeping materials and belongings in order;
messy, disorganized work; has poor time management; fails to meet
deadlines).
f. Often avoids, dislikes, or is reluctant to engage in tasks that require
sustained mental effort (e.g., schoolwork or homework; for older
adolescents and adults, preparing reports, completing forms, reviewing
lengthy papers).
g. Often loses things necessary for tasks or activities (e.g., school materials,
pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile
telephones).
h. Is often easily distracted by extraneous stimuli (for older adolescents and
adults, may include unrelated thoughts).
i. Is often forgetful in daily activities (e.g., doing chores, running errands; for
older adolescents and adults, returning calls, paying bills, keeping
appointments).

2. Hyperactivity and impulsivity: Six (or more) of the following symptoms have
persisted for at least 6 months to a degree that is inconsistent with developmental
level and that negatively impacts directly on social and academic/occupational
activities:
Note: The symptoms are not solely a manifestation of oppositional behavior,
defiance, hostility, or a failure to understand tasks or instructions. For older
adolescents and adults (age 17 and older), at least five symptoms are
required.
a. Often fidgets with or taps hands or feet or squirms in seat.
b. Often leaves seat in situations when remaining seated is expected (e.g., leaves
his or her place in the classroom, in the office or other workplace, or in other
situations that require remaining in place).
c. Often runs about or climbs in situations where it is inappropriate. (Note: In
adolescents or adults, may be limited to feeling restless.)
d. Often unable to play or engage in leisure activities quietly.

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 e. Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or
uncomfortable being still for extended time, as in restaurants, meetings; may be
experienced by others as being restless or difficult to keep up with).
f. Often talks excessively.
g. Often blurts out an answer before a question has been completed (e.g.,
completes people’s sentences; cannot wait for turn in conversation).
h. Often has difficulty waiting his or her turn (e.g., while waiting in line).
i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or
activities; may start using other people’s things without asking or receiving
permission; for adolescents and adults, may intrude into or take over what others
are doing).
B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12
years.
C. Several inattentive or hyperactive-impulsive symptoms are present in two or more
settings (e.g., at home, school, or work; with friends or relatives; in other activities).
D. There is clear evidence that the symptoms interfere with, or reduce the quality of,
social, academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of schizophrenia or
another psychotic disorder and are not better explained by another mental disorder
(e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder,
substance intoxication or withdrawal).

DSM-5 Diagnosis
Specify whether:
Combined presentation: If both Criterion A1 (inattention) and Criterion A2 (hyperactivity-
impulsivity) are met for the past 6 months.
Predominantly inattentive presentation: If Criterion A1 (inattention) is met but Criterion A2
(hyperactivity-impulsivity) is not met for the past 6 months.
Predominately hyperactive/impulsive presentation: If Criterion A2 (hyperactivity-impulsivity)
is met and Criterion A1 (inattention) is not met for the past 6 months.

Specify if:
In partial remission: When full criteria were previously met, fewer than the full criteria have
been met for the past 6 months, and the symptoms still result in impairment in social, academic,
or occupational functioning.

Specify current severity:

Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, and
symptoms result in no more than minor impairments in social or occupational functioning.
Moderate: Symptoms or functional impairment between “mild” and “severe” are present.
Severe: Many symptoms in excess of those required to make the diagnosis, or several
symptoms that are particularly severe, are present, or the symptoms result in marked
impairment in social or occupational functioning.

4. PROVIDE TREATMENT
(Class I, LOE C unless otherwise indicated)
1. Provide or offer referral regarding ADHD symptom management, and psycho-
education or effective coping strategies for both the patient and family.

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 2. Follow medication treatment protocol and medication chart (Appendix B and
Appendix C). (Class I, LOE A) Specific patient needs or wishes should be
considered and therapy should be individualized.
3. Little data is available on the use of therapeutic stimulants in pregnancy, but
currently they are not associated with major congenital malformations. Risks of
discontinuation of therapy should be considered (e.g., driving, vocational
responsibilities) along with the benefits for each individual patient. (Class IIb,
LOE C)
4. Long term benefit should be assessed for each patient, especially those who
continue treatment from a childhood diagnosis. A trial discontinuation of
therapy can be considered as children age into adulthood to assess ongoing
benefit of therapy.
5. In situations where there is increased risk of substance abuse or diversion,
non stimulant preparations or slow release stimulants are preferred and can be
used to initiate treatment. When crushed, slow release stimulants resemble
immediate release preparations in terms of onset and effect.
6. Adults with ADHD who are also parents may benefit from therapy to assist
them with parenting skills.
7. Consider vocational and/or educational accommodation.
8. For patients at high risk of substance abuse, consider establishing a drug
contract or conducting periodic drug screens.
9. Adjuvant psychotherapy.

