Further Outpatient Care

Follow-up for attention deficit hyperactivity disorder (ADHD), previously termed attention deficit disorder (ADD), varies and depends on the patient's profile, the clinician's experience, and the access to healthcare providers.

After the patient's condition is stabilized, a follow-up frequency of every 6-12 weeks is often appropriate for the first year.

After that, patients whose conditions are stable may do best with visits every 4 months to assess their medications.

Psychotherapy may need to be continued for months to years.

Complications

Coexisting neuropsychiatric disorders and learning disorders can complicate the diagnosis and treatment of ADHD (ADD). See History.

Prognosis

The prognosis for patients with ADHD (ADD) is excellent if the following conditions are present:

The patient has no major comorbidity.
Medication management takes into account minor comorbidities and the great range of individual responses.
Patients and caregivers receive appropriate education about ADHD (ADD) and ADHD (ADD) management.
Adherence to therapy continues.
Any and all coexisting learning disabilities are diagnosed, and remediation is scheduled and undertaken.
Any and all coexisting emotional problems are investigated and treated appropriately by a primary care provider or the patient is referred to a mental health professional.

Patient Education

Provide information about the pathophysiology in lay terms.

Provide information about complementary therapeutic approaches to medication (eg, involvement of education specialists, counseling or coaching, school accommodations, parent training).

Provide clinical medication information.

Include appropriate follow-up parameters.

Attend to administrative issues related to medication (eg, prescription writing and safety, compliance with state laws).

Provide emergency information.

Seek school accommodations.

Provide contact information for local and national support organizations.

Provide literature or written resources (eg, books, periodicals).

For excellent patient education resources, visit eMedicineHealth's Mental Health Center. Also, see eMedicineHealth's patient education article Attention Deficit Hyperactivity Disorder.

Questions

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Pliszka SR, Wilens TE, Bostrom S, Arnold VK, Marraffino A, Cutler AJ, et al. Efficacy and Safety of HLD200, Delayed-Release and Extended-Release Methylphenidate, in Children with Attention-Deficit/Hyperactivity Disorder. J Child Adolesc Psychopharmacol. 2017 Aug. 27 (6):474-482. [QxMD MEDLINE Link]. [Full Text].
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Table 1. Pediatric Dosing of Stimulant Medications

