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	Florida Best Practice Guidelines for ADHD in Children and Adolescents The panel discussed the use of stimulants and other agents for the treatment of ADHD. Level 0: Appropriate assessment and non-medication interventions as a critical part of care. This approach is consistent with the recommendations of the American Academy of Child and Adolescent Psychiatry and the Texas Children’s Medication Algorithm Program. With regards to pharmacotherapy options for ADHD, the panel was provided with information regarding the Texas algorithms, the Expert Consensus Guidelines, and the American Academy of Child and Adolescence Psychiatry’s work on ADHD. There was general agreement with the options for ADHD without co-occurring anxiety, psychotic, tic, or mood disorders. Level I: The panel felt that there was substantial evidence to support the use of monotherapy with stimulants using either methylphenidate or amphetamine preparations. The expert panel agreed that the practice of using agents within the same class with different half-lives was appropriate. Level II: Options included the stimulant class not tried at Level I. If failure occurred with a methylphenidate agent then amphetamine agents could be used. The experts did not recommend combining classes. The panel discussed the use of skin patches and decided not to recommend them as first-line agents due to the fact that hypersensitivity reactions to methylphenidate could occur if switched to oral preparations from a skin patch. Level III: The expert panel supported the use of Atomoxetine, a non-stimulant that is approved by the FDA for ADHD. There was extensive discussion with regards to the use of Atomoxetine. The panel decided to place this option at a lower level due to a lower effect size than stimulants and safety warnings regarding suicidality. However it could be used as first-line in patients with severe anxiety disorders, or in cases where stimulants were unacceptable due to possible side effects, and patient or family preference. The panel agreed that there might be situations where adjunctive use of Atomoxetine in a patient with partial response to stimulants would be appropriate. Level IV and V: Options included Bupropion or tricyclics with the exception of desipramine, which is shown to have some significant cardiac issues related to its use in children. Imipramine, Bupropion, and Nortryptiline have been evaluated in small sample size studies in children with ADHD. Once again, monotherapy should be attempted with these agents. Level VI: Alpha-2 agonist such as Guanfacine and Clonidine were recommended and have shown some benefit as monotherapy and in combination with stimulants in children with ADHD with co-occurring tic disorders. These data are derived from single studies. The expert panel decided against placing Modafinil in the current guidelines due to safety issues raised by the FDA. A decision is still pending. In addition, the panel decided not to vote on the selegiline patch due to lack of data and clinical experience. The issue of combination therapy was discussed for co-occurring disorders and the panel decided to place those recommendations regarding treatment options in the guidelines for depression, bipolar disorder, tic disorders, and aggression respectively. Child & Adolescent    » ADHD    » Depression    » Bipolar Disorder    » Tourettes Syndrome    » Aggression Adults    » Schizophrenia    » Bipolar Disorder