ADHD Medications Part 2
When Do Meds Start Working?
How long does it take for an ADHD medication to have an effect? Is there an adjustment period, or do you know right away that it is a good option for managing symptoms?
There are two classes of medication for ADHD that treat symptoms: the stimulants and alpha agonists.
The stimulant medications are effective as soon as they cross the blood-brain barrier, which takes 45 to 60 minutes. Consequently, in adults, it is possible to change the dose of stimulant medication every day to determine the optimal molecule and dose in less than a week. Schoolchildren, however, often lack the ability to tell the clinician how the medication is affecting their functioning and mood. For patients under the age of 15, the medication dose can be raised only once a week, to allow time for parents and teachers to assess the effect on symptoms.
The alpha agonist medications, Intuniv (guanfacine) and Kapvay (clonidine), are different. It often takes five to seven days after a dosage change to assess their benefits. As a result, it may take weeks to determine the optimal dose for these medications.
Do appetite suppression and weight loss suggest that my son is taking too high a dose of stimulant?
Not necessarily. Appetite suppression is the only side effect of stimulants that is not necessarily dose-related. More predictive of appetite suppression is the child who is already thin and a picky eater. You can try a lower dose of stimulant medication while you're waiting for the next appointment with the pediatrician, but this usually results in loss of benefits for your child's ADHD. Although no one likes to take several medications, additional medication is often required for children who have appetite suppression lasting longer than two months, or who continue to lose weight. Talk with your doctor.
ADHD and Mood Disorders
How do you treat ADHD in a person who has been diagnosed with a mood disorder?
Seventy percent of people with ADHD will have another major psychiatric condition at some time in their life. Mood disorders, major depression, dysthymia, and bipolar mood disorder are the most common conditions that coexist with ADHD. Most clinicians determine which condition is of most concern to the patient and proceed to treat that condition first. If the patient has suicidal thoughts, is unable to get out of bed, or is manic, the clinician will treat the mood disorder first and then reassess the symptoms of ADHD. If there is no urgency to treat depression, most clinicians will treat the ADHD first.
Time for a Higher Dosage?
How do you know when it is time to go up in dosage? Will increasing my medication's dosage help — or is trying a new medication the way to go?
It is important to remember that with both the stimulant medications and the alpha agonists there is a "therapeutic window." Doses that are too low or too high are ineffective. Since there is no factor that predicts either the optimal class of medication or the optimal dose in a given individual, dosing needs to be determined on the basis of target symptoms — determining the impairments the person is experiencing that they would like medication to manage. There are many things about ADHD that most people would like to keep — cleverness, high IQ, problem-solving ability, and relentless determination. Each person will have his or her own list.
Start with the lowest dose of stimulant medication, increasing it periodically. Continue to increase the dose, as long as the target symptoms improve without the development of side effects. At some point, however, you'll increase the dose and won't see further improvement. At that point, the previous dose is the optimal dose. When working with small children who have difficulty giving feedback, clinicians use scales (the Connor global index scale, for instance), which compare the ADHD patient to non-ADHD children of the same gender and age.
This article appears in the Spring 2013 issue of ADDitude.
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To pose your questions about ADHD medications, visit the ADHD Medications support group on ADDConnect.