5. COMPLETE FOLLOW-UP CARE

Adults with a new diagnosis, uncontrolled symptoms or change in medication should be
seen within 30 days by a clinician who can assess for side effects and adjust medication
if needed. Monthly contacts or visits should be routine until functionality is significantly
improved. Once functionality is improved, follow-up appointments every 3 to 6 months
are recommended. Informants should be included, as available, in follow-up sessions.
(Class I, LOE C)

At each follow-up visit (Class I, LOE C):

1. Review should specifically include diurnal variation in symptoms, as this
informs recommendations for change in timing/formulation of the medications
prescribed.
2. Review target symptoms, job/school performance, relationship issues.
3. Monitor for adherence to therapy, drug side effects/toxicity or signs of
abuse/diversion. Also monitor vital signs to assess for increases in blood
pressure and pulse.
4. Review impressions of informants.
5. Adjust therapy as needed.

Medications must be prescribed in accordance with Wisconsin Chapter 961 for

controlled substances:
1. Prescription must be written for legitimate medical indication.
2. Sign/date prescription on date of issue with:
a. Patient full name/address.
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 b. Drug name, strength, dosage form, quantity, directions for use.
3. Up to 3 monthly prescriptions may be given to patients.
a. The date of issue (date of prescription is written) must be on all three
prescriptions.
b. The prescriber writes “fill on or after XX/XX/XXXX” for two prescriptions to be
filled at a later date.
c. A prescription for a CII controlled substance cannot be dispensed more than
60 days after the date of issue on the prescription order.

Disclaimer
CPGs are described to assist clinicians by providing a framework for the evaluation and
treatment of patients. This Clinical Practice Guideline outlines the preferred approach
for most patients. It is not intended to replace a clinician’s judgment or to establish a
protocol for all patients. It is understood that some patients will not fit the clinical
condition contemplated by a guideline and that a guideline will rarely establish the only
appropriate approach to a problem.

References
1. Meszaros A, Czobor P, Balint S, Komlosi S, Simon V, Bitter I. Pharmacotherapy of adult
attention deficit hyperactivity disorder (ADHD): a meta-analysis. Int J Neuropsychopharmcol.
2009:12(8): 1137-1147.
2. Faraone, SV, Glatt SJ. A comparison of the efficacy of medications for adult attention-
deficit/hyperactivity disorder using meta-analysis of effect sizes. J Clin Pshychiatr 2010:
71(6): 754-763.
3. Weiss N. Assessment and treatment of ADHD in adults. Psychiatric Annals. 2011: 41(1):
23-31. Pediatrics 2011: 128: 1007-1022.
4. Greenhill, Laurence, Pliszka, Steven,et al., Practice Parameter for the Use of Stimulant
Medications in the Treatment of Children, Adolescents, and Adults; J Am Acad of Child
Adoles Psychiatry. 2002; 41 (2 Supplement): 26S – 49S.
5. Kessler, Ronald; Adler, Lenard; et al, Patterns and Predictors of Attention-
Deficit/Hyperactivity Disorder Persistence into Adulthood: Results from the National
Comorbidity Survey Replication. Biol Psychiatry 2005; 57: 1442-1451.
6. Kessler, Ronald; Adler, Lenard; et al, The World Health Organization Adult ADHD Self-
Report Scale (ASRS): a Short Screening Scale for Use in the General Population.
Psychological Medicine, 2005; 35: 245-256.
7. McGough, James J and Russell Barkley, Diagnostic Controversies in Adult Attention Deficit
Hyperactivity Disorder. Am J Psychiatry 2004; 161:1948-1956.
8. Montano, Brendan, Diagnosis and Treatment of ADHD in Adults in Primary Care. J Clin
Psychiatry 2004; 65: (suppl 3): 18-21.
9. Searight, Russell, Burke, John and Fred Rottnek, Adult ADHD: Evaluation and Treatment in
Family Medicine. Am Fam Physician 2000; 62: 2077-86.
10. Weiss, Margaret and Candice Murray, Assessment and Management of Attention-Deficit
Hyperactivity Disorder in Adults. SMAJ; 168: 715-22.
11. Meijer WM, Faber A, van den Ban E, and Tobi H. Current Issues Around the
Pharmacotherapy of ADHD in Children and Adults. Pharm World Sci 2009; 31:509-16.
12. Nutt DJ, Fone K, Asherson P, Bramble D, et al. Evidence-based guidelines for management
of attention deficit/hyperactivity disorder in adolescents in transition to adult services and in

