The Basics of Safely Prescribing Medications for ADHD with Job Corps Students David Kraft, MD, MPH Region 1 Mental Health Specialist John Kulig, MD, MPH.

The Basics of Safely Prescribing Medications

for ADHD with Job Corps Students

David Kraft, MD, MPHRegion 1 Mental Health Specialist

John Kulig, MD, MPHJob Corps Lead Medical Specialist

Overview• The most frequent mental health

problems in Job Corps where medications are prescribed include depression and anxiety.

• The next most common problem at many centers is attention-deficit/ hyperactivity disorder (ADHD).

Learning Objectives Participants will be better able to:• Describe clinical indications (e.g., starter

doses, follow-up doses, etc.)• List potential side effects of psychotropic

medications• Describe indications and strategies to

stop medications • List potential drug interactions

Outline• Overview of psychotropic drugs for ADHD• Diagnostic categories (DSM-5)• Clinical indications• Dosages – starting, typical, maximum• Black box warnings• Side effects• Drug interactions• Indications to discontinue medications • Ongoing frequency of follow-up

Diagnosis of ADHD• Diagnostic Features of ADHD in adults

– Symptoms of Inattention• Puts things off until the last minute• Has difficulty sustaining attention to reading or paperwork• Shifts activities often

– Symptoms of Hyperactivity• May be impatient, feels restless• Has difficulty engaging in quiet activities• Always needs to be busy after school or work or while on

vacation– Symptoms of Impulsivity

• Frequently interrupts others during school classes or at work

Evaluation for ADHD• Clinical indications:

– Academic or behavioral problems– Symptoms of inattention, hyperactivity or impulsivity

• Obtain history from student, school, family members• Administer validated tools or review records :

– NICHQ Vanderbilt Assessment Scales – ages 6-12– Conners Comprehensive Behavior Rating Scales – ages 6-18– Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom

Checklist• Clinical practice guidelines:• http://pediatrics.aappublications.org/content/128/5/1007• http://www.aafp.org/afp/2012/0501/p890.html

Diagnostic Criteria for ADHD (DSM-5)

• Symptom and Duration Criteria– A persistent pattern of inattention, hyperactivity or both that

interferes with functioning or development and is characterized by (1), (2) or both

1. Inattention • Six or more inattention symptoms• Symptoms have persisted for at least 6 months• Degree is inconsistent with developmental level• Negatively directly affects social and academic functioning

2. Hyperactivity and Impulsivity• Six or more hyperactivity-impulsivity symptoms• Symptoms have persisted for at least 6 months• Degree is inconsistent with developmental level• Negatively directly affects social and academic functioning

Diagnostic Criteria for ADHD (DSM-5)

Onset, Setting and Quality of Functioning CriteriaB. Several inattentive or hyperactive-impulsive symptoms were

present prior to age 12 years.C. Several inattentive or hyperactive-impulsive symptoms are

present in 2 or more settings (e.g. at home or school, with friends or relatives, in other activities).

D. There is clear evidence that the symptoms interfere with, or reduce quality of, social, academic or occupational functioning.

Exclusion CriteriaE. Symptoms do not occur exclusively during the course of

schizophrenia or another psychotic disorder and are not better explained by another mental disorder.

DSM-5 Symptoms of Inattention in ADHD

• Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.

• Often has trouble sustaining attention in tasks or play activities.• Often does not seem to listen when spoken to directly.• Often does not follow through on instructions and fails to finish

tasks - schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).

• Often has difficulty organizing tasks and activities.• Often avoids, dislikes, or is reluctant to engage in tasks that

require sustained mental effort over a long period of time (such as schoolwork or homework).

• Often loses things necessary for tasks or activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, cell phones).

• Often easily distracted by extraneous stimuli.• Often forgetful in daily activities.

DSM-5 Symptoms of Hyperactivity and Impulsivity in ADHD

• Hyperactivity– Often fidgets with or taps hands or feet, or squirms in seat.– Often leaves seat in situations when remaining seated is expected.– Often runs about or climbs in situations where it is not appropriate

(adolescents or adults may be limited to feeling restless).– Often unable to play or engage in leisure activities quietly.– Often "on the go," acting as if "driven by a motor".– Often talks excessively.

• Impulsivity– Often blurts out an answer before a question has been completed.– Often has difficulty waiting his/her turn.– Often interrupts or intrudes on others (e.g., butts into conversations

or games).

Changes in DSM-5 for the Diagnosis of ADHD

• Symptoms can now occur by age 12 rather than by age 6. 

