ADHD

(Attention Deficit Hyperactivity Disorder)

Treatment Options and Considerations for
Management in Children and Adolescents
 Introduction
Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder caused
by structural, functional, and/or neurotransmitter alterations in the brain that are first
evident in childhood (before the age of 12).1,2 The three hallmarks of ADHD are inattention,
hyperactivity, and impulsivity.3 These symptoms are evident to varying degrees in
individuals with ADHD.

ADHD was recognized as a medical condition over 200 years ago.4 Its prevalence is now
estimated at 5-9% for children and 3-5% for adults in Canada.2 ADHD can have an impact
on many aspects of life, including learning ability, behaviour, and emotional regulation.
Many additional mental health conditions and learning disabilities may co-exist or
complicate the diagnosis of ADHD. These are commonly known as comorbidities.2

Although ADHD is the most common childhood psychiatric disorder in Canada, it remains
under-recognized and underdiagnosed.5 Optimal treatment for ADHD consists of a
combination of non-pharmacological (e.g., behavioural therapies) and pharmacologic
therapies.3 The Canadian ADHD Resource Alliance (CADDRA) guidelines list five tiers of
holistic-based care for ADHD:3
1. Adequate education of parents/caregivers and their families
2. Behavioural and/or occupational interventions
3. Psychological treatment
4. Educational accommodation
5. Medical management

ADHD is the most treatable mental health condition.6 Pharmacists are in a unique position
in the community to improve ADHD awareness and to provide support for parents,
caregivers, teachers, and patients.

The goal of this guide is to help pharmacists improve the quality of life for parents/
caregivers and patients through education as well as recommendation of appropriate
individualized treatment options for the management of ADHD.

V1.0_2018 i
 Table of Contents

Learning Objectives ▪ ADHD Overview 3

After successful completion of this learning activity pharmacists will be better able to: ▪ Principles of ADHD Management in Children and Adolescents 15
• Describe the symptoms of ADHD and reasons for suspecting ADHD in children
and adolescents ▪ Pharmacological Management of ADHD 23
• Dispel myths surrounding ADHD
• Review ADHD comorbidities ▪ Focus on Communication/Counselling and Education of Parents/Caregivers 37
• Discuss the classes and individual medications used for management of ADHD with
respect to mechanism of action and benefit/risk profiles used to individualize treatment ▪ References 45
recommendations
• Gain an understanding of the assessment of bioequivalence of drugs used for treatment ▪ CE Questions 51
of ADHD
▪ Notes 57
• Communicate with parents/caregivers and teachers in a manner that promotes improved
knowledge about ADHD and related management strategies, and ultimately enhances
ADHD outcomes

Author: Tom Smiley BScPhm, PharmD, CTE

Expert Reviewers:
• Dean Elbe BScPharm, PharmD, ACPR, BCPP
• Jacinthe Leblanc Baccalauréat, Pharmacy, BCPP, PgCert Psychiatric Therapeutics

Disclosure: The author wishes to declare that he has no conflicts of interest. One of the expert reviewers declares
that she has been a member of an advisory board and a conference speaker for a company other than this sponsor.

© 2018 Teva Canada Limited. All rights reserved.

Disclaimer: This guide has been prepared by pharmacists for pharmacists, in consultation and collaboration with
Teva Canada Limited and its healthcare specialty services partner, Pear Healthcare Solutions Inc. While every
effort has been made to ensure the accuracy and integrity of the evidence-based medical and pharmacological
information and advice contained in this guide, pharmacists and other healthcare professionals using this guide
must continue to (a) exercise their own independent clinical judgment when counselling patients or providing
medical or pharmaceutical care within their scope of practice and authorized acts, and (b) follow all policies,
procedures and guidance of their governing health regulatory college. This guide is not intended for use by
patients or other non-healthcare professionals, and is not a substitute for medical or pharmaceutical advice or
consultation.

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ADHD Overview
 ADHD Overview

Pathogenesis and Epidemiology of ADHD Although criteria for diagnosis of ADHD exist, there are no objective tests that
unequivocally diagnose ADHD.3 For ADHD to be diagnosed, six or more symptoms that
ADHD symptoms vary greatly among individuals with respect to symptom severity, indicate inattentiveness or hyperactivity-impulsivity must be present for at least
combination of symptoms, progression or regression of symptoms, and comorbidities. six months to a degree that negatively impacts directly on social and academic or
Although no single risk factor can explain the cause or course of ADHD, evidence suggests occupational activities.8 Several symptoms must have been present before 12 years of
that first-degree relatives of individuals with ADHD are two to eight times more likely to age and must be present in two or more settings (e.g., school, work, home) and must
be diagnosed with the condition than relatives of individuals who are unaffected.7 There interfere with, or reduce the quality of, social, academic, or occupational functioning. For
is a greater than 50% chance that a parent with ADHD will have a child with ADHD.2 older adolescents and adults (aged 17 and older), at least five symptoms are required to be
present for diagnosis.8
Many different environmental factors are suggested by observational evidence to be
associated with ADHD, but researchers have found it difficult to identify which are The symptoms do not occur exclusively during the course of schizophrenia or another
definitely causal. Environmental factors that have been concluded to be risk factors but psychotic disorder and are not better explained by another mental disorder (e.g.,
not “causal” risk factors include:7 mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance
• Maternal smoking, alcohol use, and substance misuse during pregnancy intoxication or withdrawal).
• Maternal stress or familial conflict
• Low birth weight, obstetrical complications, and prematurity Inattentiveness (≥ six symptoms for at least six months)
• Exposure prenatally or postnatally to toxins such as certain types of pesticides and lead • Often fails to give close attention to details or makes careless mistakes in schoolwork,
It is important to understand that although genetics does play a role in increased risk for at work, or during other activities
ADHD, the effects of inherited and non-inherited factors are interdependent. Therefore, • Often has difficulty sustaining attention in tasks or play activities
when speaking to families it is important to stress that although inheritable risks increase • Often does not seem to listen when spoken to directly
the probability of ADHD, assessing level of increased risk is not possible.7
• Often does not follow through on instructions and fails to finish schoolwork, chores,
or duties in the workplace (not due to oppositional behaviour or failure to understand
Symptoms of ADHD instructions)
• Often has difficulties organizing tasks and activities
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) of the
American Psychiatric Association describes three presentations of ADHD:7 • Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental
effort
1. Predominantly inattentive presentation
• Often loses things necessary for tasks or activities
2. Predominantly hyperactive/impulsive presentation
• Often is easily distracted by extraneous stimuli
3. Combined (inattentive and hyperactive/impulsive) presentation
• Often is forgetful in daily activities
Most individuals with ADHD have combined symptoms of inattention and hyperactivity/
impulsivity, but one set of symptoms may be more prominent than the other. Furthermore,
the presentation may change over time (e.g., hyperactivity may lessen as an individual
ages, and inattentive symptoms may continue or become more functionally impairing).

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 ADHD Overview

Hyperactivity/Impulsivity (≥ six symptoms for at least six months) Dispelling Myths about ADHD
• Often fidgets with or taps hands or feet, or squirms in seat ADHD has been stigmatized over the years. Children diagnosed with ADHD may often be
• Often leaves seat in situations when remaining seated is expected mislabelled as being unmotivated, defiant, and lazy.9 There are a number of additional
myths associated with ADHD that are outlined in the table below.10
• Often runs about or climbs in situations where it is inappropriate
• Often unable to play or engage in leisure activities quietly Myth Fact
• Often is “on the go” or acts as if “driven by a motor” ADHD is a new problem caused by demands ADHD has been documented for over
• Often talks excessively on modern society and watching too much 200 years and there is no evidence that
TV/playing video games/excessive too much “screen time” causes ADHD.
• Often blurts out an answer before a question has been completed smartphone/tablet use.
• Often has difficulty waiting his or her turn
A diet high in sugar can cause ADHD. There is no evidence to show that junk food
• Often interrupts or intrudes on others or high sugar intake causes ADHD or that
diet changes reduce likelihood of an ADHD
ADHD is classified as mild, moderate, or severe according to severity based on social or diagnosis.
occupational functional impairment.9 Symptoms may be in partial remission if full criteria
were previously met, fewer than full criteria have been met in the past six months, and the ADHD can be completely managed by Some children have been observed to
symptoms still result in impairment in social, academic, or occupational functioning. eliminating certain foods from the diet. exhibit more severe hyperactive behaviours
when consuming excessive amounts of
certain sugars, dyes, and preservatives, but
ADHD and Executive Functioning improvement based on elimination of these
foods to minimize ADHD symptoms is not
ADHD coexists with impairment of executive functioning. Executive functioning is the based on clinical trial evidence.3
mental process that allows individuals to start and finish a task on time by planning ahead
Poor parenting causes ADHD. ADHD is not caused by bad parenting. Certain
while applying learning from past experience.9 A person affected by ADHD is likely to parenting techniques can help to improve some
show deficiencies in these areas. Executive functioning skills help individuals to identify symptoms of ADHD.
a problem, find solutions, regulate behaviour and emotions, control attention levels, and
resist distractions. Too many children are diagnosed The level of awareness of ADHD has increased
with ADHD. over the last number of years. ADHD was
Working memory is an important part of executive functioning. It helps people to recall initially thought of as a boy’s illness whereas
learning from past experiences and manipulate it at the same time. Working memory now it is recognized in girls as well.
problems in individuals with ADHD may affect the ability to maintain attention and can
have an effect on reading comprehension, written expression, and math skills.9
Reasons for Suspecting ADHD
It is important to understand that symptoms of ADHD can vary from day to day and hour
to hour. As outlined earlier, it is the level to which the symptoms are expressed and the Symptoms or “red flags” that may prompt a parent, caregiver or teacher to inquire about
inability to regulate them that results in a diagnosis of ADHD. the possibility of ADHD are closely associated with the diagnostic criteria outlined earlier.
The following table has been designed to outline the symptoms in lay language and in a
format that facilitates easy referral.