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 adults: Recommendations from the British Association for Psychopharmacology. J
Psychopharmcol 2007; 21: 10-41.
13. National Collaborating Center for Mental Health, Attention deficit hyperactivity disorder.
Diagnosis and management of ADHD in children, young people and adults. London (UK):
National Institute for Health and Clinical Excellence (NICE)’ 2008 Sep. 59 p (Clinical
guideline; no. 72).
14. Surman Craig BH. ADHD in Adults. Medscape 2005 Weiss Nicholas. Assessment and
Treatment of ADHD in Adults. (Psychiatric Annals) 2011 Jan: Vol 41:1.
15. Freeman, MP. ADHD and pregnancy. Am J Psychiatry 2014; 171:723-728.
16. Volkow, ND, Swanson, JM. Clinical practice: Adult attention deficit-hyperactivity disorder.
New England Journal of Medicine 2013;369:1935-1944.

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Appendix A

Figure 1. AHA/ACC Modified GRADE Grading Scheme

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Appendix B
Adult ADHD Medication Algorithm

Diagnosis of definite or probably adult ADHD made

Co-morbid
Treat/refer co-morbid
YES psychiatric or substance NO Last revised/reviewed: 10/2014
disorder first. ADHD- Adult – Ambulatory Guideline
abuse disorder?

At increased
risk for substance
YES NO
abuse/
diversion?
Non-stimulant
medication or slow- Stimulant or
release simulant non-stimulant
medication medication

If stimulant chosen,
consider drug
contract and/or
periodic drug
screens.

Improved
symptoms/function
YES NO
on monthly follow-
up?

Adjust dose or try alternative

medication.

If repeated adjustments of
Continue medication with medication are not successful,
3-6 month follow-up reconsider diagnosis, and consider
referral to psychiatry.

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 Appendix C
Medications for Treatment of Attention-Deficit/Hyperactivity Disorder
GENERAL CONSIDERATIONS FOR STIMULANTS
• Consider cardiac risk factors before initiating therapy • Monitor patient weight and vital signs
• Use cautiously if history of tics • Pellet/beaded capsule formulation may be opened and sprinkled on soft
• Give with/after food and swallow whole with liquids food
• Longer-acting stimulants may have greater problematic effects on • Nonabsorbable tablet shell may be seen in stool (Concerta)
evening appetite and sleep • Consider cardiovascular evaluation before initiating therapy
• Use cautiously if history of substance abuse or diversion concern
Methylphenidate Products
Usual Dosing
Strengths Duration of Adult Titration Dose
Product Names Maximum Daily Dose
Available Action (titrate every 7 days, unless
otherwise indicated)

methylphenidate tab^* 5-20 mg given 2-3 times daily FDA: 60 mg

5,10, 20 mg tab ≤ 4 hours
(Ritalin) Titrate by 5-10 mg every 7-14 days Off label: 100 mg if over 50 kg
Short acting
methylphenidate ^* (Methylin) 2.5, 5, 10mg chew tab
5–20 mg given 2-3 times daily FDA: 60 mg
(equivalent to Ritalin) 5 mg/5mL, 10mg/5mL ≤ 4 hours
Titrate by 5-10 mg every 7-14 days Off label: 100 mg if over 50 kg
solution
methylphenidate SR tab^* 20–60 mg (divided in 1-2 doses/day)
(Ritalin SR) 4 – 6 hours (20-40 mg in morning, 20 mg in FDA: 60 mg
20 mg tab
Medadate ER and generics rated early afternoon) Off label: 100 mg if over 50 kg
AB equivalent Titrate by 20 mg/day
Intermediatemethylphenidate^* (Methylin ER) 10,20 mg tablet
acting 10-60 mg daily FDA: 60 mg
(equivalent to Ritalin SR) 4 – 6 hours
Off label: 100 mg if over 50 kg
4-6 hours
Methylphenidate tab^* 20-60 mg daily FDA: 60 mg
20 mg tablet 4 – 6 hours
(Metadate ER) (divided in 1-2 doses/day) Off label: 100 mg if over 50 kg
dexmethylphenidate^* (Focalin) 2.5–10 mg given twice daily at least FDA: 20 mg
2.5, 5, 10 mg tab 4 – 6 hours
cap 4 hours apart Off label: 50 mg

