Back to referral guidelines
Print Friendly, PDF & Email
Primary care management and referral guideline Primary care management and referral guideline

ADHD Medication Management – Child and Youth – Management and referral guideline

This guideline does not cover ADHD medication management for patients:

  • with conditions involving multiple organ systems requiring detailed surveillance e.g., Down syndrome, neurofibromatosis.
  • aged < 13 years taking antipsychotics.
  • of any age taking antipsychotic medication without a Therapeutic Goods Administration (TGA) indication.

Red flags

  • Cardiovascular complications
  • Symptoms of psychosis, severe depression, and suicide risk

Purpose

Primary care management and referral guidelines contain condition-based information for GPs about when to refer a patient, assessment and management measures that should be taken prior to submitting a referral, and what should be included in a referral to the relevant outpatient department or specialist service.

Introduction

  • Management of patients aged 6 to 18 years taking ADHD medications is generally done as part of a shared care arrangement with a paediatrician or a paediatric or adolescent psychiatrist.
  • Discharge of children from paediatric services is not an endpoint of care and patients may be referred back as required.

Assessment

Check:

  • the patient’s eligibility for general practitioner follow-up.

Eligibility for general practitioner follow‑upA specialist for the management of ADHD has assessed and diagnosed the patient, and commenced any ADHD medications used, and all of:

  • Transfer of care to the general practitioner has been arranged.
  • There is unlikely to be a significant change of management over the next 6 months.
  • The general practitioner is able to make minor or expected changes to management.
  • There is agreement in place for the patient to be referred back to the specialist if required.
  • the patient’s current ADHD medications.

Medications for ADHD

  • Commonly used medications:
    • Stimulants – the two used in ADHD are methylphenidate (most common) and dexamfetamine.

      Dexamfetamine

      • Dexamfetamine – 5 mg immediate‑release tablet (duration 4 to 6 hours)
        • Greater risk of side‑effects and diversion than methylphenidate
        • Given once or twice a day
      • Long‑acting lisdexamfetamine (Vyvanse) – 30, 50, 70 mg capsules (duration about 12 hours)
        • Given once a day early in the morning
        • Not to be used under age 6 years
      • Primarily used in those who have not responded to methylphenidate

      Methylphenidate

      • Ritalin short‑acting – 10 mg tablets (duration of action 2 to 4 hours)
        • Use to titrate the dose and timing and then convert to long‑acting, or use in addition to the long‑acting form.
        • Usually given twice a day – early in the morning and then around 10:30 am to midday.
        • An additional dose of one half to 1 tablet can be given regularly after school or ad hoc for activities e.g., sport, music lessons.
        • Timing of early morning dose can be adjusted depending on need e.g., before going to school or on waking, if needed to get ready for school
      • Ritalin long‑acting:
        • 10, 20, or 30 mg capsules (duration of action 4 to 6 hours)
        • 40 mg capsules (duration of action about 6 hours)
      • Concerta – 18, 27, 36, or 54 mg extended‑release tablets (duration of action ≥ 6 to 8 hours)
      • These are controlled (Schedule 8) drugs.
      • A mg/kg dose may help in defining upper limit of the dose of stimulant.
      • Longer-acting formulations may eliminate the need for dosing at school – used after the patient has shown both a response and tolerance to short‑acting methylphenidate.
      • A patient who does not respond to or tolerate one psychostimulant may do so with an alternative.
    • Atomoxetine

      Atomoxetine

      • Selective noradrenaline reuptake inhibitor (SNRI), mechanism of action in ADHD is unknown.
      • Not a Schedule 8 drug and has low risk of abuse.
      • Used if stimulants not tolerated but should not be used in combination with stimulants.
      • Useful for co‑morbid anxiety, psychosis, or tics – should be prescribed in consultation with child psychiatrist or paediatrician.
      • Atomoxetine (Strattera) – 10, 18, 25, 40, 60, 80, 100 mg capsules.
      • Use with caution if known prolonged QT syndrome or epilepsy.
      • Target dose – 1.2 mg/kg a day, maximum 1.4 mg/kg (or 100 mg) a day.
      • Given once or twice a day.
  • Less frequently used medications:
    • Clonidine
      Clonidine
      Clonidine 100 or 150 microgram immediate release tablets, prescribed at an average dose of 0.003 to 0.005 mg/kg per day divided in 3 to 4 doses.

      • Sometimes used for its sedative effect – may be useful in markedly aggressive children or those with problematic sleep disturbance on stimulants
      • Risk of significant rebound hypertension
      • May cause sedation, and there is reported rare association with depression
      • Patients taking clonidine often remain under the care of the paediatric service
      • General practitioners are advised not to:
        • initiate this medication.
        • change the dose without discussing with a paediatrician.

