1. Components of a Comprehensive ADHD Treatment Plan Jennifer A. Ganem MS, APRN Londonderry Square 50 Nashua Road, Suite 208 Londonderry, NH 03053-3221 (603) 432-3399

2. Jennifer A. Ganem MS, APRN Educational/ Workplace Accommodations Community Support Medication Behavioral Intervention Coaching ADHD

3. Community Support CHADD Support Groups Local Regional National Virtual Parent Support Groups Hospitals/ Behavioral Health Center Parent/ School Collaborative Groups Jennifer A. Ganem MS, APRN

4. Educational / Workplace Accommodations Individuals with Disabilities Education Act (IDEA) Section 504 of the Rehabilitation Act of 1973 A child's disability must "substantially limit" the child’s ability to learn requiring the need for specialized services or accommodations All determinations of “substantial limitation” must be made without regard to the "ameliorative effects of mitigating measures“ This means that the question of whether a "substantial limitation" exists must be determine before any intervention for that limitation is implemented "Mitigating measures" includes such things as medication, assistive technology, learned behavioral modifications, psychotherapy, and/or reasonable accommodations Parent Information Center provides workshops on the special education process and have trained advocates for a nominal fee http://www.parentinformationcenter.org Jennifer A. Ganem MS, APRN

5. Coaching Coaches assist ADHDers with identifying their personal strengths and weaknesses developing concrete strategies to manage their symptoms in all areas of life Coaches are supportive and hold ADHDers accountable Coaching can be done in-person, via the phone and/or virtually Coaching can be individual, couples and/or group Resources to locate an ADHD Coach: www.CHADD.org www.adhdcoaches.org www.addresources.org Jennifer A. Ganem MS, APRN

6. Behavioral Interventions Incentive charts, token systems… Social Skills Groups “Therapy” learn to manage symptoms of co-morbid mental health disorders, such as depression, anxiety, oppositional behavior, tic disorders, OCD… Can be individual, family and/or group Jennifer A. Ganem MS, APRN

7. Medication A prescriber should: Explain all of your medication options Inform you of the potential side effects and how to manage them Inform you how long it will take before the effect of the medication is observed Inform you of what time of day to take the medication and how long the medication will last (duration) Discuss how the medication’s effectiveness will be evaluated over time Inform you how often you’ll need to be seen Instruct you to lock all medication Address ALL OF YOUR CONCERNS Jennifer A. Ganem MS, APRN

8. Long Acting ADHD Meds (amphetamine) Adderall XR (methylphenidate) ConcertaMetadate CDRitalin LA Focalin XR DaytranaQuillivant XR atomoxetine (Strattera) lisdexamphetamine (Vyvanse) Guanfacine XR (Intuniv)

9. How the Long-Acting Stimulants Differ: 1. Mechanism of Action: Methylphenidate is believed to be primarily a dopamine reuptake inhibitor with some mild norepinephrine reuptake inhibition. Amphetamine is believed to be a dopamine reuptake inhibitor and a strong norepinephrine reuptake inhibitor. It’s also thought to block the dopamine pump - increasing dopamine secretion. 2. How they are released 3. The duration of efficacy Jennifer A. Ganem MS, APRN

10. Both methylphenidate and amphetamine have been shown to have similar side effect profile and response rates of 70-75%. If there is a trial of each type of stimulant, the response rate increases to 80-90%. Jennifer A. Ganem MS, APRN

11. Concerta Delivers methylphenidate using an immediate-release coating and a delayed-release osmotic mechanism 22% immediate, 78% delayed release Designed for 12-hour effect Available dosages: 18mg, 27mg, 36mg, 54mg Approved up to 72mg/day (Adolescents commonly need daily doses of 1-1.5mg/kg ) Approved 6-65yo To be effective the tablet can not be broken, crushed or chewed Jennifer A. Ganem MS, APRN

12. Metadate CD Biphasic delivery of methylphenidate using immediate and delayed-release beads within a capsule 30% immediate, 70% delayed Designed for 8-hour effect Available dosages: 10mg, 20mg, 30mg, 40mg, 50mg, 60mg Capsules can be opened and contents mixed with applesauce Approved 6-15yo Jennifer A. Ganem MS, APRN

13. Ritalin LA Biphasic delivery of methylphenidate using immediate and delayed-release beads within a capsule 50% immediate release, 50% delayed Designed for 8-hour effect Available dosages: 10mg, 20mg, 30mg, 40mg Approved 6-12yo Jennifer A. Ganem MS, APRN

