What to do when your patient is avoiding swallowing their ADHD medication?
Erin Dillon-Naftolin, MD
PAL Consultant
Many kids do not learn to swallow pills until around age 10, but some can learn as young as 5-6 years old.
Practical tips:
- Encourage them to sit up straight, use a glass of water and practice relaxation techniques prior to starting.
- Do daily practice with a small candy first until comfortable swallowing to avoid bitter taste and choking sensation. Gradually moving from sprinkles or Nerds (Nestle) up to Tic Tacs (Ferrero) or mini M&M’s (Mars) can give good success.
- Changing head position can give a different sensation, a wider esophageal diameter and delayed closure that may help. Turning laterally to swallow with the chin over the shoulder was the most popular position in the study.1 There is a nice video you can share with families: www.ucalgary.ca/research4kids/pillswallowing.
For patients who resist pill swallowing or cannot swallow medications:
For ADHD medications there is a nice visual chart at http://www.adhdmedicationguide.com/ that is a helpful reference you can pull up with families to show size of pills and formulation options.
Chewable/ODT:
*Methylphenidate based: Cotempla XR (grape), Quillichew ER (cherry), methylphenidate chewable (grape)
* Amphetamine based: Adzenys XR-ODT (orange), Evekeo-ODT, Vyvanse chewable (strawberry)
Liquid:
*Methylphenidate based: Quillvant XR (banana), Methylin Solution (grape)
*Amphetamine based: Dyanavel XR (bubblegum), Adzenyx (orange), ProCentra (bubblegum)
Sprinkles:
-Pros: Helpful to have no flavor for many children with oral sensitivities
-Cons: Child must finish food/drink it is on/in and it is an extra step in the morning routine that can be a barrier to adherence for some families
*Methylphenidate based: Adhansia XR, Aptensio XR, Focalin XR, Ritalin LA, Metadate CD, Azstarys, Jornay
*Amphetapine based: Mydayis, Adderall XR, Dexedrine Spansule, Vyvanse
*Non-stimulant: Qelbree
Patches:
-Pros: Nice option for children with complete oral aversion to medications. Nice benefit that the dose stops when patch is removed for families who need to control when the stimulant effect wears off.
-Cons: Can be tempting for children to pick off and remove. Can have itching or redness at patch site and for kids with darker skin tones can cause hyperpigmentation
* Methylphenidate based: Daytrana- dosed daily in 10, 15, 20 and 30 mg sizes,
* Non-stimulant: Clonidine- dosed weekly in dose ranges from 0.1-0.4 mg, less sedating than IR formulation for daytime use
Crushable:
-Pros: May be able to hide in highly desirable foods or follow with special drink they only get after medicine.
-Cons: Will have unpleasant bitter taste
*Methylphenidate based: Focalin IR, Ritalin IR
*Amphetamine based: Evekeo, Zenzedi, Adderall IR
*Non-stimulant: guanfacine IR, clonidine IR
Must be swallowed whole:
*Methylphenidate based: Methylphenidate ER (Concerta), Metadate ER
*Non-stimulant: Guanfacine ER (Intuniv), Clonidine ER (Kapvay) and atomoxetine (Strattera)
SSRI Medications: Citalopram, escitalopram, fluoxetine, paroxetine and sertraline come in liquid formulations.
Antipsychotic Medications: Aripiprazole and risperidone come in liquid and ODT formulations. Olanzapine has an ODT option.
1 Kaplan BJ, Steiger RA, Pope J, Marsh A, Sharp M, Crawford SG. Successful treatment of pill-swallowing difficulties with head posture practice. Paediatr Child Health. 2010 May;15(5):e1-5. doi: 10.1093/pch/15.5.e1. PMID: 21532781; PMCID: PMC2912624.
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News & Notes
Registration for our February 11, 2023 virtual conference is open!
- Time: 8:30 am - 12:00 pm
- Featured topics & presenters:
- ADHD Update | Dr. Rebecca Barclay
- Psychotropic Medications to Support Children with Autism: A Case-Based Approach | Dr. David Camenisch
- Perinatal Mood Disorders | Dr. Carmen Croicu & Dr. Ramanpreet Toor | University of Washington Perinatal Psychiatry
PAL will be closed on the following day:
- Presidents' Day - Monday, February 20, 2023
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 PAL Spotlight
Dr. Douglas Russell joined the PAL team in March of 2017. He received his medical degree from Jefferson Medical College and completed both his psychiatry residency and child psychiatry fellowship training at UCLA. Prior to medical school he worked as a radio producer at KUSC fm, a classical public radio station in Los Angeles. He received his BA in music from Wesleyan University. He is always willing to chat about music! If you would rather talk shop, his clinical interests include ADHD and other neurodevelopmental disorders, integrated/collaborative care, and prevention/health promotion. In addition to his work at PAL, Dr. Russell also works in the Seattle Children’s PEARL clinic and supervises child and adolescent psychiatry fellows in our training clinic.
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Upcoming CME Conferences
February 11, 2023
Location: virtual conference
Register here!
April 22, 2023
Location: Bellingham
June 3, 2023
Location: virtual conference
Visit our website for the most updated information on upcoming conferences and to view slides from our previous conferences.
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First Approach Skills Training (FAST) Trainings
PAL is offering another series of free training events for primary care-based behavioral health providers across Washington. The First Approach Skills Training (FAST) team will offer live, interactive trainings for treating anxiety, depression, behavior problems, posttraumatic stress, teen behavior challenges, and early childhood concerns in integrated primary care settings. Click any of the registration links below to learn more and get registered. Again, these trainings are free within Washington State and designed for behavioral health professionals working in integrated primary care settings.
FAST-Behavior | February 28, 2023 | 9:00 am - 11:00 am | Register here
FAST-Anxiety | March 14, 2023 | 9:00 am - 11:00 am | Register here
FAST-Early Childhood | March 28, 2023 | 9:00 am - 11:00 am | Register here
FAST-Depression | April 4, 2023 | 9:00 am - 11:00 am | Register here
FAST-Trauma | April 18, 2023 | 8:30 am - 11:30 am | Register here
FAST-Parenting Teens | May 9, 2023 | 9:00 am - 11:00 am | Register here
FAST-Early Childhood | May 16, 2023 | 9:00 am - 11:00 am | Register here
Visit our website for the most updated information on upcoming trainings.
For questions about resources or provider training opportunities, please contact us at FAST@SeattleChildrens.org.
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