      In stable patients, it is safe for the general practitioner to provide a continuing script at the same dose.

    • Tricyclic antidepressants
      Tricyclic antidepressants
      Amitriptyline (Endep) or nortriptyline (Allegron)

      • Sometimes used “off-label” in ADHD as a mood stabiliser.
      • Should be prescribed in consultation with child psychiatrist or paediatrician.
      • Can cause potentially fatal arrhythmias and should only be initiated by specialists experienced in their use.

      In stable patients, it is safe for the general practitioner to provide a continuing script at the same dose.

  • Regulatory requirements for prescribing ADHD medications

    Regulatory requirements for prescribing ADHD medications

    • A “treatment Report to the Chief Executive for treatment with schedule 8 medicines” is not required for patients aged < 18 years being treated with psychostimulant medications for ADHD.
    • For other requirements for a valid schedule 8 script, see Queensland Health – Regulatory Requirements and Resources.

At each visit:

  • check growth, heart rate, blood pressure (BP), and puberty development.
    • Growth:
    • Pulse (for tachycardia) and BP:
      • Compare with the NIH – Blood Pressure Levels by Age and Height Percentile.
      • Monitor for persistently elevated BP and consider BP cut-offs for action by age (assumes child is 50th centile for height).

        BP cut-offs for action by age

        • Age 4 to 6 years:
          • systolic 100 mmHg
          • diastolic 70 mmHg
        • Age 7 to 10 years:
          • systolic 115 mmHg
          • diastolic 75 mmHg
        • Age 11 to 13 years:
          • systolic 120 mmHg
          • diastolic 77 mmHg
        • Age ≥ 14 years:
          • systolic 130 mmHg
          • diastolic 80 mmHg

        Shorter children usually have slightly lower blood pressure.

    • Puberty development:
      • Consider the possibility of delayed puberty in children on stimulants, especially if poor growth.
      • Ask the patient to self‑assess using the Tanner stages card.
    • If cardiovascular (CV) symptoms, obtain a 12‑lead ECG and discuss with your local paediatric team (routine CV monitoring is not necessary).

      Cardiovascular (CV) symptoms

      • Palpitations or tachycardia
      • Shortness of breath or chest pain (on exertion)
      • Syncope or presyncope
    • Look for ECG changes e.g., arrhythmias, prolonged QT interval.
  • compliance with treatment, and behavioural strategies.
  • ask about common problems in children and adolescents with ADHD:
    • Escalating oppositional behaviour
      Escalating oppositional behaviour
      May be due to:

      • dose becoming ineffective, leading to poor impulse control.
      • change in relationships at school e.g., bullying.
      • change in family dynamics, e.g., separation, new people in the household, parental depression or anxiety.
      • anxiety or depression.
      • sleep disturbance.
    • Increased impulsivity or hyperactivity – a previously adequate dose may become ineffective due to growth or to increasing academic demands on the patient in higher grades.
    • Anxiety or irritability, and depression
      Anxiety or irritability
      Externalising behaviours such as over‑activity and disruption may be due to:

      • poor impulse control – methylphenidate improves control.
      • anxiety – methylphenidate worsens anxiety.

      It can be difficult to distinguish between anxiety and poor impulse control.

    • Sleep problems – difficulty falling asleep or maintaining sleep, or restless sleep.
    • Appetite
  • review any additional prescribed medications, use of caffeine and alcohol, and consider potential drug interactions.

    Additional prescribed medications

    • MAO inhibitors
    • Tricyclic antidepressants
    • SSRIs
    • Phenothiazines
    • Antiepileptics
    • Anticoagulants
    • Cimetidine
    • Over the counter medications (especially ephedrine derivatives)
  • ask about other side effects of ADHD medications.

    Side‑effects of ADHD medications

    • Stimulants
      • Common:
        • Cardiac e.g., palpitations, tachycardia
        • Gastrointestinal e.g., nausea, vomiting, constipation, dyspepsia
        • Poor growth or weight loss
        • Difficulty falling asleep
        • Anxiety
      • Uncommon – serious CV symptoms e.g., arrhythmias, shortness of breath, chest pain, presyncope or syncope
    • Atomoxetine
      • Common:
        • Insomnia
        • Dry mouth
        • Loss of appetite
        • Dyspepsia
        • Nausea or vomiting
        • Drowsiness
      • Uncommon:
        • Psychiatric problems e.g., psychosis, mania, aggression, or suicidal ideation
        • Liver dysfunction
    • Tricyclics
      • Common:
        • Dry mouth
        • Blurred vision
        • Constipation
        • Drowsiness
      • Uncommon:
        • Postural hypotension
        • Arrhythmias
    • Clonidine
      • Serious rebound hypertension may occur if ceased abruptly
      • Clonidine may cause sedation and there is reported rare association with depression
      • Be mindful of interactions with other drugs (especially pseudoephedrine)

Management

If significant CV signs or symptoms, discuss with your local paediatric team on call or arrange transfer to your nearest ED as appropriate.