• Several symptoms now need to be present in more than one setting rather than just some impairment in more than one setting. 

• New descriptions were added to show what symptoms might look like at older ages. 

• For adults and adolescents age 17 or older, only 5 symptoms are needed instead of the 6 needed for younger children.

1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?

2. How often do you have difficulty getting things in order when you have to do a task that requires organization?

3. How often do you have problems remembering appointments or obligations?

4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?

5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?

6. How often do you feel overly active and compelled to do things, like you were driven by a motor?

Quick Screening Tool (ASRS-v1.1) Symptom Checklist (Part A)

7. How often do you make careless mistakes when you have to work on a boring or difficult project?

8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?

9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?

10. How often do you misplace or have difficulty finding things at home or at work?

11. How often are you distracted by activity or noise around you?

12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?

Quick Screening Tool (ASRS-v1.1) Symptom Checklist (Part B)

13. How often do you feel restless or fidgety?14. How often do you have difficulty unwinding and

relaxing when you have time to yourself?15. How often do you find yourself talking too much

when you are in social situations?16. When you’re in a conversation, how often do you

find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?

17. How often do you have difficulty waiting your turn in situations when turn taking is required?

18. How often do you interrupt others when they are busy?

Quick Screening Tool (ASRS-v1.1) Symptom Checklist (Part B) (cont’d)

• During admission process: Health records supporting both diagnosis and treatment of ADHD should be requested.

• Even with records, center health staff, especially the CMHC, should review the diagnosis with each student, especially current treatment. Use of the CCMP for ADHD may help define how to assist each student.

• The Center Physician may be requested to continue medication treatment, either directly or with the help of a community psychiatrist, especially if there are any questions about the appropriateness of the current medication regimen. [Note: most states only allow dispensing 1 month at a time of stimulant medications, so students cannot bring 90 days of meds with them.]

Working with Students: Continuation of Treatment

Working with Students: Students Not Previously Diagnosed/Treated

• If available, use community mental health resources to provide ADHD evaluation.

• Appropriately licensed CMHCs (practicum students/interns under their supervision) or Center Physicians with specialized training in ADHD assessments may provide this service. Evaluations to document ADHD must meet community standards and be included in the Student Health Record.

• Psychotropic medication treatment of students who are newly diagnosed with ADHD may need recommendations from a consulting psychiatrist if the center physician does not feel comfortable prescribing a course of treatment. 

• [Note: Most states do NOT allow stimulant prescriptions for more than 30 days at a time, with close monitoring.]

• Individual must meet ADHD criteria in current Diagnostic and Statistical Manual (DSM)

• The definition of ADHD has been updated in DSM 5 to more accurately characterize the experience of affected adults. It is also now listed in the “Neurodevelopmental Disorders” chapter to reflect brain developmental correlates with ADHD.

• Assessment must document evidence of several symptoms present in more than on setting that interferes with, or reduces the quality of, social, academic or occupational functioning.

• Input from instructors and residential staff needs to be collected, to support diagnosis and treatment decisions.

• Acceptable tests include Norm Referenced Rating Scales, self-report and/or observer report format (e.g. Conners’ Rating Scale—adult or child/adolescent version; The Barkley Adult ADHD Rating Scale–IV; Brown ADD Scales)

(Note: Psychological and educational testing is NOT included as part of CMHC regular duties per PRH. Consideration should be given for testing to be done outside of PRH hours with separate compensation.)

Necessary Elements of Assessment

Psychotropic Medication for ADHD

Stimulants• Methylphenidate: standard/extended release

[Ritalin, Concerta, Focalin, Metadate, Daytrana, Quillivant]• Amphetamine: standard/extended release

[Adderall, Dexedrine, Vyvanse]

α2 Adrenergic Agonists• Guanfacine: standard/extended release [Intuniv]• Clonidine: extended release [Catapres]

Norepinephrine reuptake inhibitor• Atomoxetine [Strattera]

Consult with psychiatrist for off-label use of anti-depressants for ADHD.