15
 Usual Dosing
Strengths Duration of Adult Titration Dose
Product Names
Available Action (titrate every 7 days, unless Maximum Daily Dose
otherwise indicated)
methylphenidate*^ (Metadate CD)
cap (bimodal release with 30% 10, 20, 30, 40, 50, 60 FDA: 60 mg
10-60mg daily
immediate release and 70% mg capsule 6 – 8 hours Off label: 100 mg if over
Titration 10-20 mg
Intermediate delayed release) 50 kg
acting
methylphenidate ER*^§ (Ritalin LA)
6-8 hours cap FDA: 60 mg
10, 20, 30, 40 mg
(bimodal release with 50% rapid 6 – 8 hours 20-60mg daily Off label: 100 mg if over
capsule
onset and 50% delayed release) 50 kg

dexmethylphenidate*^§ (Focalin 10 - 12
XR) (bimodal release with 50% 5, 10, 15, 20, 25, 30, hours
immediate release and 50% 35, 40 mg capsule 5-20 mg 5–40 mg daily FDA: 40 mg
delayed release) once Off label: 50 mg
daily

12 hours
methylphenidate ^ (Daytrana) 10, 15, 20, 30 mg (with 2 -3
10-30mg patch daily
Long acting patch patch hour FDA: 30 mg
Titrate by next highest strength patch
apply to hip for 9 hours delay)

FDA: 54 mg for children,

Methylphenidate*^§ (Concerta) tabs
72 mg for adolescents
(bimodal release with immediate
18, 27, 36, 54 mg tab 10 hours 18-54mg once daily and adults
onset and delayed release)
(titrate by 18 mg) Off label:
90 mg adolescents
(>40 kg)
^ FDA approved for treatment of ADHD, * Generic product, §Oral long acting methylphenidate products have immediate release and extended release
components.
.

16
 Amphetamine Products
Usual Dosing
Duration
Product Names Strengths Available (titrate every 7 days, unless Maximum Dose
of action
otherwise noted)
Short acting Dextroamphetamine* 5, 10 mg tablet 4-6 hours 2.5 -15 mg two to three times FDA: 40 mg
1 mg/mL solution Daily Off label: 60 mg
Titration 5 mg/week (>50 kg)
Intermediate acting dextroamphetamine capsule SR*§ 5, 10, 15 mg capsule 6-8 hours 5-15mg 2 timestwice daily FDA: 40 mg
(Dexedrine spansules) (bimodal release with Titration 5 mg Off label: 60 mg
50% immediate release and 50% delayed (>50 kg)
release)
amphetamine mixed salts tab ^combo* 5, 7.5, 10, 12.5, 15, 20, 5-8 hours 52.5-30mg FDA: 40 mg
(Adderall) * 30 mg tab 1-2 times once or twice daily Off label: 40 mg
Titration 2.5-5 mg once (≤ 50kg), 60 mg
or twice daily (>50 kg)
Long acting amphetamine mixed salts capsule^* combo 5, 10, 15, 20, 25, 30 10 hours 10-30mg once daily FDA: 30 mg
(Adderall XR)*§ (bimodal release with 50% capsule Titration 5-10 mg Off-label: 30 mg
immediate release and 50% delayed (≤ 50kg),
release) 60 mg (>50 kg)
lisdexamfetamine (Vyvanse) capsule^ 20, 30, 40, 50, 60, 10-12 hours 20-70mg once daily FDA: 70 mg
70 mg capsule Titration 10-20 mg daily

^ FDA approved for treatment of ADHD, * Generic product, §Oral long acting methylphenidate products have immediate release and extended release
components.

17
 GENERAL CONSIDERATIONS FOR NON-STIMULANTS
• May be used in cases of history of tics worsening from stimulants • Give with/after food and swallow whole with liquids
• Avoid bupropion if history of seizure or eating disorders • Medication of choice if concern about abuse or diversion
• Monitor closely for behavioral side effects including suicidal ideation with • Consider cardiovascular risk factors before initiating tricyclic therapy and
atomoxetine, tricyclics, and bupropion as identified in FDA Black Box evaluate further if needed
warning for anti-depressants • Consider initiation with lower doses to improve tolerability
• Guanfacine and clonidine may be used as adjunctive therapy with stimulants.