14. Daytrana Continuous delivery of methylphenidate through DOT Matrix transdermal patch Efficacy from 2 hours* through 12 hours Approved for a 9 hour wear time (12 hour duration) Available dosages: 10mg, 15mg, 20mg, 30mg Approved 6-12yo * first time point measured in studies Jennifer A. Ganem MS, APRN

15. Quillivant XR Liquid form of extended release methylphenidate (25mg/5ml) 20% immediate release, 80% delayed release 12 hour duration with peak plasma concentration at 5 hours Starting dose is 20mg (4ml) given orally once daily in the morning with or without food. Dosage can be increased 10- 20mg per day to a maximum dose of 60mg daily. Approved 6 and up, but age 65+ have not been studied Jennifer A. Ganem MS, APRN

16. Focalin XR Delivers dexmethylphenidate (active enantiomer of racemic methylphenidate) using immediate and delayed-release beads within a capsule 50% immediate release, 50% delayed 10 to 12-hour effect Available dosages: 5mg, 10mg, 15mg, 20mg, 30mg Capsules can be opened and contents mixed with applesauce Approved 6yo-adult Jennifer A. Ganem MS, APRN

17. Adderall XR Delivers mixed salts of amphetamine using immediate and delayed-release beads within a capsule 50% immediate release, 50% delayed release Designed for 12-hour effect Available dosages: 5mg, 10mg, 15mg, 20mg, 25mg, 30mg Approved 6yo-adult Jennifer A. Ganem MS, APRN

18. Vyvanse It’s a pro-drug, meaning it doesn’t become active until various processes occur in the body. It’s the most consistently released stimulant from person to person. 13 to 14-hour effect Available dosages: 20mg, 30mg, 40mg, 50mg, 60mg, and 70mg Capsules can be opened and contents mixed with 4 ounces of water Approved 6yo-adults Jennifer A. Ganem MS, APRN

19. Strattera Non-stimulant medication (NE reuptake inhibitor) Designed for 24-hour effect Available dosages: 10mg, 18mg, 25mg, 40mg, 60mg, 80mg Recommended starting dose is 0.3mg/kg/day, which is titrated over 1-3 weeks to a dosage of 1.8mg/kg/day or 80mg Approved 6yo-adults Jennifer A. Ganem MS, APRN

20. Intuniv Non-stimulant medication (long-acting* alpha-2 agonist) Designed for 24-hour effect Starting dose is 1mg with dosage increases of 1mg per week with a final dosage of 0.05-0.12mg/kg Available dosages: 1mg, 2mg, 3mg, 4mg To be effective as a long-acting agent, the tablet can not be broken, crushed or chewed. Approved 6yo-18yo * The short-acting agent (guanfacine/Tenex) is NOT interchangeable Jennifer A. Ganem MS, APRN

21. Common Side Effects Stimulants: headache, lack of appetite, insomnia, mood instability*, stomach pain, increased BP/pulse, exacerbation of tics With Daytrana only – irritant contact dermatitis* Side effects typically decrease with continued use. * = Exceptions. If you these side effects, stop the medication and call your provider ASAP! Strattera: headache, lack of appetite, sedation, mood instability*, stomach pain, increased BP/pulse, exacerbation of tics Intuniv: NO impact on appetite headache, sedation, lack of appetite, decreased BP/pulse Jennifer A. Ganem MS, APRN

22. Managing Decreased Appetite Maximize the hungry times of day by having additional (healthy) food Yogurt smoothies at night Have small protein-based snacks throughout the day Nuts Peanut butter crackers Cheese sticks Greek yogurt Jennifer A. Jennifer A. Ganem MS, APRN APRN – Nov 2013

23. Managing Insomnia – Good Sleep Hygiene Use the bed only for sleeping so that the bed is positively associated with sleeping This means no reading, eating, watching TV, etc… Set and maintain a regular sleep schedule and keep as close to it as possible on weekends Do not take naps during the day Get exposure to sunlight in the morning Get some daytime exercise and avoid exercise 2 hours before bedtime Reduce the use of computers and television within two hours of bedtime, because it can alter natural body rhythms If doing either, wear amber lensed safety glasses for a couple of hours before bedtime to help block the blue light emissions. This allows the brain to produce melatonin. Jennifer A. Ganem MS, APRN

24. Keep the bedroom at a comfortable temperature; keep it dark and free of distractions Mute the cell phone or keep it out of the room! Use a sound machine or fan for white noise Reduce stress and/or try relaxation techniques before bed Take a hot bath or have decaffeinated tea as a drop in body temperature helps increase drowsiness Move the clock so you can’t clock-watch Use nightlights in the bathrooms and hallways Avoid caffeine after 2pm Avoid alcohol before bed Jennifer A. Ganem MS, APRN