Dosing: MethylphenidateMedication (generic/trade)

Starting dose Maximal daily dose

Duration of effect

Category

Ritalin IR tabletsFocalin IR tablets

5 mg and 5 mg2.5 mg and 2.5 mg

60 mg20 mg

3-5 hours stimulant

Ritalin SRMetadate ERMethylin ERpulse capsules

10 mg10 mg10 mg

60 mg60 mg60 mg

7-8 hours stimulant

Ritalin LA Metadate CDFocalin XRpearl capsules

10-20 mg10-20 mg5 mg

60 mg60 mg30 mg

8-12 hours stimulant

Concertapump capsules

18 mg 54 mg 12 hours stimulant

Daytrana transdermal patch

10 mg 60 mg 12 hours stimulant

Quillivant XR liquid

10-20 mg 60 mg 8-12 hours stimulant

Methylphenidate• Onset of effect within 30-45 minutes• Once daily dosing optimal• Dose can be increased weekly with monitoring• Boxed warning: potential for abuse and dependence –

related problem with diversion• Precautions include elevation in BP and heart rate,

cardiovascular events, psychiatric events, seizures, tics• Adverse effects include appetite suppression, insomnia

and abdominal pain• Drug interactions with MAOIs, vasopressors, coumadin

anticoagulants and some anticonvulsants• Can discontinue abruptly or taper over a few days if high

dose• Dose equivalent to twice that of amphetamine dose

Dosing: AmphetamineMedication (generic/trade)

Starting dose Maximal daily dose

Duration of effect

Category

Adderall IR tablet

5 mg and 5 mg 4-6 hours apart

40 mgdivided

4-8 hours stimulant

Dexedrine capsule

5 mg 40 mg 6-9 hours stimulant

Adderall XRcapsule

5-10 mg 30 mg 8-12 hours stimulant

Vyvansecapsule

20 mg 70 mg 8-12 hours stimulant

ProCentraliquid

5 mg (5 ml) 40 mg 8 hours stimulant

Amphetamine• Onset of effect within 30-45 minutes• Once daily dosing optimal• Dose can be increased weekly with monitoring• Boxed warning: cardiovascular concerns – targeted history

and exam – no routine ECGs or cardiology consultation• Boxed warning: potential for abuse and dependence – related problem with diversion• Precautions include elevation in BP, cardiovascular events,

psychiatric events, seizures, tics• Adverse effects include appetite suppression, insomnia,

abdominal pain, weight loss, nervousness• Drug interactions with MAOIs, antihistamines,

antihypertensives, anticonvulsants, antidepressants• Can discontinue abruptly or taper over a few days if high dose• Dose equivalent to half that of methylphenidate dose

Dosing: Secondary OptionsMedication (generic/trade)

Starting dose

Maximal daily dose

Duration of effect

Category

guanfacine IRTenex

0.5-1.0 mgdivided

4 mg divided

4-8 hours α2A adrenergic agonist

guanfacine ERIntuniv

1.0 mg once qd

7 mg once qd

24 hours α2A adrenergic agonist

clonidine IR Catapres

0.05 mgdivided

0.4 mgdivided

3-5 hours α2 adrenergic agonist

clonidine ERKapvay

0.1 mg qhs 0.4 mgdivided

12-24 hours α2 adrenergic agonist

atomoxetinecapsulesStrattera

40 mg/day 100 mg/day

continuous after 4-6 weeks for full effect

norepinephrine reuptake inhibitor

Guanfacine• Onset of effect within 30-45 minutes• Once daily dosing optimal – extended release• Dose can be increased weekly with monitoring• No boxed warnings• Precautions include hypotension, bradycardia, syncope;

sedation and somnolence; cardiac conduction anomalies• Adverse effects include hypotension, somnolence,

fatigue, nausea, lethargy• Drug interactions with clarithromycin, ketoconazole,

glucocorticoids, some anticonvulsants• Discontinue by tapering daily dose in 1 mg increments

every 3 to 7 days – monitor BP and pulse• Dose equivalence: IR guanfacine 1.0 mg = ER guanfacine 1.5 mg

Clonidine• Onset of effect within 30-60 minutes• Once daily dosing optimal – extended release• Dose can be increased weekly with monitoring• No boxed warnings• Precautions include hypotension, bradycardia, syncope;

sedation and somnolence; cardiac conduction anomalies• Adverse effects include somnolence, fatigue, dry mouth,

irritability, nightmares, insomnia, dizziness, constipation• Drug interactions with sedatives, antihypertensives,

tricyclic antidepressants,• Discontinue by tapering daily dose in 0.1 mg increments

every 3 to 7 days – monitor BP and pulse

Atomoxetine• Initial effect in 1-2 weeks – full effect in 4-6 weeks• Once daily dosing optimal• Dose can be increased to target dose after a minimum of