Non-Stimulant Products

Product Names Strengths Available Duration of Action Usual Dosing Maximum Dosing

nortriptyline* (Pamelor,
10, 25, 50, 75 mg
Aventyl) 0.5 mg/kg/day (May divide dose to 2 mg/kg or 100 mg
capsule 8-24 hours
2-3 times daily) (whichever is lowest)
10 mg/5 mL solution

6 mg/kg/day (or 300 mg

3 -6 mg/kg/day (or
bupropion* (Wellbutrin) 75, 100 mg tab Whichever is lowest)
4-5 hours 150 mg – 300 mg, whichever is lowest)
Anti- Divide into 2 or 3 daily doses
Divide into 2 or 3 daily doses
depressants
bupropion SR* 3 -6 mg/kg/day (or 6 mg/kg/day (or 300 mg
100, 150, 200 mg tab
(Wellbutrin SR) 12 hours 150 mg – 300 mg, whichever is lowest) whichever is lowest)
Divide into 2 daily doses. Divide into 2 daily doses.

bupropion XL* 3 -6 mg/kg/day (or 6 mg/kg/day (or 300 mg

150, 300 mg tab 24 hours
(Wellbutrin XL) 150 mg – 300 mg, whichever is lowest) whichever is lowest)
clonidine tab ER^
0.1-0.4 mg/day
(Kapvay) 0.1, 0.2 mg tab At least 10-12 hours 0.4 mg/day
Titration: 0.1 mg every 7 days

Alpha-agonists 0.05 mg
at bedtime; 01 mg (≥ 45 kg)
clonidine* (Catapres) 0.1, 0.2, 0.3 mg tab At least 4-6 hours
Titrate by 0.05 mg (<45 kg) or 0.1 mg 0.4 mg (>45 kg)
(≥ 45 kg) increments to twice daily,
three times daily, four times daily

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 Product Names Strengths Available Duration of Action Usual Dosing Maximum Dosing

0.5 mg at bedtime (<45 kg),

1 mg at bedtime (≥ 45 kg)
guanfacine* (Tenex) 1, 2 mg tab
6-8 hours Titrate by 0.5 mg (<45 kg) or 1 mg 0.4 mg (>45 kg)
(≥ 45 kg) increments to twice daily,
Alpha-agonists three times daily, four times daily

0.05-0.12 mg/kg daily (or 1-4 mg once

guanfacine tab ER^* At least 10-12 hours
1, 2, 3, 4 mg tabs daily) 4 mg/day
(Intuniv)
Titration: 1 mg every 7 days
Norepinephrine
reuptake atomoxetine^ (Strattera) 10, 18, 25, 40, 60, 80, Initial dose )40 mg/day)
At least 10-12 hours FDA: 100 mg/day
inhibitor capsule 100 mg capsule After > 3 days (increase to 80 mg daily)

*Generic product
^ FDA Approved

Potential Harms: Side Effects of Pharmacotherapy

 Stimulants: The most common side effects include appetite decrease, weight loss, insomnia, or headache. Less common side effects include
tics and emotional lability/irritability, liver toxicity, hypertension, cardiac arrhythmia and psychosis.
 Atomoxetine: Side effects of atomoxetine that occurred more often than those with placebo include gastrointestinal distress, sedation, and
decreased appetite.
 The U.S. Food and Drug Administration (FDA) and its Pediatric Advisory Committee have reviewed data regarding psychiatric adverse events
to medications for the treatment of attention deficit/hyperactivity disorder (ADHD). For each agent examined (all stimulants, atomoxetine, and
modafinil), there were reports of rare events of psychotic symptoms, specifically involving visual and tactile hallucinations of insects.
Symptoms of aggression, suicidality (but no completed suicides), and cardiovascular issues were also reported.
 Bupropion may cause mild insomnia or loss of appetite. The highest recommended dose of bupropion is 450 mg. Higher doses may increase
the risk of seizure.
 Tricyclic Antidepressants (TCAs) such as nortiptyline - frequently cause anticholinergic side effects such as dry mouth, sedation, constipation,
changes in vision, or tachycardia. Among the TCAs, desipramine should be used with extreme caution in children and adolescents because
there have been reports of sudden death. For TCAs electrocardiography should be considered for patients at risk and be performed at
baseline and after each dose increase. Once the patient is on a stable dose of the TCA, a plasma level should be obtained to ensure the level
is not in the toxic range.
 Alpha- agonists: Side effects of alpha-agonists include sedation, dizziness, and possible hypotension. Abrupt discontinuations of alpha-agonist
are to be avoided.
 Combinations of Medications: There have been four deaths reported to the FDA of children taking a combination of methylphenidate and
clonidine, but there were many atypical aspects of these cases.

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