Jefferson Prince, MD, Thomas A. M. Kramer, MD, Jane Feldman, MD


March 26, 2003

In This Article

Special Treatment Issues

Much has been made of the impact of long-acting preparations of stimulants and once-a-day medications in general in the treatment of ADHD. There is probably no other age group in which the introduction of these medications has been more beneficially dramatic than in adolescence. It is considerably easier for adolescent patients to comply with their medication when they only take it once a day. Whatever embarrassment is involved by having to go to the school nurse is accentuated in adolescence. These newer medications have eliminated this concern as an issue. It is true, however, that adolescents often need supplemental short-acting stimulants at the end of the day in addition to a long-acting preparation in the mornings. This is because the day, for an adolescent, is considerably longer than it is for a younger child. Often, the benefit of the stimulant medication will not last into the evening hours when adolescents do their homework. High schools typically start very early in the morning, and the 7 am dose is gone by 7 pm when homework is far from done. Giving additional immediate-release stimulants toward the end of the day usually solves this problem. This can be done at home after school, early enough in the evening so as not to cause insomnia. It is also important to point out that adolescents in general are much more tolerant of insomnia than younger children. Indeed, for many of them, it is a normative if not desired state.

There has been much concern by both practitioners and parents about the use of stimulants in the adolescent population. This concern is based on the fact that this treatment involves giving medication that has both abuse potential and street value to a population at risk for substance abuse. There has also always been a counter argument that much of the substance abuse in ADHD patients involves self-medication, and, as such, appropriate treatment would limit the risk of substance abuse. Recently, 2 articles were published in the journal Pediatrics providing strong evidence that substance abuse is not accentuated and may be actually protected against by treatment of ADHD.[1,2]

The following case will illustrate some of the points discussed above:

A 17-year-old male freshman college student halfway through his first semester is referred by the college tutoring service for psychiatric evaluation. The referral states that the student seems to be unable to concentrate long enough to either attend lectures or complete his assignments. Specifically, he appears to be unable to sit down long enough to do large amounts of reading required for his courses, and attempts to organize him better with time management and improved study habits have proven unsuccessful. This is the first time the patient has been away from home; he is the older of 2 children in a close-knit family and speaks to his parents on the phone every day. He was successful in high school, getting good grades and being very active in a number of activities and sports, but admits he was not "the best" at any of them. He denies any current or past subjective depression, or any sleep or eating disturbance, and describes his mood as "frustrated." He denies any substance abuse, saying that he tried alcohol and marijuana in high school but didn't like how they made him feel. He will currently drink a beer or two with friends to be social. The rest of the family and social history was unremarkable. Psychiatric examination was essentially within normal limits.

ADHD was suspected, and the patient was started on extended-release methylphenidate (Concerta) and titrated up to a dose of 36 mg/day. This provided good effect during the day; the patient was able to attend class and take notes considerably more effectively. Organizing himself and studying in the afternoons was also considerably improved. However, the student complained of being unable to get any work done after dinner in the evenings. A dose of 5 mg of immediate-release methylphenidate was added at 5 pm with improvement, and subsequently increased to 10 mg, with good result. The patient did state he was unable to go to sleep before 1 am, but was happy with this as it made him academically more productive, and he was able to schedule his classes no earlier than midmorning. He continued on this regimen through the end of the term and finals and did quite well in his course work.

ADHD is a very heterogeneous disorder in the timing of its presentation and its symptoms. Whether these represent a number of different related disorders or variants on the same deficit remains unknown, but clinicians need to understand how to diagnose and treat ADHD in all of its forms.