Significant CV signs or symptoms

  • Presyncope or syncope
  • Shortness of breath or chest pain on exertion
  • Palpitations
  • ECG changes (arrhythmia, prolonged QT interval)
  • Suspected cardiomyopathy

If significant psychiatric symptoms (e.g., psychosis, severely depressed, or risk of self-harm or suicide), refer to child and youth mental health for acute assessment.

If concerns about elevated BP, repeat the measurement in a few days to a week, and discuss with your local paediatric team if BP remains elevated.

If suspected delayed puberty, discuss with your local paediatric team.

Address other concerns:

  • Growth

    Growth concerns

    • If the patient is falling across one major weight or height centile line, consider:
      • increasing caloric intake.
      • separating meals from medication dose e.g., give breakfast before morning dose.
      • withdrawing medication on weekends or vacations if parents can cope and routine can be relaxed.
    • If the patient has significant falling across centiles e.g., two major centile lines, consider:
      • reducing dose or withdrawing medication.
      • seeking specialist advice.

    Poor gain in height is more significant than poor weight gain – have a lower threshold for discussion with a paediatrician.

  • Escalating oppositional behaviour – if concerns about dose becoming ineffective, see increasing impulsivity below.

    Managing escalating oppositional behaviour

    • If change in relationships at school, encourage parents to work cooperatively with the school and to be protective but not combative.
    • If simple parent skills training is ineffective, or if parents prefer, request psychological services.
      • Some services may attract a subsidy, so contact individual providers for information.
    • If appropriate, prepare:
  • Increasing impulsivity or hyperactivity – do not increase the dose of stimulants as the child grows unless there is an increase in symptoms.

    Increasing impulsivity or hyperactivity

    • Rule out compliance issues and misuse of medication.
    • If dose is < 1 mg/kg/day, increase the dose and review at 4 weeks.
      • If taking short‑acting methylphenidate (Ritalin) or dexamfetamine, for patients:
        • < 30 kg – increase the dose by half a tablet per day.
        • > 30 kg – increase the dose by half to 1 tablet per day.
      • If taking a long‑acting stimulant drug, increase to next tablet strength.
      • Seek advice from a specialist if the higher dose seems ineffective.
    • Impulsivity requires higher doses in general than improving focus and attention.
    • Doses should usually not exceed 1 mg/kg/day – seek specialist advice.
  • Anxiety, irritability, and other mental health problems, – e.g. depression, aggression, mania.

    Anxiety, irritability, or other mental health problems

  • Sleep

    Sleep problems

    • Difficulty falling asleep:
      • Ensure good sleep routine:
        • No computer for 1 hour before bed
        • No television for 30 minutes before bed
        • Silent house for 20 minutes once child in bed
        • Initially consider later bedtime to associate bedtime with falling asleep
        • Younger children may benefit from a weighted blanket or firm tucking-in
      • If the patient is taking Concerta, consider changing to Ritalin long-acting or to short-acting tablets, with no dose after midday.
      • Trial withholding medication on holidays or weekends:
        • If problems improve, they are likely related to methylphenidate.
        • If problems unchanged or worse, seek specialist advice.
      • If refractory sleep problems, cease the stimulant and discuss with the paediatrician
    • Inability to maintain sleep:
      • Check environment:
        • Dark room
        • Exclude disruption from others in household
        • Avoid reliance on parent to soothe back to sleep e.g., aim for self-settling
      • Consider slow release melatonin (Circadin):
        • Start at 2 mg given 30 minutes before bedtime
        • Increase to 4 mg if needed
    • Restless sleep:
      • Ask about obstructive sleep apnoea (OSA) symptoms:
        • Snoring
        • Apnoeas
        • Snorting or gasping
        • Daytime somnolence or hyperactivity
        • Sweating at night
      • Refer to your local ENT service if indicated

    See Raising Children Network:

Review other important considerations:

  • Weekends and vacations

    Weekends and vacations

    • If there is no requirement for medications on weekends (e.g., if parents can cope and routine can be relaxed), consider skipping these days.
    • Need for medication will vary on vacations and use can be individualised. Consider:
      • omitting the drug.
      • using a smaller dose.
      • only using for certain occasions e.g., family gatherings or outings.
  • Misuse
    Misuse
    Occasionally a carer can take or sell a child’s medication

    • Be cautious about lost scripts or demands for excessive doses.
    • Only replace a lost prescription once.
    • If ongoing concerns, refer back to specialist service, and consider changing to non-stimulant medications.
  • Feedback from teachers

    Feedback from teachers

    • May be useful in determining effectiveness of medication or change of dose.
    • Can be either:
      • a simple narrative report describing how the child is going, or
      • a formal scale or questionnaire (can make it easier for the teacher to respond but not essential) – see Vanderbilt teacher assessment scale.
    • Detailed child behaviour checklists are generally used only in the diagnostic phase and not required for monitoring in primary care.

Advise the patient and family about treatments not recommended for ADHD e.g., special diets, complementary therapies.

Treatments not recommended for ADHD
There is no evidence to recommend or support any of these for the management of ADHD:

  • Elimination or restriction diets
  • Diet supplementation with essential fatty acids e.g., fish oils
  • Chiropractic treatment
  • Behavioural optometry
  • Biofeedback (including neurofeedback)
  • Homeopathy
  • Acupuncture
  • Physical activity
  • Massage
  • Sensory integration therapies

Schedule regular review at recommended intervals for patients aged:

  • < 10 years – every 3 months
  • ≥ 10 years – every 6 months

Consider annual discussion about ceasing medication.

Ceasing medication
Timing:

  • Timing is very individual and depends on the initial indication e.g., usually required for longer for impulse control than attention to task.
  • Sometimes medication is ceased or restarted based on academic demand.
  • Ask if the patient or parent feel there is still a benefit from medication:
    • If not, trial ceasing medication – parents can do this at any time, except with clonidine.
    • If unsure, consider a trial at least once a year:
      • during school term, to assess the response both at home and at school.
      • when the patient has a good relationship with the teacher and school.
      • but not at the beginning of a school year or exam times.
  • If an adolescent patient wants to withdraw medication earlier, support their decision to do so but suggest waiting until they have a good relationship with a trusted teacher.
    • If teacher or school considers the patient to be “trouble”, consider delaying withdrawal and further consultation with school and family.
    • If a significant deterioration in schoolwork, encourage the patient to restart medication.

How to cease medication:

  • Methylphenidate and dexamphetamine:
    • At standard doses, medication can be ceased abruptly without tapering – parents can try this at any time.
    • If dose is > 1 mg/kg/day (methylphenidate) or > 0.5 mg/kg/day (dexamphetamine), halve dose for 1 to 2 weeks then cease.
  • Strattera – may be ceased abruptly without tapering.
  • Clonidine:
    • Always discuss with paediatrician.
    • Do not withdraw clonidine abruptly as there is a risk of rebound hypertension.
    • During gradual decrease monitor for warning symptoms e.g., headaches, visual disturbance

If appropriate, prepare:

Consider referral to your local General Paediatrics service for patients at puberty, or in grade 6 or 7, who have not been seen by a specialist for ≥ 2 years. This is at the discretion of the general practitioner and parents and is not necessary if the patient is going well.

Consider transitioning the patient to adult services when the patient is approaching age 18 years.

Transitioning to adult services
There may be a need for treatment with stimulant medication to continue into adulthood.

  • If ongoing prescription over the age of 18 years is required, refer to a psychiatrist, as new authorisation will be required.
  • Consider and prepare a GP Mental Health Treatment Plan.

When to refer

  • If significant cardiovascular signs or symptoms, discuss with your local paediatric team on call or arrange transfer to your nearest ED as appropriate
  • If significant psychiatric symptoms, refer to your local child and youth mental health service for acute assessment or Child and Youth Mental Health Acute Response Team for an acute crisis
  • Refer to your local General Paediatrics service if:
    • the patient has not been seen by a specialist for ≥ 2 years (at parents’ discretion).
    • concerns about misuse or diversion of psychostimulants.
    • persistently elevated BP.
    • deterioration of symptoms (oppositional behaviour, impulsivity, anxiety or irritability, sleep problems).

Patient will be reviewed by the paediatrics team on a priority basis if a significant change in their condition and the general practitioner clearly notes this in the referral letter.