A handout of ADHD Symptoms/Red Flags can be printed from the Centre for ADHD
Awareness, Canada (CADDAC) website at http://caddac.ca/adhd/understanding-adhd/
in-general/symptoms/.

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ADHD Overview

Also, a teacher and parent rating scale entitled SNAP-IV 26 (Swanson, Nolan and Pelham Assessment of ADHD in Children and Adolescents
Questionnaire) for assessing inattention and hyperactivity/impulsivity is available on
the 3rd edition of the Canadian ADHD Practice (CADDRA) website in the CADDRA ADHD The 2011 CADDRA guidelines contain a number of assessment tools along with instructions
Assessment Toolkit (CAAT) forms section on p. 8.21 - 8.22 at https://caddra.ca/pdfs/ on the particular assessments that each individual involved in the patient’s care should
caddraGuidelines2011_Toolkit.pdf. complete as appropriate.2 The assessment tools recommended by the 4th edition of the
Canadian ADHD Practice guidelines (CADDRA guidelines) for initial information gathering
Symptoms of Attention Dysregulation11 in children and adolescents in whom ADHD is suspected, and for documenting changes
over time, include the SNAP-IV 26 questionnaire (for use by parents/caregivers and
• Difficulty regulating, switching, and • Unable to remember verbal instructions
teachers) as well as the CADDRA Teacher Assessment Form (for use by teachers).2 When
prioritizing attention, including over-focusing • Misinterpreting instructions
on stimulating activities • Unable to pay attention to details appropriate, adolescents may be asked to complete a self-assessment utilizing the
• Easily distracted from the task at hand by • Difficulty completing work without being Adult ADHD Self-Report Scale (ASRS). The Weiss Functional Impairment Rating Scale
noises or things going on around them reminded Self-Report (WFIRS-P) may also be considered for use by parents/caregivers and/or for
• Frequently looking around • Losing things self-assessment by adolescents.
• Difficulty staying focused on one activity • Difficulty organizing belongings and work
• Daydreaming • Difficulty starting things • SNAP-IV 26 Checklist – Very similar to the ADHD checklist (i.e., same number of items
• Not focusing on speaker when spoken to • Forgetting normal routines for attention, hyperactivity/impulsivity, and oppositional defiant disorder), but scoring is
different.
Possible Symptoms of Hyperactivity/Impulsivity11
• CADDRA Teacher Assessment Form – This form provides a structured mechanism for
Hyperactivity Impulsivity
• Fidgeting and squirming • Acting or reacting before considering
the teacher to report on the child’s/adolescent’s academic performance and classroom
• Problems remaining seated consequences performance (behaviours, ability to follow instructions, peer relationships, etc.) as well
• Talking excessively and at inappropriate • Butting into conversations as to indicate any accommodations that are in place and how effective they are.
times • Blurting out answers in the classroom
• Weiss Functional Impairment Rating Scale Self-Report (WFIRS-S) – Symptoms of ADHD
• Often running and climbing • Beginning work before instructions are given
• Standing instead of sitting at the table • Disturbing others’ belongings
do not always result in actual impairment and vice versa. The WFIRS contains items that
• Unable to settle into a quiet activity • Touching, grabbing, hitting others are most likely to represent a patient’s target of treatment. Therefore, it should be used
• Constantly on the go • Problems waiting for turn or standing in line before and after treatment to allow assessment of whether ADHD has improved and if the
• Frequently handling or touching objects • Making impulsive decisions patient’s functional difficulties are better.
and other people
All forms mentioned above can be found online in the CADDRA ADHD Assessment Toolkit
Warning Signs That May Be Present in Learning Environment11
forms section of the 3rd edition of the CADDRA guidelines found at https://caddra.ca/pdfs/
• Inattention • Difficulty understanding what is read caddraGuidelines2011_Toolkit.pdf.
• Easily distracted • Problems paying attention to details
• Incomplete work • Problems with spelling and math
• Problems with getting homework done • Problems with sequencing
• Problems bringing homework and necessary • Forgetting deadlines or difficulty completing
books home work on time
• Difficulty remembering to hand in work • Problems starting and organizing larger
• Not able to produce the same amount and/ assignments and projects
or level of schoolwork as others • Frequent daydreaming
• Need for repeated instructions • Excessive talking, interrupting, blurting out
• Misinterpreting instructions and questions answers
on assignments or tests • Touching, pushing, grabbing others
• Difficulty with handwriting • Problems dealing with frustration

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 ADHD Overview

Effect of ADHD on Children Socially and in Family Interaction ADHD Comorbidities

Although it is common for preschool children to be very active and impulsive, ADHD is It is estimated that 50-90% of all children with ADHD have at least one comorbid
often recognized even at this early stage of life. At this age, children with ADHD tend to be condition, while approximately one-half have at least two comorbidities.² Children with
perceived as more difficult to control and exhibit delayed development and social skills. ADHD who also have comorbid conditions have been shown to have significantly greater
social, emotional, and psychological difficulties than those without comorbid conditions.2, 3
In the primary school years, children with ADHD stand out from their peers with respect
to reduced academic functioning. As a result, they may be rejected by their peers and Presence of a specific learning disorder is evident in up to 45% of children with ADHD.²
develop poor self-esteem. The child may be drawn to a poor peer group in order to gain Executive functioning challenges, discussed earlier, in addition to learning disabilities,
acceptance. Comorbid disorders may become apparent and difficulty sleeping may further further contribute to lower levels of academic achievement compared to the potential
impair behavioural functioning during the day. At this point, families are trying to adapt to of a child with ADHD.² Although some school boards across Canada do not currently
life with a hyperactive and impulsive child, and often struggle. recognize ADHD as qualifying a student as a “special needs student,” the landscape seems
to be changing.² Both CADDRA, the national physicians’ ADHD alliance, and CADDAC,
In some individuals with ADHD, the condition may not be recognized until adolescence. the national parent and patient support and advocacy network, have advocated to the
Some children with ADHD may do very well in elementary school, but ADHD symptoms Ministries of Education for standardized educational accommodations across Canada.²
are uncovered when school becomes more complex in the high school years (multiple CADDRA and CADDAC believe that all neurobiological and mental health disorders need to
teachers, more homework, many projects due at once, etc.).2 be recognized by educational institutions in order for individuals to receive the necessary
multimodal care.²
Research suggests that hyperactivity declines with time in adolescents. However,
difficulties with attention cause more impairment as an individual grows older. Because Beyond a specific learning disorder, comorbidities include:* 2, 3
adolescents are exposed to riskier situations, impulsivity symptoms may lead to a greater
level of experimentation than in those who do not have ADHD.2 Adolescents with ADHD • Oppositional defiant disorder (ODD): ODD is a behavioural problem that is characterized
are at higher risk for school failure, poor social relationships, and motor vehicle accidents by active confrontation of authority (most often parents). A child with ADHD overlapping
and are more likely to experiment with tobacco, alcohol, drugs, and sex.2 Adolescents with with ODD exhibits distinct characteristics which include refusing to comply with rules,
ADHD are twice as likely to abuse substances as those who do not have ADHD.2,3 deliberately annoying others, blaming others for their own mistakes and a spiteful,
vindictive attitude.2
It is important for health professionals to develop a therapeutic alliance with an
adolescent with ADHD and to treat the individual as an adult (i.e., not totally reliant on • Conduct disorder (CD): Children with CD show a pattern of repeated aggression, lying,
parents).² This is why adolescents are often asked to complete their own WFIRS-Self- stealing, vandalizing, and skipping school. CD may be preceded by ODD.2
Report. This approach may prompt the adolescent to be more forthcoming with issues • Anxiety disorders: Up to one-third of children with ADHD have anxiety issues. Anxiety
associated with risky behaviours, which then can provide an opportunity for open can be treated with behavioural interventions (relaxation therapy, yoga, etc.; simplifying
discussion and education. For example, adolescents with ADHD are at higher risk for environment; decreasing activities that cause anxiety), cognitive behavioural therapy,
teenage pregnancy, therefore education about birth control is necessary. and medical treatment (ADHD should be treated first to gauge effect on anxiety and dose
and/or choice of medication adjusted appropriately).