Table 1. Pediatric Dosing of Stimulant Medications

Medication	Initial Pediatric Dose	Pediatric Dosage Range and Maximum Dose*	Common Pediatric Dose*	Preparations
Methylphenidate immediate release (IR) (Ritalin, Methylin, generic)	2.5-5 mg	0.1-0.8 mg/kg/dose PO qd to 5 times/d; not to exceed 60 mg/d	0.3-0.5 mg/kg/dose PO tid/qid	All preparations available as 5-mg, 10-mg, or 20-mg scored tabs; Methylin also available as 2.5-mg, 5-mg, or 10-mg chewable tab and PO solution (5 mg/5 mL and 10 mg/mL)
Methylphenidate sustained-release (SR) (Ritalin LA, Metadate CD)	Convert from IR or use 10 mg.	0.2-1.4 mg/kg/dose PO qd/tid; not to exceed 60 mg/d	0.6-1 mg/kg/dose PO qd/bid	10-mg, 20-mg, 30-mg, or 40-mg tabs (Metadate also has 50-mg and 60-mg tabs.); can be sprinkled into soft food (Do not cut, crush, or chew.)
Methylphenidate extended release (ER)‡ (Ritalin SR, Methylin ER, Metadate ER, Quillivant XR, generic SR)	Convert from IR May initiate treatment with Quillivant XR	0.2-1.4 mg/kg/dose PO qd/tid; not to exceed 60 mg/d Quillivant XR: Once daily dosing	0.6-1 mg/kg/dose PO qd/bid	20-mg Spansules (Do not cut, crush, or chew) Quillivant XR 5 mg/mL suspension
Methylphenidate OROS tablets (Concerta)	Convert from IR or use 18 mg.	0.3-2 mg/kg PO qd; not to exceed 54 mg/d	0.8-1.6 mg/kg PO qd	18-mg, 27-mg, 36-mg, and 54-mg tabs (Do not cut, crush, or chew.)
Methylphenidate Delay-release/extended-release (Jornay PM)	20 mg PO at 8 pm	Titrate weekly in increments of 20 mg; not to exceed 100 mg/day	Adjust timing of administration between 6:30 pm and 9:30 pm to optimize tolerability and efficacy the next morning and throughout the day	20-mg, 40-mg, 60-mg, 80-mg, 100-mg capsules; can be sprinkled into soft food (Do not cut, crush, or chew)
Methylphenidate transdermal patch (Daytrana)^†	Convert from IR or use 10 mg (12.5 cm² patch) released over 9 h and titrate up prn.	0.3-2 mg/kg released over 9 h; not to exceed one 30-mg patch	10-30 mg released over 9 h	10-mg, 15-mg, 20-mg, 30-mg patches, applied to the hip
Dexmethylphenidate IR (Focalin)	2.5-5-mg	0.1-0.5 mg/kg/dose PO qd to qid; not to exceed 20 mg/d	0.2-0.3 mg/kg/dose PO bid/tid	2.5-mg, 5-mg, or 10-mg scored tabs (Do not cut, crush, or chew.)
Dexmethylphenidate extended release (Focalin-XR)	5-10-mg	0.2-1 mg/kg/dose PO qd to bid; not to exceed 20 mg/d	0.4-0.6 mg/kg/dose PO qd/bid	5-mg, 10-mg, or 20-mg scored tabs; can be sprinkled into soft food (Do not cut, crush, or chew.)
Serdexmethylphenidate/dexmethylphenidate (Azstarys)	26.1mg/5.2mg	After 1 week, increase to 52.3 mg/10.4 mg qAM OR Decrease to 26.1 mg/5.2 qAM	Not to exceed 52.3 mg/10.4 mg	Capsules: 26.1mg/5.2mg; 39.2mg/7.8mg; 52.3mg/10.4mg May open capsule and sprinkle entire contents into 50 mL of water or over 2 tablespoons of applesauce
Dextroamphetamine (Dexedrine, Dextrostat)	2.5-5 mg	0.1-0.7 mg/kg/dose PO qd/qid; not to exceed 60 mg/d	0.3-0.5 mg/kg/dose PO qd/tid	Dexedrine: 5-mg scored tabs; Dextrostat: 5-mg and 10-mg scored tabs
Dextroamphetamine Spansules (Dexedrine CR)	5 mg	0.1-0.75 mg/kg/dose PO qd/bid; not to exceed 60 mg/d	0.3-0.6 mg/kg/dose PO qd/bid	5-mg, 10-mg, or 15-mg Spansules; can be sprinkled into soft food (Do not cut, crush, or chew.)
Dextroamphetamine Transdermal (Xelstrym)	6-17 years: Apply 4.5 mg/9 hr patch initially	May increase by increments of 4.5 mg/week; not to exceed 18 mg/9 hr Titrate dose according to patient’s clinical response and tolerability	4.5 mg/9hr to 18 mg/9hr	Apply to application site 2 hr before an effect is needed and remove within 9 hr after application Use only 1 patch/24 hr
Mixed amphetamine salts IR (Adderall, generic)	2.5-5 mg	0.1-0.7 mg/kg/dose PO qd/qid; not to exceed 40 mg/d	0.3-0.5 mg/kg/dose PO tid/qid	5-mg, 7.5-mg, 10-mg, 12.5-mg, 15-mg, 20-mg, or 30-mg scored tabs
Mixed amphetamine salt XR (Adderall-XR)	Convert from IR or use 5-10 mg	0.2-1.4 mg/kg/dose PO qd/tid Not to exceed 30 mg/d	0.6-1 mg/kg/dose PO qd/bid	5-mg, 10-mg, 15-mg, 20-mg, 25-mg, or 30-mg Spansules; can be sprinkled into soft food (Do not cut, crush, or chew.)
Lisdexamfetamine (Vyvanse)	30 mg PO qam	30-70 mg PO qam	Data limited	20-mg, 30-mg, 40-mg, 50-mg, 60-mg, or 70-mg caps (Swallow cap whole, sprinkle into soft food, or dissolve contents in glass of water and drink immediately.)Risk of apnea in patients with chronic pulmonary disease; closely monitor these patients, when initiating and titrating therapy; alternatively, consider the use of alternative non-opioid analgesics in these patients (see Black Box Warnings and Contraindications)
Amphetamine (Evekeo, Dyanavel XR), Adzenys XR-ODT	Evekeo: 2.5 mg PO BID/TID Dyanavel XR: 2.5-5 mg PO once daily Adzenys XR-ODT: 6.3 mg PO qAM	Evekeo: 2.5 mg BID/TID; only in rare cases is it necessary to exceed 40 mg/day Dyanavel XR: 2.5-5 mg/day; not to exceed 20 mg/day Adzenys XR-ODT: Not to exceed 18.8 mg/day (aged 6-12 y) or 12.5 mg/day (aged 13-17 y)	Data limited	Evekeo: 5-mg, 10-mg tablets Dyanavel XR: 2.5-mg/mL extended-release oral suspension (do not substitute oral suspension for other amphetamine products on a milligram-per-milligram basis) Adzenys XR-ODT: 3.1-mg, 6.3-mg, 9.4-mg, 12.5-mg, 15.7-mg, 18.8-mg extended-release oral disintegrating tablets
Note. In general, when the terms methylphenidate, Dexedrine, and Ritalin are used without abbreviations for extended-release preparations (eg, continuous release [CR], SR, osmotic-release oral system [OROS]), a short-acting, IR preparation is implied. ^* Maximum pediatric dose suggested by the US Food and Drug Administration (FDA). Although some children benefit greatly from doses greater than these, benefit from use of either the lowest and highest ends of the dose range is uncommon. †The methylphenidate patch contains a different total methylphenidate dose than the name implies because it is designed to last 12 hours (eg, 10-mg patch [patch size 12.5 cm²] delivers about 10 mg over 9 h [estimated delivery rate is 1.1 mg/h for this particular patch]). Delivery rate varies depending on patch size. ‡Many patients describe their experience with methylphenidate SR preparations as erratic and uncomfortable.

