Dosing and special considerations Initiation of ADHD medication is usually begun over the weekend to allow parents time to observe for adverse effects, to better manage the drug titration process, and to minimize academic disruptions.41 Although more expensive, the extended-release formulas are often selected to eliminate the need for multiple doses and to decrease perceived stigma associated with medication administration at school.24 Longer-acting formulations have also been shown to increase treatment adherence. Adding shorter-acting doses in late afternoon, however, may be helpful if the child experiences difficulty concentrating (eg, on homework, sports, driving).24
Although drug holidays are not usually recommended, children can be evaluated for this individually. For example, a child whose ADHD symptoms primarily involve inattention may only require medication on school days.37
Follow-up During the titration process, which can take up to three months, weekly clinician contacts—some by phone—to monitor effectiveness, adherence, and adverse effects are recommended (see Table 3). Blood pressure and heart rate should be monitored carefully and titration continued as needed until optimal response to treatment has been achieved.24 Monitoring should continue every three months for the first year of treatment and biannually thereafter.24 After several years, it is reasonable to consider a closely monitored drug-free trial period to determine if medication is still necessary.24 Finally, clinicians should remain cognizant of the potential cardiovascular effects of longer-term stimulant use and adhere to clinical guidelines.42
If coexisting conditions such as severe mood or anxiety disorders are present and improvement is not noted in core ADHD symptoms after three months of treatment, the patient should be referred to a mental health specialist.23
CONCLUSION Primary care providers must be knowledgeable about ADHD and offer appropriate evidence-based interventions, treatments, and supportive measures to patients and families dealing with this disorder. Clinicians should know what resources are available for parents of children with ADHD. Psychoeducation for parents, families, and teachers is imperative to ensure positive home and school environments. Each treatment plan requires an individual approach, and optimal use of all available resources is desirable. Implementing evidence-based recommendations will increase the overall quality of life for children and families dealing with ADHD and optimize behavioral outcomes.
The authors would like to thank Laurie Rockelli, PhD, RN, PMHCNS-BC, and William Campbell, EdD, RN, for their revisions and support in the completion of this article.
