Stimulant Strategies, Part 2
Rule #2: Start at the lowest dose possible and adjust it upward if necessary.
Because everyone has a unique response to medication, a physician may need to increase the dosage — it's typically done every three to seven days — to arrive at an optimal dose. This adjustment is called titration. Doctors start at the lowest dose to provide a baseline for how much more (if any) of the drug the child needs, explains Roy Boorady, M.D., a child and adolescent psychiatrist and clinical coordinator of psychopharmacology at New York University Child Study Center. At some point, though, the dose will be increased, but the child will not see a clear increase in performance. At that point, says Dr. Dodson, the lower of the two doses will become the optimal dose.
"Don't think in terms of high dose or low dose, think of the right dose," advises Dr. Dodson. "I like to use the eyeglass analogy: When you are getting new eyeglasses, you don't care whether the prescription is high or low. You just want it to be right. And you get that by approximation."
Gender, height, and age aren't reliable gauges as to how a child will respond to medication — nor is weight. That's because each child metabolizes medication at a different rate. While one 83-pound child might see a benefit from 5 mg of Ritalin, another might need a higher dosage to achieve the same effect.
Physicians do use weight as a starting point. "Even though dosage is not directly related to weight, we have to start somewhere," says Stephen C. Copps, M.D., director of Central Georgia's Institute for Developmental Medicine in Macon, Georgia. "So I choose to start with the lowest dose possible."
In Copps's practice, kids who weigh under 60 pounds should start at 2.5 mg (half a tablet) of Ritalin two to three times per day. Anyone over 60 pounds will start with 5 mg two to three times a day, four hours apart. Dr. Copps then monitors the child's response to the medication and how long it works — and adjusts it upward if necessary.
This article appears in the October/November issue of ADDitude.
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