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Author

Maggie A Wilkes, MD Resident Physician, Department of Psychiatry, Medical University of South Carolina College of Medicine

Maggie A Wilkes, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Medical Association, American Psychiatric Association

Disclosure: Nothing to disclose.

Coauthor(s)

Stacey M Cobb, MD Fellow in Developmental and Behavioral Pediatrics, Clinical Instructor, Department of Pediatrics, Medical University of South Carolina College of Medicine

Stacey M Cobb, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, Society for Developmental and Behavioral Pediatrics

Disclosure: Nothing to disclose.

Eve G Spratt, MD, MSc Professor of Pediatrics and Psychiatry, Division of Developmental Pediatrics, Medical University of South Carolina; Director, Pediatric Consultation Liaison Psychiatry, Medical University of South Carolina Children's Hospital at Charleston

Eve G Spratt, MD, MSc is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry

Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen School of Medicine

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Acknowledgements

Zainab P Contractor, MD Medical Director, The Affinity Center

Disclosure: Nothing to disclose.

Chet Johnson, MD Professor and Chair of Pediatrics, Associate Director, Developmental Pediatrician, Center for Child Health and Development, Shiefelbusch Institute for Life Span Studies, University of Kansas School of Medicine; LEND Director, University of Kansas Medical Center

Chet Johnson, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Christine A Mayhall, PhD Clinical Psychologist, The Affinity Center

Christine A Mayhall, PhD is a member of the following medical societies: American Psychological Association

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.