Practice Parameter for the Use of Stimulant Medications in the Treatment of Children, Adolescents, and Adults

More than 60 years ago, serendipitous observation revealed that the drug dl-amphetamine reduces the disruptive symptoms of hyperkinetic children. Today, four stimulant medications are available for clinical use: methylphenidate (MPH), dextroamphetamine (DEX), mixed-salts amphetamine (AMP), and pemoline (PEM). They are the most widely prescribed psychotropic medications for children, primarily in the treatment of attention-deficit/hyperactivity disorder (ADHD). Long thought of as a childhood disorder, ADHD is now known to persist into adolescence and adulthood, and adults are increasingly being treated with stimulants for this condition. Stimulants are also indicated for the treatment of narcolepsy, based on controlled studies. This practice parameter will (1) review the literature pertinent to the clinical use of stimulants; (2) describe indications and contraindications for stimulant treatment, with an emphasis on judicious use; (3) describe the initiation and dosing of the various stimulant agents; (4) describe the side effects encountered in stimulant treatment; (5) discuss long-term maintenance using stimulant agents; and (6) discuss the combination of stimulants and other psychotropic agents in the treatment of comorbid conditions. EXECUTIVE SUMMARY The treatment of patients with stimulant medications requires the consideration of many factors that cannot be fully conveyed in the brief executive summary. The reader is encouraged to review the entire practice parameter. Each recommendation in the Executive Summary is identified as falling into one of the following categories of endorsement, indicated by an abbreviation in brackets following the statement. These categories indicate the degree of importance or certainty of each recommendation. “Minimal Standards” [MS] are recommendations that are based on substantial empirical evidence (such as well-controlled, double-blind trials) or overwhelming clinical consensus. Minimal standards are expected to apply more than 95% of the time, i.e., in almost all cases. When the practitioner does not follow this standard in a particular case, the medical record should indicate the reason. “Clinical Guidelines” [CG] are recommendations that are based on limited empirical evidence (such as open trials, case studies) and/or strong clinical consensus. Clinical guidelines apply approximately 75% of the time. These practices should always be considered by the clinician, but there are exceptions to their application. “Options” [OP] are practices that are acceptable but not required. There may be insufficient empirical evidence to support recommending these practices as minimal standards or clinical guidelines. In some cases they may be appropriate, but in other cases they should be avoided. If possible, the practice parameter will explain the pros and cons of these options. “Not Endorsed” [NE] refers to practices that are known to be ineffective or contraindicated.