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 ADHD Overview

• Tourette syndrome and Tic disorders – The most common tic disorder is blinking. When • Developmental coordination disorder (DCD) – There is no clear prevalence rate
a patient has Tourette syndrome (combination of motor and vocal tics) and it co-occurs for comorbidity, but individuals with ADHD combined with coordination challenges as
with ADHD and obsessive compulsive disorder, he/she is said to have the “Tourette demonstrated by issues such as balance problems, dyslexia, and poor handwriting have
Syndrome Triad.” a higher risk of poorer ADHD outcomes associated with psychosocial functioning in early
adulthood.
• Epilepsy – Some studies show a higher incidence of ADHD symptoms in children with
epilepsy. There is also a strong trend towards higher incidence of epilepsy among children Additional potential ADHD comorbidities include antisocial personality disorder (ASPD),
with ADHD, and epilepsy tends to be more severe. borderline personality disorder (BPD), and disruptive mood dysregulation disorder (DMDD).
• Obsessive compulsive disorder (OCD) – Although the lifetime prevalence of OCD in the
*Note: Detailed accounts of the comorbidities associated with ADHD are beyond the scope
general population is 1-3%, the reported rates of ADHD-OCD existing together are highly
of this learning activity. Please refer to the 4th edition of the CADDRA guidelines Chapter 2
inconsistent in published studies. When they do occur together the individual has an
at www.caddra.ca.
increased risk of tic disorders and Tourette syndrome.
• Major depressive disorder – There is much overlap between major depression associated
with consistent negative mood and anhedonia (inability to feel pleasure) and ADHD. Differential Diagnosis of ADHD
Overlapping symptoms of ADHD and major depressive disorder include loss of motivation,
It is important to recognize the difference between comorbid conditions discussed
demoralization, problems concentrating, and restlessness or irritability. Depression may
earlier and disorders that “mimic” ADHD. A differential diagnosis ensures that the issues
be secondary to ADHD or vice versa.
being dealt with are those of ADHD and not of another condition that may have similar
• Bipolar disorder – A controversial diagnosis in children and adolescents; the mood characteristics. Many conditions identified earlier as comorbidities such as generalized
disorder presentation should be episodic in nature and not represent chronic mood anxiety disorder, OCD, major depression, bipolar disorder, autism spectrum disorder, and
dysregulation. In most cases in children or adolescents, the condition is comorbid. learning disabilities can coexist with ADHD, or exist without the symptoms that are used
Children with ADHD do not necessarily later develop bipolar disorder. to diagnose ADHD.2 Chapter 2 of the 4th edition of the CADDRA guidelines found at
www.caddra.ca offers charts which distinguish between distinct and overlapping features
• Autism spectrum disorder (ASD) – A high percentage of individuals who meet DSM-5
of ADHD and the comorbid condition of interest.
criteria for ASD meet full criteria for ADHD. (Although the criteria for ASD has been
updated in DSM-5 to include autism, Asperger’s syndrome, childhood disintegrative As there are no tests that “unequivocally” diagnose ADHD, physicians are required to
disorder, and pervasive developmental disorder not otherwise specified, a study showed conduct a thorough history and full functional review along with physical examination
that up to 58% of individuals with autism and 85% with Asperger’s syndrome met full to fulfill a differential diagnosis.2 As mentioned earlier, comorbidities are common.2
criteria for ADHD per DSM-IV criteria.) Therefore, differential diagnosis can be a very complex undertaking. The CADDRA
• Substance use disorders – There is significant risk of ADHD patients using illicit guidelines recommend that the assessing physician consider a second opinion or referral
substances and at an earlier age than general population — especially nicotine, to an ADHD specialist if the patient has a clinical history that is complex.2 A correct
cocaine, and cannabis. It is estimated that individuals with ADHD have twice the risk for diagnostic assessment is critical for appropriate pharmacological therapy prescribing
development of substance use disorders. and patient management.

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Principles of ADHD Management in Children and Adolescents
 Principles of ADHD Management in Children and Adolescents

ADHD Goals of Therapy Two basic types of behaviour management techniques exist:13
1. Antecedent-focused behaviour support strategies: These strategies set children up
The goals of therapy in ADHD include the following:3
for success by provision of a structured environment with reminders to keep them on
• Eliminate or significantly decrease the core ADHD symptoms. track. Organization, consistency, and clear communication with positive, specific
• Improve behavioural, academic, and/or occupational performance. feedback are key.
• Improve self-esteem and social functioning. 2. Consequence-oriented behaviour management strategies: In this approach to
• Minimize adverse effects of medications. behaviour management, the child is rewarded for specific behaviour. This may include
strategies such as awarding children check marks on a chart or gold stars when a
• Improve quality of life. particular behaviour is achieved. The target goal or goals should be discussed with
the child and only one or a few behaviours should be addressed at a time. Once a
Behavioural Therapies certain number of check marks or stars are earned, the child can turn them in for a
reward. The child can chart his/her progress on a graph as a visual reminder of progress
Behavioural therapy with respect to ADHD is associated with teaching parents/caregivers being made. Once the desired behaviour becomes automatic, the child can start
(and possibly teachers) methods for improving the behaviour of a child with ADHD.3 working towards new goals.
Parent- or teacher-training is considered first-line in preschool-aged children, as addition Response-cost procedures refer to the check marks or stars being taken away for specific
of stimulant medications is used only for preschoolers with moderate to severe ADHD who misbehaviour (i.e., it is important for the child to know exactly what he/she has done to
do not respond to behavioural therapy and only if benefit outweighs harm.3 lose the check mark or star).13
A large study (Multisite Multimodal Treatment study of children with ADHD [MTA]) It is important to provide a child with ADHD with more immediate feedback more often.
involving 579 children with combined subtype ADHD and aged 7 to 9 years found When rewards are earned, they should be awarded right away.13
that combined behavioural/pharmacological therapy was equal to pharmacological
therapy alone in terms of benefits on core ADHD symptoms, but combined behavioural/ With respect to helping children with ADHD cope with social and emotional problems, it
pharmacological therapy was more effective at reducing oppositional behaviours and is important for parents/caregivers and teachers to teach, model, and support appropriate
anxiety, and improved social interactions and self-esteem to a greater degree than behaviour as well as provide plenty of positive feedback when appropriate behaviour is
pharmacological or behavioural treatment alone.12 displayed by the child.13
Parent training programs as well as counselling and support groups can be located with Communication between caregivers (e.g., parents and teachers) can help to improve
the help of that patient’s attending physician and through support groups found on the outcomes for children with ADHD. Parents/caregivers should provide teachers with
CADDAC website at: http://caddac.ca/adhd/resources/support-groups/. information about educational history and the interests of their child. Regular communication
between teachers and parents/caregivers is important. This can be facilitated by a system
General areas in which parents/caregivers and teachers can provide support to the child such as a school-home communication notebook. It is critical that the teacher understands
with ADHD include organization, structure, consistency, and communication.13 the special needs of the child.13

Information about counselling patients/caregivers and additional strategies for managing

children with ADHD can be found in the section “Focus on Communication/Counselling and
Education of Parents/Caregivers.”

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 Principles of ADHD Management in Children and Adolescents

Role of Pharmacological Therapies in ADHD Management Bioequivalence of Drugs Used for Treatment of ADHD
The MTA study concluded that pharmacological therapy of ADHD alone was more effective Parents/caregivers/patients and even some physicians may be under the impression that
than behavioural therapy alone for reducing core ADHD symptoms.11 For parents/caregivers brand name drugs are of higher quality and are more effective than generic drugs. This
wondering if they should try behavioural therapy alone in a child diagnosed with ADHD, opinion may be more strongly held when considering medications as clinically important
this is important information. Recall that combined behavioural/pharmacological therapy as medications that treat ADHD.
is not more effective than pharmacological therapy alone for core ADHD symptoms but
is better than either approach alone for some secondary outcomes according to the MTA ADHD medications are expensive, and most often the cost of treatment will be borne by
study results.12 a third-party payer such as the provincial government or an employer. Patients must be
made aware that regardless of the payer, it is in everyone’s best interest to use the least
Details about each of the following medications can be found in the next section expensive version/brand of the same medication. Very often the third-party payer will
(“Pharmacological Management of ADHD”) and in Table 1 (fold-out drug table). insist on it due to fiscal responsibility. It is also very important that providing the generic
version of a medication to a patient not affect adherence or the effectiveness of therapy.

First-line Agents:3 As the medication experts, we need to understand the similarities and differences between
various brands of the same medication ourselves, in order to be confident in our response
The long-acting stimulant medications amphetamine mixed salts (Adderall® XR®), to our patients’ questions. This also enables us to enter into discussions about the processes
lisdexamfetamine (Vyvanse®), methylphenidate controlled-release (Biphentin®), and associated with ensuring that medications are bioequivalent.
methylphenidate extended-release (Concerta®) are considered first-line agents by CADDRA
for management of ADHD due to their superior effectiveness and once-daily dosing (see It is critical that our patients remain confident that they are taking the correct medication.
section on “Pharmacological Management of ADHD”).3,14 This can be accomplished by a pharmacy team that is knowledgeable, communicates
effectively, and anticipates the questions patients are likely to ask.
Second-line Agents:3 Bioavailability is the term used to describe the rate and extent to which an active drug is
absorbed into the bloodstream and is delivered to the site of action.15 This is determined
• Atomoxetine (Strattera®), a non-stimulant selective norepinephrine reuptake inhibitor is by measuring the area under the curve (AUC) of drug concentration in plasma versus time
a second-line monotherapy for the treatment of individuals six years of age and older who and the maximum drug concentration (Cmax) in plasma. AUC correlates well with the total
have not responded to or not tolerated stimulant therapy.3 It is not indicated as adjunctive amount of drug reaching the bloodstream (total drug exposure). In Canada, the amount of
therapy to stimulants but has been used “off-label” for that purpose. active ingredient in the brand name drug and the generic drug must be the same. If two
• Guanfacine XR (Intuniv XR®) is a selective alpha2A-adrenergic receptor agonist and is drugs (e.g., a brand name drug and a generic drug) are “bioequivalent,” it means that there
indicated as monotherapy and as adjunctive therapy to stimulant treatment for children is no clinically-significant difference in their bioavailability.15 However, although the AUC
and adolescents aged 6 to 17 years who have had a suboptimal response to stimulant and Cmax may be the same for two drugs, the time to reach maximum concentration (Tmax)
therapy alone. may be different. As an example, brand name methylphenidate extended-release releases
• Short- and intermediate-acting stimulant medications, dextroamphetamine, 22% of the drug within approximately one hour after ingestion, while the following 78%
dextroamphetamine sustained-release capsule (Spansule®), methylphenidate and is released from an extended-release core.16 There have been reports of issues associated
methylphenidate SR, are indicated for use as required for particular activities; to augment with behavioural changes in some people switching from the brand name to a generic
long-acting formulations early or late in the day, or early in the evening; or when long- drug, which may be associated with differences in Tmax.2 To address these issues, newer
acting stimulant medications are cost-prohibitive. Dextroamphetamine products are used generic formulations of methylphenidate extended-release tablets have been developed
to augment long-acting amphetamine mixed salts and lisdexamfetamine while short-acting that more closely achieve the AUC, Cmax and Tmax of the original formulation.17,18 With respect
methylphenidate products are used to augment methylphenidate extended-release and to changing from brand name methylphenidate extended-release tablets to a generic
methylphenidate controlled-release products. brand, CADDRA states the following: “The decision to switch to a generic formulation is

