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3yr
8-year-old boy with ADHD

Justin is in 3rd grade and has trouble with school routines. It is difficult to get him groomed and dressed in the morning, as well as getting his backpack organized. 



At school, Justin’s teachers note that he is very intelligent, but exhibits difficulties focusing and sitting still in class. Except for some topics of interest such as stars, dinosaurs, or animals—on which he can focus intently—he has trouble maintaining focus on other subjects. He is often restless and fidgets in his seat, with his teachers constantly reminding him to sit still and stay on task. Justin also tends to blurt out answers and interrupt with off-topic commentary. When away from his desk, Justin runs around and exhibits difficulty following instructions. Although Justin realizes that he is misbehaving, he says he can’t “stop” himself.



After school, he has trouble completing his homework in a timely manner. The teacher says it should only take 40 minutes to complete the homework given but it takes 2-3 hours while his mother supervises at the kitchen table. His mother reports that he also has trouble with evening routines and winding down before bedtime.   



When choosing a treatment for children with ADHD, how do you rank the following 4 factors: onset of effect, duration of effect, tolerability, and dosing options? 



What other factors do you consider when determining how to treat ADHD?


  • 3yr
    Thanks, All, for your wonderful input! How long does it take to clinically establish onset of effect, duration of effect, tolerability, and dosing options?
  • 3yr
    Most children have difficulty in focusing on subjects which are of little or no interest to them. Has anyone spoken to the teacher to see if the child has an IEP or has the mother been taught any behavioral techniques that may be helpful? You can train a 4,000 pound elephant without prescribing medication. After these techniques look for family background and emotional issues at home.
  • 3yr
    Tolerability followed by duration of effect. Patients and parents will most likely be willing to try a medication and continue its use.
  • 3yr
    I would assume tolerability is the most important as patient would not comply with meds if he has all these side effects
  • 3yr
    Duration of action is very important - especially not lasting too long in an 8 year old so his appetite doesn't get overly suppressed throughout the day and he doesn't have any medication-triggered sleep problems. Second, which ties into duration, is tolerability. Some ADHD meds make kids into zombies which isn't tolerable to any of the stakeholders. Dosing options are also very important - once a day is key, as is the ability to have a chewable, drinkable or "sprinkleable" formulation. I don't find onset of action to be all that much of an issue
  • 3yr
    tolerability would be the first with onset of action and duration of action to follow and dosing options then. detailed screening for comorbidity and family history might be helpful in order to determine optimal treatment plan
  • 3yr
    Tolerability, duration, onset then dosing would be my order, but I would add family history, abuse history in family/caregivers and medical history as other important factors in choosing a med for him.
  • 3yr
    The lack of focus and attention are the biggest concerns for me and my patients because it may lead to frustration and a worsening of mood and anxiety, particularly at school.

    I target doses of medication to approve concentration first, hoping that this helps with mood and behaviors. Obviously, the speed of onset is important, especially when there's been a delay in coming into treatment. Getting medication to last throughout the day can be tricky, and I always focus on sleep as many ADHD patients are also hyperactive in their sleep. If using a stimulant, I want to make sure it does not cause insomnia; I may add or choose to start with a non-stimulant, particularly when poor sleep occurs.

    Once daily dosing, at home, is preferable for most children so they don't get singled out at school, and it's generally easiest to take something first thing every morning. My preference is to treat everyday, even during summer and school breaks. This is most important in teens, and when patients are driving, so I don't think of ADHD just as a school issue.
  • 3yr
    Several factors come into play when choosing medications, to include Accurate diagnosis, Family Hx, Ruling out underlying medical co-morbidities, Other Psychiatric co-morbidities, etc. Of the factors posted in the case Hx, all are important, but to prioritize, I believe Tolerance is on top of list (helps compliance), then Duration of action (helps decide frequency of dosing), then onset of action. Review case by case basis.
  • 3yr
    Duration of effect
  • 3yr
    Effectiveness

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