  • Discuss with your local paediatric team if:
    • medication side‑effects not resolving e.g., headaches, gastrointestinal, sleep disturbance.
    • the patient has significant fall across centiles for growth e.g., 2 major centile lines.
    • delayed puberty.
  • If restless sleep and symptoms suggestive of obstructive sleep apnoea (OSA), refer to your local ENT service.
  • If problems managing the patient’s mood or behaviour, consider referring for psychological assessment and support.

Referring to your local Paediatric services

Public

Check the patient’s catchment area before requesting assessment. When services are available in the patient’s local area, refer the patient to the local hospital.

Queensland Children’s Hospital

Referral can be made by either:

  • GP Smart Referral via BP or Medical Director
  • Secure messaging
    Secure messaging
    Send a written request to the Referral Centre via eReferral
    (Medical Objects ID: RQ402900084, HealthLink ID: qldrchld):

    • To download templates, see Referral Forms.
    • If unable to attach investigations or use secure messaging, fax to 1300 407 281.

    For more information, contact the Referral Centre:
    P.O. Box 3474, South Brisbane QLD 4101
    Phone 1300 762 831
    Fax 1300 407 281

Insert the required information into referral.

  • Patient’s demographic details
    • Full name, including aliases
    • Date of birth
    • Residential and postal address
    • Telephone contact number(s) – home, mobile and alternative
    • Medicare number, where eligible
    • Name of the parent or caregiver, if appropriate
    • Preferred language and interpreter requirements
    • Identifies as Aboriginal and/or Torres Strait Islander
  • Practitioner details
    • Full name
    • Full address
    • Contact details – telephone, fax, email
    • Provider number
    • Date of request
    • Signature
  • Relevant clinical information about the condition
    • Presenting symptoms – evolution and duration
    • Physical findings
    • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
    • Body mass index (BMI)
    • Details of any associated medical conditions which may affect the condition or its treatment (e.g., diabetes), noting these must be stable and controlled before the request
    • Current medications and dosages
    • Drug allergies
    • Alcohol, tobacco, and other drugs use
  • Clinical modifiers
    • Impact on education
    • Impact on home
    • Impact on activities of daily living (ADLs)
    • Impact on ability to care for others
    • Impact on personal frailty or safety
    • Identifies as Aboriginal and/or Torres Strait Islander
  • Other relevant information
    • Willingness to have surgery, where surgery is a likely intervention
    • Choice to be treated as a public or private patient
    • Compensable status e.g., DVA card, WorkCover policy number, motor vehicle insurance
  • Reason for request
    • To establish a diagnosis
    • For treatment or intervention
    • For advice and management
    • For specialist to take over management
    • Reassurance for general practitioner or second opinion
    • For a specified test or investigation unavailable to the general practitioner, or the patient can’t afford or access
    • Reassurance for the patient and family
    • For other reason e.g., rapidly accelerating disease progression
    • Clinical judgement indicates a referral for specialist review is necessary

Relevant pathology and radiology results (printed for the patient and sent with the referral)

Private

Search for a provider via the National Health Services Directory.

Guideline approval and disclaimer

Guideline approval history
Version no. 1.0 Approval date 18/05/2018 Review date 01/05/2020

Disclaimer

The information contained in this GP referral and management guideline is intended for information purposes only. The information has been prepared using a multidisciplinary approach with reference to the best information and evidence available at the time of preparation. No assurance is given that the information is entirely complete, current, or accurate in every respect.
This guideline is not a substitute for clinical judgement, knowledge and expertise, or medical advice. Variation from this guideline, taking into account individual circumstances may be appropriate.
This guideline does not address all elements of standard practice and accepts that individual clinicians are responsible for the following:
  • ●  Providing care within the context of locally available resources, expertise, and scope of practice.
  • ●  Supporting consumer rights and informed decision making in partnership with healthcare practitioners including the right to decline intervention or ongoing management.
  • ●  Advising consumers of their choices in an environment that is culturally appropriate and which enables comfortable and confidential discussion. This includes the use of interpreter services where necessary.
  • ●  Ensuring informed consent is obtained prior to delivering care.
  • ●  Meeting all legislative requirements and professional standards.
  • ●  Applying standard precautions, and additional precautions as necessary, when delivering care.
  • ●  Documenting all care in accordance with mandatory and local requirements.
Children’s Health Queensland disclaims, to the maximum extent permitted by law, all responsibility and all liability (including without limitation, liability in negligence) for all expenses, losses, damages and costs incurred for any reason associated with the use of this guideline, including the materials within or referred to throughout this document being in any way inaccurate, out of context, incomplete or unavailable.

Resources

Contact details

Hospital Switchboard
(Ask for the General Paediatric Registrar)
t: 07 3068 1111

feedback
Fact sheet footer