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 Principles of ADHD Management in Children and Adolescents

an individual-based decision and we strongly advocate that the patient/family be advised Pharmacists and their pharmacy staff have an important role to play in educating patients
of the switch, told to check for clinical changes in efficacy or tolerability and report any about the bioequivalence and quality control requirements of generic and brand name
changes to their pharmacist and doctor.”3 versions of the same drugs. Lecturing patients about their concerns is not a viable
option. Instead, patients should be shown that they are being listened to. Bioequivalence
There is a common misconception that generic drugs are approved if measured principles can then be explained in a calm and confident manner. If the patient/family
concentration in the blood falls within 80% to 125% of the brand name drug. In actual would still prefer the branded version of the medication after open discussion or they have
fact, in order to be deemed bioequivalent, the 90% confidence interval of the area under experienced altered effectiveness following a trial of the generic formulation, then the
the curve (AUC) must fall within 80% to 125% of the AUC of the brand name drug.19 The brand name version should be supplied without judgment.
90% confidence interval is a statistical term that simulates a range of measurements,
sampled on numerous occasions, within which we can be confident that the population
true result lies.19 Therefore, for the entire confidence interval to fall within the 80% to
125% range, the difference in blood concentrations between brand name and generic (i.e.,
the variance) is usually less than 5%.19 Unfortunately, many health professionals believe
that the 90% confidence interval limit of 80% to 125% indicates that a generic medication
could vary in blood concentration by up to 20% to 25% (a 45% variance), compared with
the brand name medication, which is not the case.19

The Canadian Agency for Drugs and Technologies in Health (CADTH) is an independent,
not-for-profit organization responsible for providing healthcare decision-makers with
objective evidence to help make informed decisions about the optimal use of health
technologies. CADTH states that “all generic drugs in Canada are approved by Health
Canada and have been shown to be bioequivalent to the Canadian Reference Product.”
The standards for bioequivalence in Canada are among the highest in the world.15

In order for a manufacturer (brand or generic) to be approved to manufacture drug

products, it must meet Good Manufacturing Practices (GMP) standards as published
by Health Canada.20 These standards are consistently assessed through inspections
of manufacturing facilities (both in Canada and abroad in such locations as India and
China) by the Health Products and Food Branch Inspectorate program of Health Canada.
If standards are not met, then an establishment licence will not be issued (if a new
manufacturing facility) or will be revoked (if an existing facility). These requirements apply
equally to facilities that produce brand name and generic drugs. Documents and guidelines
relating to GMP standards can be found online at https://www.canada.ca/en/health-
canada/services/drugs-health-products/compliance-enforcement/good-manufacturing-
practices.html.

20 21
Pharmacological Management of ADHD
 Pharmacological Management of ADHD

Mechanism of Action of ADHD Medications CADDRA: 16 Considerations in Medication Selection in the

Treatment of ADHD3
Although the exact pathophysiologic mechanism of ADHD is unknown, investigators point
to abnormalities associated with genetic changes that affect brain structure and function Sixteen different considerations for medication selection in the treatment of ADHD have
as well as the cholinergic, dopaminergic, noradrenergic, GABAergic, glutamatergic, and been proposed. These are outlined in the table below.
serotonergic pathways of the neurons in the brain as important contributors.21 Research
has shown that among neurotransmitters in the brain’s neurotransmitter pathways, the Consideration Comments
catecholamines norepinephrine and dopamine play important roles, especially with
respect to attention/focus and thinking.22 They both help to maintain alertness, increase 1. Age • Treatment of ADHD before the age of six should be conducted under
focus, and sustain thought, effort, and motivation.22 and individual the direction of a specialist.
variation • Women of childbearing age should speak with their physician if
The stimulants used for treatment of ADHD are sympathomimetic drugs which increase planning a pregnancy as effects of ADHD medications on the unborn
intrasynaptic dopamine and norepinephrine by inhibiting the presynaptic reuptake child and while breastfeeding are unknown.
• Response to treatment varies widely among individuals. Clinicians
mechanism (both methylphenidate and amphetamine derivatives) and releasing
should not oversell effectiveness of medications.
presynaptic catecholamines (amphetamine derivatives).23 • Patient difficulty with swallowing pills may affect product choice.
Atomoxetine, a non-stimulant medication, is a potent selective norepinephrine reuptake 2. Duration • Duration of effect of medications varies among individuals. Medication
inhibitor.23 Atomoxetine reduces ADHD symptoms and reduces tic severity.24,25 of effect dosage should be titrated to cover all periods of daytime impairment
(i.e., beyond classroom/work setting) to improve overall quality of life.
Guanfacine is an alpha-2 adrenergic agonist. Guanfacine is more selective for the • Some patients may experience a duration of effect that is shorter, or
alpha-2A receptor than clonidine and is approved for treatment of ADHD in an extended- longer, than indicated in product monograph.
release (XR) dosage form. Guanfacine XR is the only agent approved as an adjunct to
stimulant medication, as the combination has been shown to be more effective than 3. Speed • Stimulant medications are the treatment of choice when urgent action
of action of is required.
either agent alone in improving some ADHD symptoms as well as tics.26,27
medication • Once emergency situations are dealt with, it is important to monitor
adherence and individualize therapy according to side effects and
patient preference to improve quality of life.
4. ADHD • Core symptoms of inattentiveness, impulsivity, and motor hyperactivity
clinical should be assessed and monitored over time (e.g., hyperactivity may
presentations decline in adolescence but transform to symptoms such as restlessness).
Attention problems often remain stable and impairing throughout
lifespan. Transformation of symptoms may require adjustment of
treatment with respect to agent used and/or dosing.

5. Comorbid • When comorbid disorder(s) exists, choice of medication should focus

symptom on the symptom that addresses the major area of impairment.
profile

6. Comorbid • Major mood disorders such as depression, bipolar disorder, and

psychiatric substance use disorder should be treated prior to ADHD.
disorders

24 25
 Pharmacological Management of ADHD

Consideration Comments Consideration Comments

7. Attitudes • Misinformation about issues such as side effects and guilt about 15. Second-line • Demonstrated efficacy and approved for ADHD
towards having caused the problem through bad parenting must be addressed. treatments • Used for patients who do not tolerate or respond to first-line treatment
medication Information provided about potential effectiveness of medication or do not have access to first-line medications. May be used for
use should be balanced and based on evidence. Patients/parents at risk for augmentation of first-line treatments, but not all are indicated for
substance abuse should not be given short-acting stimulants. Parents/ this use.
caregivers/patients should be educated about risks associated with
diversion of medication. 16. Off-label • Higher side effect profile and less efficacious
treatments
8. Affordability • Pharmacists should help parents/patients access and coordinate all
available programs for payment or provision of medication. These may
include government, third-party insurers, special access programs, and Effectiveness and Dosing Principles of Medications Indicated
clinical trial participation. In addition, prescribers should be educated
about costs and coverage of medications for ADHD treatment in order for Treatment of ADHD
that an informed decision may be made in this regard.
Please refer to Table 1 for information about specific products.
9. Medical • A thorough medical assessment and a pharmacist drug review need
problems to be carried out to ensure suitability of a medication for an individual’s In 65% to 75% of cases patients will respond to an approved ADHD medication at the first
and other medical circumstances (e.g., potential drug interactions, cardiovascular trial.3 Patients who do not respond to one stimulant may find that another improves their
medications issues, blood pressure problems). symptoms.3
10. Associated • Patients must be made aware of side effects that may occur and how to
features similar tell if they are getting too much medication (e.g., feeling too “wired,” Stimulant Medications
to medication too irritable, or too serious). Time of side effect with respect to dosing
side effects is important. For example, if effects experienced when medication is Long-acting formulations of stimulant medications (i.e., methylphenidate or amphetamine)
wearing off, symptoms may be rebound from patient “crashing” due to are first-line therapy for treatment of ADHD.2 Seventy percent or more of patients who
rapid decline in medication blood level.
receive stimulant therapy have experienced clinically-significant decreases in core ADHD
11. Combining • If a second medication is required, it is important to combine ADHD symptoms in controlled trials.3 Clinical benefits include improved focus, concentration,
stimulants medication safely with other medication (e.g., for severe anxiety, a and attention span, and reduced hyperactivity, impulsivity, and fidgeting.14 Moreover, many
with other stimulant could be combined with an antidepressant). studies have demonstrated sustained improvement with ongoing medication. Academic
medications performance has been shown to benefit with ongoing treatment over five years.14
12. Potential • Non-medical use of prescription stimulants is an important issue —
for misuse/ short-acting drugs carry higher risk for misuse and diversion.
Methylphenidate- and amphetamine-based stimulant medications have similar efficacy
diversion • Myth that stimulants increase academic performance and tolerability.2 Although some individuals respond to stimulant therapy within the first
• Misuse in attempt to experience euphoria week, it is prudent to trial a particular stimulant for three to four weeks.2 Therapy should
be continued for six to 12 months if the patient responds adequately and there are minimal
13. Health • Critical that reliable sources of information are used adverse effects experienced. If a stimulant medication is not tolerated or is ineffective
professional • Upgrading clinical skills and staying up to date very important
after three to four weeks of therapy, a medication from the other class of stimulants should
attitude • Must be comfortable working with the knowledgeable parent/
towards ADHD caregiver, teacher, and family
be prescribed.2
medications

14. First-line • Have best risk-benefit profile — longer duration therapies increase
treatments adherence, diminish misuse/diversion risk, reduce rebound, and
provide longer medication coverage

26 27
 Pharmacological Management of ADHD

In some individuals the symptoms of ADHD may decline as a child enters adolescence. The CADDRA guidelines designate guanfacine XR as a second-line agent due to its lower
Patients should be weaned off the stimulant for a two-to-three week period once a year response rate, slower onset of action, and side effect profile compared to stimulants.2 It
to allow reassessment of behaviour and to confirm if the stimulant is still needed. This may be particularly useful for ADHD patients with comorbid tic disorders or significant
procedure, often referred to as a “drug holiday,” is often carried out in the summer, before anxiety, oppositional behaviours, and aggression.
the school year starts again.3

Drug holidays may also be advised if adverse effects such as growth suppression or more If Response to Treatment Is Unsatisfactory
than 10% weight loss have occurred.3
If response to treatment has not occurred in spite of recommended dosages being
reached, the diagnosis should be reviewed, including comorbidities, and adherence to the
Atomoxetine prescribed medication regimen should be checked.

