Taking medication is usually the first step in treating ADHD. What do you do when it does not work, when your child’s symptoms grow worse, or when side effects occur? Here is a checklist of common problems that children and parents face, and my solutions to them.

The Medication Doesn’t Work

Some parents claim that their distracted or hyperactive child shows no improvement. The most common reason for this lack of response is an incorrect diagnosis. Maybe your child’s behaviors are caused by an academic problem, such as a learning disability (LD), or an emotional problem. Many parents tell their doctor that their child can’t sit still or pay attention in school. Without asking questions or conducting tests, the physician writes a prescription. The diagnosis of ADHD is not that simple. Specific criteria must be met before an ADHD diagnosis is made: establishing that the behaviors have been chronic (existed since preschool or early elementary school) and pervasive (at home, in school, with peers).

In some cases, the diagnosis may be correct, but the prescribed dosage may be incorrect. Determining the right dosage is not based on age or body weight, but on how quickly the medication is absorbed into the bloodstream and passed into the brain. A 250-pound adult may need 5 mg., while a 60-pound child may require 20 mg. Since the dose needed is specific to the patient, medication should be started low, at 5 mg. If no benefits are seen, the dose should be increased, by 5 mg., every five to seven days until the correct dose is determined.

Finally, many children diagnosed with ADHD have additional problems. The most frequent are LD, anxiety disorders, depression, anger control problems, or obsessive-compulsive disorder. Stimulants manage ADHD symptoms, but don’t address symptoms caused by related disorders.

The Medication Doesn’t Work All the Time

A terror in the morning. Think about how your child acts when he is on medication and when he is not. Most problems occur before the medication starts working or when the dose doesn’t last the full four or eight hours noted on the label. Eight-year-old Kristen takes an eight-hour capsule of methylphenidate at breakfast, just before she leaves for school. She does well in school, and her teacher thinks she is wonderful. Her parents have a different perspective. “We have to stay on top of her in the morning. It’s a task to get her to eat, take her pill, and be ready on time.”

To keep your child calm and focused in the morning, wake her up an hour earlier than usual and give her the medication. Then let her go back to sleep. If your child can’t go back to sleep, discuss using Daytrana, a methylphenidate patch, with your doctor. Apply the patch to your child’s thigh while she’s asleep, and the medication will start to work within an hour. (If you do this, an earlier afternoon dose may be needed.)

Afternoon crashes. Maybe there is a dip in coverage around noon, and your son has difficulties between 12 and 1. Maybe he begins to act up around 4 p.m., or bounces off walls around 8 p.m. Play detective to determine when his ADHD symptoms worsen. Maybe the four-hour tablet lasts only three hours with your child. Perhaps the eight-hour capsule you are giving him is not releasing evenly. Tell your physician when medication doesn’t work—and he can reconfigure the dosage schedule or change the medication.

The Medication Causes Side Effects

Loss of appetite. A healthy appetite often returns in several weeks. If not, try delaying the first dose until after your child has eaten breakfast. Lunch is often a bigger challenge. A nontraditional lunch, such as a food supplement milkshake, like Ensure, or a high-protein energy bar, might get him to eat. To increase your child’s appetite at dinnertime, hold off giving the 4 p.m. tablet after dinner. If none of these suggestions work, ask your family doctor for a referral to a nutritionist who has experience working with ADHD. If your child’s appetite doesn’t return, talk with your doctor about switching to another stimulant or to a nonstimulant.

Sleep problems. Stimulants affect the area of the brain that induces sleep. Skipping the 4 p.m. dose may help—but not at the cost of your child becoming unmanageable. If you find that this is the case, try this experiment. With your doctor’s permission, add an 8 p.m. four-hour tablet. A small dose of stimulant helps some children fall asleep. If the experiment fails and your child still can’t fall asleep, your doctor might suggest Benadryl. Many parents find that a small dose of melatonin helps with sleep.

Other side effects. Thirty to fifty percent of individuals with ADHD have a co-occurring condition. In some cases, stimulant medication exacerbates these disorders or causes the disorders to become clinically apparent. If you see that your child becomes more anxious or fearful, unhappy, or angry on stimulants—but that the symptoms stop when he is off the medication—talk with your doctor.

It is essential that emotional-regulation problems be treated promptly. A doctor will often prescribe a selective serotonin reuptake inhibitor (SSRI) to treat these disorders. Then the stimulant medication can be reintroduced without causing difficulties. Medication might be needed to address tic disorders as well.

Your Child Resists or Refuses to Take Medication

Educate your child about the medication he is taking. Don’t tell him it’s a vitamin pill. You will have a hard time building trust later, when he finds out the truth. Explain what ADHD is and how it affects his life. Tell him how the medication decreases ADHD symptoms. Explain that he might experience side effects, but that they will be dealt with by you and his doctor. Your child will be more cooperative if he participates in the process.

You and Your Spouse Disagree About Medication

If one parent feels strongly that your child shouldn’t be taking medication and expresses that to your child, you may have a serious problem. If the child has conflicting views about the benefits of medication, he might stop taking it or question why he has to take it. Set up an appointment with your doctor to discuss the diagnosis and the value of medication with your spouse.