- Begin with a short-acting stimulant such as methylphenidate (MPH).
- Start with a low dose and increase slowly.
- Suggested starting dose of MPH for a child: 0.15 mg/kg/dose (or 2.5 mg). For an adolescent, consider beginning with a low dose of a long-acting stimulant in the morning.
- Titrate upward weekly to a target dose of 0.25-0.5 mg/kg/dose. This is a general guideline. Some children may not show positive effects until higher doses are reached, yet some may experience adverse reactions at the lower doses.
- Positive effects should be seen immediately or within days of reaching an appropriate dose.
- Focalin® (the D-isomer of methylphenidate) has approximately twice the potency of Ritalin® when used at equivalent milligram dosing; it is therefore recommended that half the Ritalin®-equivalent dose be used when prescribing Focalin®.
- Begin with once-daily dosing. If the maximum dose of MPH tolerated by a child is 2.5 mg, may add a second (and third, if needed) daily dose of 2.5 mg. If a child tolerates an MPH dose of 5 mg or more, may convert to a long acting stimulant at 10 mg.
- Mixed amphetamine salts (Adderall®, Dexedrine®) have not undergone clinical trials in individuals on the
autism spectrum. This should not, however, preclude the use of these medications if a clinician feels a trial
would be of benefit to a patient.
- As with MPH, begin at a low dose and slowly adjust upward until positive or adverse effects are seen.
- At equivalent milligram doses, Dexedrine® has approximately twice the potency of methylphenidate. When using Dexedrine®, begin at half of the methylphenidate-equivalent dose.
- At equivalent milligram doses, Adderall® is approximately 1.5-fold more potent than methylphenidate. When using Adderall®, use approximately three-fourths of the methylphenidate-equivalent dose.
- Consider starting with half the initial dose that would be appropriate for a neurotypical child. Begin with once-daily dosing and add a second daily dose as tolerated. Transition to a long-acting formulation when a single dose of 5 mg or higher is tolerated.
- For an adolescent, consider beginning with a low dose of a long-acting stimulant in the morning.
- Monitor closely for adverse effects with frequent in-office or phone follow-up.
- Adverse effects include sleep disturbance, appetite changes, irritability, anxiety, tics, headache and GI disturbance.
- In children with underlying anxiety, administration of stimulants may worsen anxiety, irritability, and emotional lability. These effects may not occur immediately and may escalate over time. Because of this, parents/teachers may not attribute an increase in anxiety or irritability to the stimulant when they become problematic a month or two out from starting or increasing the stimulant.
- Mild adverse effects seen initially may be transient and improve over time while taking the medication.
- If severe adverse effects are experienced, stimulant medication may be discontinued without a taper.
- Several small trials have been conducted to assess the efficacy and tolerability of atomoxetine in
individuals on the autism spectrum with mixed results. [Charnsil: 2010]
[Troost: 2006] Atomoxetine may be effective in reducing
hyperactivity with less impact on inattentiveness. Favorable effects are typically seen 3-4 weeks after
initiating treatment with atomoxetine. As with most other psychotropic medications, individuals on the
autism spectrum may be more vulnerable to adverse effects of atomoxetine, which include fatigue, sleep
disturbance, irritability, and gastrointestinal disturbance. As with stimulant medications, atomoxetine may
cause tachycardia and hypertension. Heart rate and blood pressure should be assessed at baseline and
monitored every 6 months. [Arnold: 2006]
- Begin at 0.5 mg/kg once daily. Increase after one month to 1.2 mg/kg/day in one morning dose or in two evenly divided daily doses.
- Total daily dose should be no higher than 1.4 mg/kg/day or 100 mg, whichever is lower.
- In one study of 1357 children prescribed atomoxetine, 6 experienced suicidal events (0.44%).These events tended to occur within 20 days of starting the medication. Clinicans and families should be aware of this low risk of suicidality and have a plan in place regarding the actions that should be taken if it occurs.
- As with typically developing children, target behaviors in the home and school should be identified at the onset of treatment and monitored for treatment effectiveness. Establish a plan with the family for follow-up. Use objective rating scales such the Nisonger Child Behavior Rating Form (NCBRF) to get an objective measure of problem behaviors. The NCBRF is a standardized scale for assessing child and adolescent behavior. Scales are available for typically developing children as well as for those with disabilities. They may be downloaded free of charge.
Nisonger Child Behavior Rating Form
A standardized tool used in assessing child and adolescent behaviors.
|Content Last Updated:||8/2010|
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