Atomoxetine is a non-stimulant medication (norepinephrine reuptake inhibitor) that is Patient responses to ADHD medication vary widely, and some may respond better to one
indicated for treatment of individuals with ADHD who are six years of age or older.2 It is class of medication than another. Therefore, if diagnosis is deemed to be correct and
not as effective as stimulants for control of ADHD core symptoms, which is why current adherence is verified, then a switch from one class of stimulant to another, or from a
CADDRA guidelines list atomoxetine as a second-line agent behind long-acting stimulants. non-stimulant to a stimulant, or vice versa, should be considered.2
Studies suggest reduction of core ADHD symptoms by at least 25% to 30% in 60% to 70%
of individuals with use of atomoxetine.3 The role of atomoxetine in therapy is for those
who have not responded to or not tolerated stimulant therapy. It may be considered for Switching Medications
individuals who have comorbid substance use disorder, depression, or nocturnal enuresis.2
• When switching from a stimulant to atomoxetine or guanfacine XR:3 Because
Atomoxetine may be particularly useful for patients who have tic disorders or comorbid
atomoxetine and guanfacine XR take several weeks to reach clinical effect, it may be
anxiety.2
best to lower the dose of the stimulant over about a three-week period once the new drug
The onset of action is slower with atomoxetine (often two weeks) than with stimulants, is started.3 However, if the stimulant was not having any clinical effect, it can be stopped
and maximum treatment effect may not be reached for six to eight weeks.3 Once effective, when the new drug is started.3
atomoxetine provides continuous coverage, including the late evening and early morning • If switching from one methylphenidate-based medication to another:3 Stop the first
periods. Dosing of atomoxetine is calibrated to the weight of the patient (see Table 1). medication and start the second at the calculated equivalent dose while taking into
Atomoxetine is normally taken once a day in the morning, but the daily dosage may be account the release mechanism.
split and taken as a morning and evening dose in order to reduce side effects. Atomoxetine
• Percent immediate/delayed release are: 100/0 for methylphenidate immediate-
is approved only for monotherapy of ADHD (i.e., it is not approved for addition to stimulant
release, 40/60 for Biphentin®, 22/78 for Concerta® (not known for generic
therapy).
methylphenidate ER formulations).
• If switching from one amphetamine product to another, initial therapy should be
Guanfacine XR stopped, and the new amphetamine product titrated up from the usual starting dose to
the effective dose.
Guanfacine XR is an alpha-2 adrenergic agonist that is indicated for treatment of ADHD
in children and adolescents six to 17 years of age who have had suboptimal response • If transitioning from atomoxetine or guanfacine XR to a stimulant: If atomoxetine or
to stimulants.28 It can be used as monotherapy or as adjunctive therapy to stimulants. guanfacine XR were having an important clinical effect and need to be continued, then
Guanfacine XR provides continuous coverage, including the late evening and early morning add the stimulant to the non-stimulant. The stimulant should be started slowly according
periods. The onset of action is slower than with stimulants, and the maximum treatment to dosing instructions, but atomoxetine can be discontinued earlier than when the
effect may not be reached for several weeks. Close follow-up is required as the side effect transition is from atomoxetine or guanfacine XR to the stimulant because of the faster
profile is unique (see Table 1).2 onset of clinical effect with the stimulant. Guanfacine XR should not be discontinued
suddenly due to the risk of rebound hypertension. The dose of the drug should be tapered
down by 1 mg decrements every three to seven days per manufacturer’s recommendation.28

28 29
 Pharmacological Management of ADHD

“Off-Label” Treatments of ADHD There is no evidence that using megadoses of multivitamins and minerals helps ADHD.
If parents are concerned about vitamin deficiency, a paediatric multivitamin containing
Antidepressants amounts of vitamins and minerals consistent with recommended dietary allowance (RDA)
can be recommended.29
Bupropion is a norepinephrine and dopamine reuptake inhibitor but lacks good clinical
trial data in treatment of ADHD in children. It is considered to be less effective than Although there is weak evidence to suggest that zinc, iron, pyridoxine, and ginkgo plus
stimulants. It may be used as adjunctive therapy in patients with comorbid conditions American ginseng might be beneficial for children with ADHD, much more research is
such as depression, cigarette smoking, and active substance use disorder.3 Bupropion may needed before these supplements can be recommended.29
also be used for patients who cannot take stimulants or atomoxetine, or have not benefited
from them. Other natural health products that have been promoted for ADHD treatment include kava
and blue-green algae. Both of these supplements are known to be associated with risks,
Tricyclic antidepressants (especially nortriptyline due to its noradrenergic activity among and parents/caregivers should be discouraged from using them.
this class) have been used to treat ADHD but are less effective than stimulants.3 They
may be used as adjunctive therapy in those patients with comorbid conditions such as In general, parents/caregivers should be warned that many “cures” are promoted on the
depression, anxiety, enuresis, and tic disorders.3 They may also be used for patients that Internet and elsewhere that have not been clinically tested in reliable trials.29
cannot take stimulants, atomoxetine, or bupropion.3 Due to the high risk of mortality
from tricyclic antidepressant overdose, limited quantities of this class of drugs should be
prescribed/dispensed.
Additional Issues Associated with ADHD and Medication Use
Please see other side effects of drugs in Table 1.
Clonidine is an alpha-2 adrenergic agonist that is not as selective for the alpha-2
adrenoreceptor and not as long-acting as guanfacine XR. It is associated with more Sleep Issues
sedation and hypotension than guanfacine XR and is usually required to be taken in three
to four divided doses/day.3 However, clonidine is less expensive than guanfacine XR and At least 50% of children and adults with ADHD have significant sleep problems.2 The most
provides an option to those who could not otherwise afford the therapy. common finding is that children with ADHD have more restless sleep than the general
population of children. This can lead to fragmented sleep, which can result in problems
with daytime functioning.2
Natural Health Products
Another common challenge is associated with falling asleep. This disorder is called
As there is a belief among some individuals that ADHD is linked to nutritional deficiency,
delayed sleep phase syndrome or DSPS.3 Patients complain that they have difficulty
health professionals often get questions about the benefits of natural health products such
falling asleep because they have trouble turning their thoughts off. This results in going
as essential fatty acids, vitamins, minerals, and amino acids. Parents and caregivers need
to bed late and getting up late. Stimulant medications may add to this problem but
to understand that good nutrition and dietary habits are essential to a child’s good health,
sometimes also “paradoxically” calm some patients with ADHD for sleep by alleviating
but there is no standardized diet that has been shown to be appropriate for all individuals
their symptoms. Long-acting formulations may have insufficient duration of action, leading
with ADHD.29
to symptom rebound at bedtime and, hence, a medication with a short duration of action
Results of a small study suggest that omega-3 fatty acids in the form of fish oil may be given to control this situation. People with ADHD are also at increased risk for
supplements may improve cognitive function and behaviour in children with ADHD aged obstructive sleep apnea, peripheral limb movement disorder, restless legs syndrome, and
eight to 13 years.29 Another study suggested benefit of a supplement containing fish oils circadian-rhythm sleep disorders.2
400 mg and evening primrose oil 100 mg.29 This evidence is weak but may be worth
In general, lack of sleep in children can result in problems with attention, emotional and
considering in some children based on the wishes of parents and the fact that adverse
behavioural regulation, cognitive functioning, and academic performance.2
effects would be expected to be minimal.29 There is little known about the potential
benefits of other omega-3 fatty acids such as flaxseed oil.29 Strategies for dealing with sleep issues include the following:2, 3
• Sleep hygiene – maintain a consistent time for going to bed and waking in the morning.
The bed should not be used for watching TV, eating, or doing homework but should be
maintained as a quiet and comfortable sleep environment.
30 31
 Pharmacological Management of ADHD

• Medication should be tailored so that the patient is not “rebounding” when they are trying • When indicated, caloric needs are more likely to be met through the use of liquid
to get to sleep. This can be accomplished by taking an additional, perhaps lesser, dose nutritional supplements or meal replacements such as Boost® or Ensure® products. It is
of the same psychostimulant in an immediate-released form just before the rebound is usually sufficient to allow frequent fluids throughout the day and high protein/high calorie
expected to occur. drinks for lunch only.
• Stimulant medications should be given as early in the morning as possible. This can • Nutritious snack foods, whole dairy products, and energy-dense foods (especially at
be accomplished by lowering the dose late in the day if using an immediate-release breakfast) should be encouraged.
formulation. If a long-acting formulation is being used, adjusting to a dosage form with a • Referral to a registered dietitian may be necessary to optimize nutritional intake in cases
different release pattern or lowering the overall dose may be a consideration. If the patient of growth faltering.
is taking an amphetamine-based prescription, then a methylphenidate-based prescription
could be considered since it has a shorter half-life. Finally, substituting a non-stimulant • If there is familial short stature or low body mass index, the CADDRA guidelines suggest
medication may be considered if deemed appropriate. considering dose reduction, change to alternate agent, or periodic drug holidays.