3 days on initial dose – monitor weekly• Can be used as adjunct treatment with stimulants• Boxed warning: suicidal ideation• Precautions include liver injury, cardiovascular events,

psychiatric events, aggressive behavior/hostility• Adverse effects include nausea, vomiting, abdominal

pain, appetite suppression, fatigue, somnolence • Drug interactions with MAOIs, some SSRIs, albuterol,

vasopressors, antihypertensives, • Can discontinue abruptly without tapering – no

withdrawal symptoms

Indications to Stop or Change Medications

• Adverse effects • Adverse effects limiting dose increases• Maximal recommended dose ineffective• Drug interactions• Lack of clarity about diagnosis• Evidence of abuse or diversion• Consider alternate class of ADHD medications• Consider adjunct therapy with secondary drugs

Preventing Stimulant Misuse• Confirm the diagnosis of ADHD prior to

initiating or refilling a stimulant prescription• Limit student’s access to prescribed stimulants

by dispensing unit doses daily on center• Assess the need for continued treatment on

weekends and breaks – driving issues• Do not replace “lost” or “stolen” medications• Secure all controlled medications double-

locked in the Wellness Center with weekly inventory and individual student MARs

• Conduct TEAP educational sessions which address stimulant misuse

Ongoing Follow-up• Students should be monitored by the

center physician (CP), CMHC, and health and wellness staff.

• If current medication is not working:• CP may consult with CMHC and adjust meds• Refer for consultation with psychiatrist in

community, if available• Refer back to original prescriber via leave or

during breaks • MSWR should be considered if student is

having acute symptoms interfering with participation in program

Accommodations and Environmental Modifications

• Allow student to tape-record assignments.

• Grant extra time for test taking and completing chores.

• Allow opportunities for breaks during the training day (e.g., getting a drink or a walk to the hallway). If there is an errand to be run, allow this student to go.

• Break down large tasks into small ones. Attach deadlines to the small parts.

• Youth with ADHD need to be able to have a "quiet area" to be able to go and regroup and calm down.

• Provide a room in the dorm away from traffic.

Accommodations and Environmental Modifications

• Encourage student to keep dorm and work area free of distraction. Clutter-free living and work areas can help students stay on task.

• Have student use visual reminders like a calendar or alerts on the cell phone to stay organized.

• Students should make frequent use of:◦    lists◦    color-coding◦    reminders◦    notes to self◦    rituals◦    files

• Instructors and residential staff can use a code word or signal to remind the student to pay attention.

Behavioral Support Suggestions

• Help student know best time of day for demanding tasks. Learn how to be in tune with "internal clock” - the time of day when he/she is at their best.

• Allow a “blow out” time for student after the training day. Student picks some kind of activity from time to time where he/she can let loose in a safe way.

• Find ways to release energy with activity or exercise (i.e., participating in center organized sports or gym activities).

• Find ways to increase self-control and expand attention (i.e., yoga, meditation, or other HEALs activities).

• Use technology as a reward. When work or chore completed, play video game or spend extra time on computer.

Summary Suggestions• Check accuracy of diagnosis, usually past history and treatment

– If student not diagnosed before entry, refer to CMHC for needed work-up– Check with educational and vocational staff regarding behaviors in class that

might suggest ADHD symptoms• Continue ongoing treatment, if reasonable, while gathering supporting

documentation. (Most states only allow one monthly prescription of stimulant medications.)

• Develop a Center Operating Procedure (COP) for your center, with the CMHC, Center Physician, and disability coordinators, regarding what you need to do if a student comes to center without an ADHD diagnosis and/or treatment plan but seems to need treatment.

• If prescribing stimulants, limit medications, as much as possible, to once daily doses at Health and Wellness Center, to minimize chances of abuse by other students.

• If doses of medication are “lost” or “stolen”, no replacements are given—there is no need for people with ADHD to take medications every day.

References• Black, DW, & Andreasen, NC (2014). Introductory

Textbook of Psychiatry (sixth edition). Arlington, VA: American Psychiatric Publishing, a Division of the American Psychiatric Association.

• Maxmen, JS, Kennedy, SH, & McIntyre, RS (2008). Psychotropic Drugs: Fast Facts, Fourth Edition. New York: WW Norton & Company, Inc.

• Riddle, MA (2016). Pediatric Psychopharmacology for Primary Care. Elk Grove Village IL: American Academy of Pediatrics

• Schatzberg, AF, & DeBattista, C (2015). Manual of Clinical Psychopharmacology, Eighth Edition. Arlington, VA: American Psychiatric Publishing, a Division of the American Psychiatric Association.