The University of Texas System

CPAN Case of the Month – December 2022

Patient: 6-year-old with ADHD combined presentation.

Patient: 6-year-old with ADHD combined presentation. 

Reason for CPAN consultation: Medication for ADHD with worsening behavioral dyscontrol.

This patient had been treated with Ritalin 10 mg at AM and noon with some success for attention, concentration, and school functioning.  The concern is recent exacerbation of irritability, defiance, and aggressive behavior, mainly at home.  When calm, he can reflect on his behavior, but says “I’m a bad boy.” No acute changes in child’s or family’s life were reported. 

The CPAN consultant and pediatrician discussed the most common reasons for the current issues.

(1) The behaviors reported are highly associated with ADHD and typically respond to stimulant therapy.  Methylphenidate, however, has a short half-life so bid administration of Ritalin is unlikely to provide much benefit for after-school behavior. 

(2) Increased irritability and dysphoria can also accompany stimulant treatment. While usually appearing with higher doses, young children may be more susceptible to them at lower doses. They are also more sensitive to the steep ups and downs in drug concentration that occur with the immediate-release stimulant preparations, so this type of “rebound” effect after school might occur. 

(3) The favorable response during school hours suggests that the dose, when it is at peak, may be adequate, but there is also room to increase dose if we were confident that he was not getting “affective toxicity” from the medication. 

(4) It is possible the child was developing a mood disorder, for which ADHD/ODD dose pose increased risk. 

Youngsters with impaired self-control and emotion regulation are often better served with full-day coverage with stimulant treatment, for which extended-release products are better suited. Therefore, the first suggestion was to switch to a long-acting methylphenidate formulation. The dose chosen (27 mg of OROS-methylphenidate) will result in a slightly lower amount of medication during school hours but will help to clarify if the current 10 mg bid dose was too high. After 1-2 weeks, if it is well tolerated and there’s room for improvement, the dose would increase to a 36 mg capsule in the morning.  Following these first steps, re-evaluate for mood symptoms and overall response of ADHD and behavioral difficulties.  Augmentation strategies or a switch to an amphetamine-based product would be considered if attempts to optimize methylphenidate were unsatisfactory. 

Take home point:

Long-acting stimulant preparations are generally preferred for patients with impairments that last nearly all day.  There are some insurance carriers that will not approve them, however. In that case, it is usually worthwhile to attempt an appeal to get authorization for extended-release products.  Since treatment remains a trial-and-error process, CPAN consultants are always available to help plan further steps for management.