• Melatonin is the only over-the-counter preparation that has been shown in clinical trials
to be safe and effective for treatment of insomnia in children with ADHD. If melatonin Cardiovascular Concerns
treatment is considered, the CADDRA guidelines recommend melatonin 3-6 mg at least
30 minutes (up to two to three hours) before desired bedtime for treatment of initial Use of ADHD medications may carry with it a small (but unproven) increase in the rare
insomnia associated with ADHD. Information on the safety and efficacy of melatonin use incidence of sudden cardiac death in children and adolescents.2 Routine electrocardiogram
long-term is not available. (ECG) testing prior to stimulant treatment is not supported by evidence and is not
recommended.12 Blood pressure and heart rate should be measured initially before starting
• Dietary bedtime snacks that are high in tryptophan (e.g., peanuts, turkey, beans, rice,
ADHD medication and during follow-up.2 CADDRA recommends that cardiac consultation
sesame seeds, cow’s milk) have been promoted as a sedating strategy but there is no
be considered in at-risk patients with cardiac conditions and that ADHD medication be
clinical evidence available to support this option.
considered only after a thorough discussion of the risks and potential benefits with the
• Valerian root (450-900 mg extract) has also been promoted for bedtime use, but clinical patient, family, and consultants.2
evidence is not available.
The following screening tool for ADHD treatment and cardiac risk assessment was
Appetite and Growth Issues published in a joint position statement with the Canadian Paediatric Society, the Canadian
Cardiovascular Society, and the Canadian Academy of Child and Adolescent Psychiatry:30
Children with ADHD are often pickier eaters than children without ADHD, and stimulant
medications may cause or exacerbate a reduction in appetite.3 Therefore, children taking The presence of ANY of the following risk factors should prompt further investigation
stimulant medication are more likely to eat at the time of day when blood levels of the or review by a specialist in paediatric cardiology:30
drug are reduced, thus having a lesser impact on appetite. • Shortness of breath with exercise (more than other children of the same age) in the
absence of an alternative explanation (e.g., asthma, sedentary lifestyle, obesity)
Children who take stimulant medication continuously for up to three years have been
• Poor exercise tolerance (in comparison with other children) in the absence of an
found to show slower growth over time compared to children not taking stimulant
alternative explanation (e.g., asthma, sedentary lifestyle, obesity)
medication.3 The Multisite Multimodal Treatment study of children with ADHD (MTA)
results suggest that adult height is reduced by about 2 cm (as compared to a local • Fainting or seizures with exercise, startle, or fright
normative comparison group [most without ADHD] when stimulant medication is taken • Palpitations brought on by exercise
continuously for 12 years.3 • Family history of sudden or unexplained death including sudden infant death syndrome,
unexplained drowning, or unexplained motor vehicle accidents (in first- or second-degree
Strategies for dealing with appetite and growth issues include the following:2, 3 relatives)
• Allowing/encouraging children to eat when they are hungry is important. Children taking • Personal or family history (in first- or second-degree relatives) of non-ischemic heart disease:
stimulants will be more likely to be hungry in the morning and rebound appetite may occur • Long QT syndrome or other familial arrhythmias
in the evening when blood levels of stimulants are lower. Dinner may be spread out into
• Wolff-Parkinson-White syndrome
two or three sessions to prevent gorging and subsequent stomach distress.

32 33
 Pharmacological Management of ADHD

• Cardiomyopathy The following chart lists some specific considerations when deciding on medication to
• Heart transplant treat ADHD.
• Pulmonary hypertension
• Implantable defibrillator Summary: Questions to Ask in Order to Help Medication
• Physical examination: Selection Process*
• Hypertension
• Organic (not functional) murmur present Question Relevance
• Sternotomy incision When do your symptoms affect you For stimulants, patients must take medication at a
• Other abnormal cardiac findings the most (e.g., school/work, exam time most appropriate to meet desired time of onset
times, leisure times, morning and/or duration of action.
routines, while driving)?
ADHD Medications and Suicidal Thoughts
Is a family member taking If yes and it is working well, then consider starting
With evidence emerging that suggests that the risk of suicidal thoughts and behaviours medication for ADHD? the same medication first (although no clinical trial
evidence supports this approach).
may apply to all ADHD drugs, Health Canada issued a safety alert in 2015.31 It is known
that ADHD itself may slightly increase risk of suicidal thought and behaviours, so a causal Is there a medication you prefer? Patients tend to respond better to medications they
relationship to ADHD drugs has not been established. Health Canada recommends the (with the exception of patients/ believe will help. This strategy also promotes the
following approach: parents at risk for substance partnership approach to care.
abuse/diversion)
• Patients taking ADHD medications, as well as their parents, families, and friends, should
monitor for suicidal thoughts and behaviours. Do you have third-party insurance Coordination of benefits and consideration of cost in
coverage? choice of medication (e.g., use of generic medications)
• Patients should report any distressing thoughts or feelings immediately to their doctor.
is an important role for the pharmacist.
This applies even after ADHD therapy has been stopped.
• Patients/parents/caregivers should consult their doctor if considering stopping ADHD Do you have trouble swallowing Options exist for individuals who cannot swallow a
a pill? pill, and pharmacists can recommend appropriate
medications or if they have been stopped, as stopping the medication could worsen
formulations/methods of administration.
ADHD symptoms.
• Before starting an ADHD medication, the patient/parent or caregiver should tell their Is treatment an urgent issue? Stimulants have the fastest onset of clinical action
doctor or pharmacist if the patient has experienced or has a family history of mental and, therefore, should be considered as first choice.
health problems, including psychosis, mania, bipolar illness, depression, or suicide. Do you have comorbid disorders Most often, the ADHD medication should be started
• Patients/parents/caregivers should speak with their pharmacist or doctor if they have that require complex care? first and residual symptoms then treated. If another
any questions or concerns about the patient’s ADHD therapy. disorder is more impairing than ADHD symptoms,
then it may need to be treated first. If the patient is
expressing suicidal or homicidal thoughts, these need
Importance of Medication Reviews to be addressed as a priority. Drug interaction issues
must be carefully anticipated and monitored.
Comprehensive medication reviews by pharmacists are a vitally important component
of care. There are many considerations (e.g., potential drug interactions, effectiveness of *First choice of medication should have an approved indication by Health Canada for
current therapies, opportunity to improve adherence through drug regimen revisions, etc.) ADHD within the specified age group.
before pharmacological therapies for ADHD and/or comorbid conditions are chosen, or for
monitoring ongoing therapy.

34 35
Focus on Communication/Counselling and Education of Parents/Caregivers
 Focus on Communication/Counselling and Education of Parents/Caregivers

Talking about Medication with the Parent/ • Having commented on the effectiveness of the medication, you don’t want to “oversell
Caregiver of a Child with ADHD it.” While it is true that approximately 80% of children diagnosed with ADHD do benefit
from the initial stimulant medication prescribed, about 20% will need to try another
When counselling anyone, we always need to be aware of the individual’s priorities and medication.32 Parents/caregivers should know this up front in case their child falls within
speak to those first. As for all children, the parents/caregivers of children with ADHD want the 20%. However, even in this scenario, 80% of the children who need to try another
them to be happy and healthy and to receive the treatment that is safe and effective. stimulant respond to that drug.32
• Explain the potential benefits of pharmacotherapy for ADHD. This includes the
Following are some tips for counselling parents/caregivers about ADHD medication for
neuroprotective effect of the medication: better interneuronal connectivity and better
the child with ADHD:
synaptic connections (synapses) in the hippocampal region of the brain, which is
• As for any medication counselling session, start by building a rapport with the parent/ responsible for memory.33 Pharmacotherapy is associated with about 85% reduction in
caregiver. risk of substance use disorders in youth with ADHD. Treating ADHD has been shown to
• Assess the parent’s/caregiver’s prior knowledge of his/her child’s condition and prevent worsening comorbidities with depression, bipolarity, anxiety, and substance use
medications and ask the parent/caregiver what his/her major concerns are. Many will be disorders. Children who received ADHD treatment had rates of unemployment three times
very educated about ADHD and available medications. If the parent’s/caregiver’s concerns lower than individuals who did not receive therapy for their ADHD as children.
are addressed first, he/she will be more likely to listen more attentively to medication • Discuss common side effects of the medication prescribed that were not brought up earlier
information that follows. Being able to dispel any myths that the parent/caregiver might due to parent/caregiver concerns, but be sure to put these into perspective. These will
have about treatment is another benefit of asking the parent/caregiver about his/her include (not a comprehensive list):
concerns first.
• Decreased appetite/weight loss/growth concerns
• Let the parent/caregiver know what you plan to discuss with him/her and ask if that would • Sleep problems
be helpful. Also, ask if there is anything else he/she would like to discuss, and empower
the parent/caregiver to ask questions about anything he/she doesn’t understand or would • Rebound effect (worsening symptoms as medication wears off)
like further information about. • Possibility of tics (most often in the form of blinking)
• Describe how the medication works in the context of the understanding of the parent/ • Explain exactly how the medication should be given, when it can be expected to take
caregiver as assessed earlier. For example: “Although we don’t know exactly what causes effect, and how long the effects are expected to last.
ADHD, we know that medications used to treat ADHD help children to focus their thoughts • Discuss the importance of the parent’s/caregiver’s role in terms of monitoring the effects
better and ignore distractions by regulating the actions of certain chemicals in the brain. of medication: How well does medication control symptoms (is the child receiving the
This helps the child to pay attention better and control their behaviour.” right dose and at the right time of day)? Which symptoms are not controlled as well (is the
• Some parents/caregivers may have concerns about the safety and efficacy of the child receiving the best medication for his/her circumstances)? What side effects have
medication. This may be particularly true of the stimulant medications, as they are known been noticed?
to be drugs of abuse in certain circles and have also been associated (although causality • Ensure that the importance of strict adherence to medication taking is understood.
remains unproven) with very rare instances of sudden cardiac death. In this regard it is Adherence to taking ADHD medications is associated with positive health outcomes,
important to be proactive, even if a parent/caregiver does not bring up the concern. For increased patient safety, and improvements in quality of life.34
example: “You may be aware that the medication that your child has been prescribed is a
• Be sure to provide small amounts of information at a time, check for understanding of the
stimulant medication, which is a controlled substance and, therefore, strictly regulated.
information, and ask if there are any questions.
You should know that the dose of the medication your child will be taking is based on
evidence from scientific studies that support the safety and effectiveness of this medication
in your child’s circumstances.”

38 39
 Focus on Communication/Counselling and Education of Parents/Caregivers

• Watch for body language that might suggest that the parent/caregiver does not understand • Parenting tips:
the information or isn’t listening attentively (recall that there is a chance that the parent • Ignore inappropriate (but not severely inappropriate — see next bullet) or irritating
may have ADHD as well). behaviour but praise positive behaviour.
• Summarize what you have talked about and make a plan for administering medication. • Reward appropriate behaviour and enact consequences for severely inappropriate
• Ensure that all points have been understood. behaviour.
• Offer resources, brochures, websites, and any information that might be of help to parent/ • Teach the child how to express his/her frustrations constructively.
caregiver in caring for the child with ADHD (does not have to be medication related). • Model the skill of forgiveness.
• When helping the child shift his/her focus, give a five- or ten-minute advance reminder
Monitoring Symptom Changes of a transition (e.g., when it is time to go to bed).
• Specialized classes on parenting children with ADHD can be very useful (general
Monitoring symptom changes is a very important role for the parent/caregiver. The
parenting classes less so).
assessment forms introduced earlier (SNAP-IV 26, CADDRA Teacher Assessment Form,
and WFIRS) are very effective for assessing change in symptoms. Weekly assessment
during a medication dosing titration period and every three months afterwards is Resources for Parents/Caregivers of Children with ADHD
appropriate.3 These tools must be brought to the physician during follow-up visits if they
are to be of any value. • Centre for ADHD Awareness, Canada (CADDAC) at www.caddac.ca
• ADHD Families at www.adhdfamilies.ca
Additional Support Tools for Parents/Caregivers • ADHD Resource Centre by The Hospital for Sick Children at www.aboutkidshealth.ca
• Support Groups and Advocates at http://caddac.ca/adhd/resources/support-groups/
As discussed earlier, it is very important that the child with ADHD be exposed to
• Clinics and Coaches at http://caddac.ca/adhd/resources/clinicsagencies/
an environment that has positive organization, structure, consistency, and clear
communication.12 To that end, a number of tools/strategies have been developed to • CADDRA public information at https://www.caddra.ca/public-information/
support the elements of a positive environment. These include:2 • Kelty Mental Health Resource Centre ADHD resources at http://keltymentalhealth.ca/
finding-help/medications/adhd
• White board reminder: This is one of the useful tools that can be used for organization
and time management and is a helpful way to remind the entire family of appointments
and schedules that are happening during the week. A centrally-located (e.g., kitchen) white Resource for Teachers
board helps to provide structure and also facilitates family communication. Review of the
white board should be scheduled at the same time once a week. This also serves as a good The Ministry of Education of British Columbia has published an excellent learning
time for communication of the successes of the past week and things to work on for the resource for teachers of children with ADHD. It is available online at
following week. http://www2.gov.bc.ca/assets/gov/education/kindergarten-to-grade-12/teach/
teaching-tools/inclusive/teaching-students-with-adhd.pdf.
• Clock timer for tasks such as homework: It is important for children with ADHD to feel
a sense of accomplishment by getting things done. This can be promoted by dividing tasks
like homework into bite-sized pieces, using a clock timer, and providing a reward if the
child completes the task in the allotted time. Homework should be done at the same time
every day to help promote organization, structure, and consistency.

40 41
 Focus on Communication/Counselling and Education of Parents/Caregivers

Summary: The Role of Pharmacists in ADHD Management

ADHD is a diagnosis that is very concerning for parents and caregivers. Pharmacists can
be very important team members with respect to parent/caregiver education, which has
been identified as one of the most important aspects of ADHD management in children.
Pharmacists are the most accessible health professionals in the community, with
pharmacies having longer hours than physicians' offices in most cases, and many
locations.

A comprehensive medication review is always in order before any medication change

is made. Recommendation of appropriate medications, dosages, and dosage forms, and
educating parents/caregivers about every aspect of their children’s therapy will help
promote optimal outcomes for the child and allay fears that parents/caregivers may have
about stimulant medications in particular. Support of the healthcare team with respect
to reinforcement of basic behaviour management principles and direction to appropriate
ADHD resources will also be appreciated.

In order to provide as much outreach to parents/caregivers as possible, pharmacists

should contact local ADHD support groups and clinics. Offers should be made to hold a
community workshop on the topic of ADHD. A supply of information about ADHD at the
pharmacy will provide further support to families in need and imply willingness of the
pharmacists in the location to discuss ADHD management.

42 43
References
References

1. ADHD Institute. Neurobiology: ADHD is associated with structural, functional and 13. Hospital for Sick Children. Behavioural Therapy for ADHD. http://www.
neurotransmitter alterations in the brain. http://adhd-institute.com/burden-of-adhd/ aboutkidshealth.ca/En/ResourceCentres/ADHD/TreatmentofADHD/Behavioural%20
aetiology/neurobiology/. Published 2017. Accessed Oct. 1, 2017. Therapy%20for%20ADHD/Pages/default.aspx. Updated 2017. Accessed Oct. 1, 2017.

2. Canadian ADHD Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, 14. Bhat V, Hechtman L. Considerations in selecting pharmacological treatments for
Fourth Edition, Toronto ON; CADDRA, 2018. Attention Deficit Hyperactivity Disorder. Pharmaceutical Journal 2016. https://www.
pharmaceutical-journal.com/research/review-article/considerations-in-selecting-
3. Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): pharmacological-treatments-for-attention-deficit-hyperactivity-disorder/20200602.
Canadian ADHD Practice Guidelines, Third Edition, Toronto, ON; CADDRA, 2011. article. February 11, 2016. Accessed Dec. 19, 2017.
4. Virani A. Attention-Deficit Hyperactivity Disorder. Compendium of Therapeutic 15. Canadian Agency for Drugs and Technologies in Health (CADTH). What are
Choices. 2017. Ottawa ON, Canadian Pharmacists Association. bioavailability and bioequivalence? https://www.cadth.ca/media/pdf/Generic_prof_
supplement_en.pdf . 2012. Accessed Oct. 1, 2017.
5. Centre for ADHD Awareness, Canada (CADDAC). ADHD facts: Dispelling the myths.
http://caddac.ca/adhd/understanding-adhd/in-general/facts-stats-myths/. Published 16. Schapperer E, Daumann H, Lamouche S, Thyroff-Friesinger U, Viel F, Weitschies W.
2017. Accessed Oct. 1, 2017. Bioequivalence of Sandoz methylphenidate osmotic-controlled release tablet with
Concerta® (Janssen-Cilag). Pharmacol Res Perspect 2015;3(1):e00072.
6. Centre for ADHD Awareness, Canada (CADDAC). Child and Adolescent ADHD.
http://caddac.ca/adhd/understanding-adhd/in-childhood-adolescence/. 17. Actavis Pharma Company. ACT Methylphenidate ER (methylphenidate hydrochloride
Published 2017. Accessed Oct. 1, 2017. extended-release tablets) product monograph. Mississauga, ON. August 1, 2017.
7. Thapar A, Cooper M, Eyre O, Langley K. What have we learnt about the causes of 18. Pharmascience Inc. pms-Methylphenidate ER (methylphenidate hydrochloride
ADHD? J Child Psychol Psychiatry 2013;54(1):3-16. extended-release tablets) product monograph. Montreal, QC. February 20, 2018.
8. Medscape. Soreff S. Attention Deficit Hyperactivity Disorder (ADHD). http://emedicine. 19. Canadian Agency for Drugs and Technologies in Health (CADTH). Similarities and
medscape.com/article/289350-overview. Published 2017. Accessed Oct. 1, 2017. differences between brand name and generic drugs. https://www.cadth.ca/generic-
drugs/similarities-and-differences-between-brand-name-and-generic-drugs. July 17,
9. Centre for ADHD Awareness, Canada (CADDAC). Understanding ADHD: In general.
2015. Accessed Oct. 1, 2017.
http://caddac.ca/adhd/understanding-adhd/in-general/. Published 2017. Accessed Oct.
1, 2017. 20. Government of Canada. Good manufacturing processes. https://www.canada.ca/
en/health-canada/services/drugs-health-products/compliance-enforcement/good-
10. Hospital for Sick Children. Myths and facts about ADHD. http://www.aboutkidshealth.
manufacturing-practices.html. February 27, 2015. Accessed Oct. 1, 2017.
ca/En/ResourceCentres/ADHD/AboutADHD/Pages/Myths-and-Facts-about-ADHD.aspx.
Updated 2017. Accessed Oct. 1, 2017. 21. Boos B, Davis S, Dunion J, Olin BR. Attention Deficit/Hyperactivity Disorder. http://c.
ymcdn.com/sites/www.aparx.org/resource/resmgr/CEs/CE_ADHD_Article.pdf.
11. Centre for ADHD Awareness, Canada (CADDAC). ADHD Symptoms/Red Flags: Warning
November 28, 2013. Accessed Oct. 1, 2017.
signs that may indicate a child or adolescent has ADHD. http://caddac.ca/adhd/
understanding-adhd/in-general/symptoms/. Published 2017. Accessed Oct. 1, 2017. 22. Medscape. Hunt RD. Functional roles of norepinephrine and dopamine in ADHD.
http://www.medscape.org/viewarticle/523887_1. (log-in required) 2006. Accessed
12. A 14-month randomized clinical trial of treatment strategies for attention-deficit/
Oct. 1, 2017.
hyperactivity disorder. The MTA Cooperative Group. Multimodal Treatment Study of
Children with ADHD. Arch Gen Psychiatry 1999;56(12):1073-1086.

46 47
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23. Wilens TE, Spencer TJ. Understanding attention-deficit/hyperactivity disorder from 33. Jenson D, Yang K, Acevedo-Rodriguez A, et al. Dopamine and norepinephrine receptors
childhood to adulthood. Postgrad Med 2010;122(5):97-109. participate in methylphenidate enhancement of in vivo hippocampal synaptic
plasticity. Neuropharmacology 2015;90:23-32.
24. Spencer TJ, Sallee FR, Gilbert DL et al. Atomoxetine treatment of ADHD in children
with comorbid Tourette syndrome. J Atten Disord 2008;11(4):470-481. 34. Ahmed R, Aslani P. Attention-Deficit Hyperactivity Disorder. An update on medication
adherence and persistence in children, adolescents and adults. Expert Rev
25. Allen AJ, Kurlan RM, Gilbert DL, et al. Atomoxetine treatment in children and
Pharmacoeconomics Outcomes Res 2013;13:791-815.
adolescents with ADHD and comorbid tic disorders. Neurology 2005;65(12):1941-
1949.

26. Cutler AJ, Brams M, Bukstein O, et al. Response/remission with guanfacine extended-
release and psychostimulants in children and adolescents with attention-deficit/
hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 2014;53(10):1092-1101.

27. Pringsheim T, Doja A, Gorman D et al. Canadian guidelines for the evidence-based
treatment of tic disorders: pharmacotherapy. Can J Psychiatry 2012;57(3):133-143.

28. Shire Pharma Canada ULC. Intuniv XR (guanfacine hydrochloride extended-release

tablets) product monograph. Toronto, ON: November 16, 2017.

29. Natural Medicines Comprehensive Database. Natural medicines in the clinical

management of attention-deficit/hyperactivity disorder. Self-Study Course #15-110.
2017.

30. Belanger SA, Warren AE, Hamilton RM et al. Cardiac risk assessment before the
use of stimulant medications in children and youth. Paediatr Child Health
2009;14(9):579-592.

31. Government of Canada. ADHD drugs may increase risk of suicidal thoughts and
behaviours in some people; benefits still outweigh risks. http://healthycanadians.
gc.ca/recall-alert-rappel-avis/hc-sc/2015/52759a-eng.php. Updated April 9, 2015.
Accessed Oct. 1, 2017.

32. Centre for ADHD Awareness, Canada (CADDAC). Treatment of ADHD in Children
and Adolescents. http://caddac.ca/adhd/document/treatment-of-adhd-in-children/.
Published 2017. Accessed Oct. 1, 2017.

48 49
CE Questions
 CE Questions

Submitting Answers to the CE Questions 1. Gloria wants to know what might have caused Josh to have ADHD. Which of the
following statements is TRUE?
a. All individuals have the potential to be diagnosed, but poor parenting results in
1. Create an account at www.healthelearning.ca if you do not already have one. the ADHD symptoms being exposed.
2. Log in to your Pear Health eLearning account and click CE COURSES. b. All individuals with ADHD have at least one first-degree relative who also
has ADHD.
3. Select “ADHD Counselling Guide,” then click ENROL NOW.
c. Inherited and non-inherited risk factors for ADHD are interdependent.
4. Follow the onscreen prompts to complete the order.
d. Low birth weight has been proven to be a cause of ADHD.
5. Click MY ACCOUNT/ENROLLED COURSES.
6. Enter the CE and select the answers to the CE Test, then click SUBMIT. 2. Gloria wants to better understand the process that ended up with Josh being
diagnosed with ADHD. Which one of the following statements is TRUE about ADHD
diagnosis in children?
Note: a. ADHD diagnosis according to DSM-5 is met when six of nine of listed symptoms in
You must correctly answer seven out of ten (70%) in order to obtain 2.0 CE units. both the inattentiveness category and the hyperactivity/impulsivity category are
You may make two attempts to achieve a passing grade. met for at least six months.
b. ADHD diagnosis according to DSM-5 is met when six of nine of listed symptoms in
If you achieve 70% or more on your first attempt, your test results and Letter of either the inattentiveness category or the hyperactivity/impulsivity category are
Completion will be emailed to you for your personal records. You can access this met for at least six months.
document under MY ACCOUNT/COMPLETED COURSES. c. For a diagnosis of ADHD, symptoms must have been present by 14 years of age at
the latest.
d. Answers b and c are both correct.

3. Gloria is concerned about the drug that her doctor wants to prescribe as it is a
“stimulant.” She wants to know if behaviour therapy on its own will be enough to
Continuing Education Questions manage Josh’s symptoms. Which of the following statements is TRUE?
Case: Gloria is the mother of Josh, a seven-year-old child who has just received a diagnosis a. Research suggests that behavioural and pharmacological therapy combined is
of ADHD. Gloria is at the pharmacy picking up a monthly refill prescription for herself and significantly more effective than pharmacological therapy alone for core ADHD
tells you the news. She seems quite flustered and tells you that she doesn’t really know symptoms.
what ADHD is all about and hopes that she didn’t contribute to Josh’s problem by the way b. Research suggests that pharmacological therapy alone is more effective than
she was handling his behaviour issues. You tell Gloria that you would like to discuss the behavioural therapy alone for core ADHD symptoms.
situation with her but first would like to know what she does understand about ADHD... c. Research suggests that behavioural therapy alone is more effective than
pharmacological therapy alone for core ADHD symptoms.
d. Answers a and b are both correct.

52 53
CE Questions

4. Gloria comes back into the pharmacy six weeks later and tells you that she thinks 8. It is six months later and Josh’s doctor has decided to add a medication to his
that Josh should try pharmacological therapy. She says that she has discussed regimen in the evening because the methylphenidate controlled-release tablet is
options with her doctor and that a stimulant has been recommended, but she and reducing symptoms significantly during the day, but seems to wear off in the early
her husband are still undecided. She would like to know more about the other evening. Which of the following would be the most appropriate choice for
options. Which of the following drugs carries Health Canada approval for treatment “augmentation” of therapy?
of ADHD as monotherapy? a. Atomoxetine
a. Atomoxetine b. Methylphenidate immediate-release tablet
b. Clonidine c. Dextroamphetamine tablet
c. Nortriptyline d. Answers b or c would be appropriate
d. Bupropion
9. Gloria is in the pharmacy and telling you that Josh is having sleep issues. Which of
5. Gloria is in a few days later with a prescription for a stimulant medication for Josh. the following statements about sleep issues while taking stimulants is TRUE?
Which of the following options would be considered first-line according to the a. Melatonin is the only over the counter preparation that has clinical trial evidence
Canadian ADHD Resource Alliance (CADDRA) guidelines? of efficacy in children with ADHD who have insomnia.
a. Dextroamphetamine Spansule b. Sleep issues in a child with ADHD who is taking stimulants are usually associated
b. Lisdexamfetamine capsule with waking too early in the morning.
c. Methylphenidate sustained-release tablet c. Dietary bedtime snacks that are high in tryptophan should be strictly avoided in
children with ADHD who have sleep issues.
d. Dextroamphetamine tablet
d. Valerian root has been shown in clinical trials to be effective in the treatment of
insomnia in children with ADHD.
6. The prescription for Josh is written for methylphenidate extended-release tablets.
Which of the following statements about this medication is TRUE?
10. Methylphenidate therapy has reduced ADHD symptoms to a degree in an 11-year-old
a. The effectiveness of this drug may be reduced by concomitant use of child who weighs 50 kg, but not to the level desired. A switch to atomoxetine is
carbamazepine. recommended. Which of the following would be the most appropriate protocol?
b. There are no generic products available for filling this prescription. a. Stop the methylphenidate and start atomoxetine at 40 mg/day.
c. Starting dose is usually 27 mg daily. b. Titrate the methylphenidate down over a three-week period and then start
d. Increasing dose titrations should be conducted every three days until atomoxetine at 50 mg/day.
clinical effect. c. Start the atomoxetine at 50 mg/day and titrate the methylphenidate down over
a three-month period.
7. Gloria is worried about the effects of the stimulant drug on Josh’s nutrition and d. Start atomoxetine at 25 mg/day and start titrating down methylphenidate over
growth. Which of the following would be your best approach? a three-week period.
a. Tell Gloria not to worry because it has never been shown that stimulant drugs
actually suppress growth in the long term.
b. Recommend that Gloria purchase a high potency megavitamin supplement for
Josh to take on a daily basis.
c. If caloric intake is a worry, a high protein/high calorie drink may be appropriate
at lunchtime.
d. Plan the highest food intake of the day for when blood levels of the stimulant
medication are the highest.
54 55
Notes
NOTES

58 59
Program Overview

An educational service for Canadian pharmacies,

brought to you by Teva Canada Limited.
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