Warning: Even Doctors Make Medication Mistakes
Get all the facts about prescribing ADHD meds to make sure your or your child’s treatment regimen is up to snuff.
Most doctors know little about the diagnosis and treatment of ADHD at any point in the life cycle. This is largely because they didn’t receive training in attention deficit in med school. If you have a clinician who is willing to work with your child, and has a good reputation among other parents dealing with an ADHD diagnosis, work closely with her to make sure your child gets optimal treatment.
The following five mistakes are, in my experience, the most common ones doctors make in treating children and adults with attention deficit. Be aware of the mistakes and question your doctor if he makes one. If you get a curt response that amounts to “You don’t know what you’re talking about,” start looking for another provider.
1. Your doctor thinks that ADHD medication is the treatment of last resort.
Non-medication-based therapies have a poor track record in treating ADHD. The old treatment approach embraced by most doctors was called multimodal therapy, a fancy term for “you have to try something more than medication.” Over time, it became clear that years of intensive behavioral and cognitive therapies didn’t add a lot of benefit to medication alone. The most recent Standard of Care from the American Academy of Child and Adolescent Psychiatry in 2007 dropped its recommendation for multi-modal therapy. The AACAP concluded that, if the child gets a robust response to medication, “medication alone is satisfactory.”
That doesn’t mean that behavioral interventions don’t work or are not needed. They deliver non-specific benefits that would be helpful to any child and family whether or not they struggled with ADHD. Any child is going to do better in a structured, predictable environment than they would in one that is chaotic and inconsistent.
2. Your doctor keeps on waiting (and waiting) to act.
Many clinicians start their conversation about treatment with the words, “I’m sorry, but your child needs to start taking medication for his ADHD.” Somewhere along the line many people started to believe that it was not ADHD, but the treatment, that was the problem. Many clinicians counsel that children should wait to start medication, despite having educational, emotional, and behavioral problems.
The largest, longest study of any childhood mental health condition is the Multimodal Treatment Study (MTA). In order to be part of that study, a child had to have “screaming ADHD.” One fourth of the research subjects were assigned to a community treatment group to find out how ADHD was being treated in real-life pediatric practices. They found that 1 out of 3 children with severe ADHD received no treatment. Despite a lot of pontificating that ADHD is over-diagnosed and over-treated, there is no evidence that this is true.
3. Your doctor uses only one medication.
There is no one right medication for everyone. The response rates for the two most commonly used first-line medications — amphetamine and methylphenidate — are the same in large groups: about 70 percent of the patients will get a good, robust response to either one you start with. When both medications are tried — on their own — about 88 percent of the patients get a good and tolerable response.
Even people who get a good response to both medications will almost always have a clear preference for one over the other. Nothing predicts in advance which medication an individual will respond to best. That preference doesn’t run in families: A parent with ADHD may take one medication while her child takes another. The only way to know is to try both medications.
4. Your doctor gives up using medication at the first sign of difficulty.
The community treatment group of the MTA study found only one treatment pattern: The clinician increased the dose of one medication until the first sign of positive benefits and then stopped raising the dose, leaving more than half the benefits of medication on the table. At a follow-up three years later, not a single doctor had gone on to optimize the medication.
There are multiple reasons why this happens. Most doctors have never received training on how to optimize the best molecule and dose. One of the most common outcomes when a person is not confident of their abilities is to give up at the first difficulty. They avoid circumstances in which there might be problems or side effects by keeping the dose as low as possible. Again, they give up early when they can say that the outcome is “good enough” rather than “the best outcome possible.” You will need to repeatedly reassure your doctor that you are willing to tolerate a few bumps along the way in order to get the very best result for your child.
5. Your doctor doses the medication according to your child’s weight.
The majority of pediatricians who treat ADHD were trained to figure out the dose of medication according to how much the child weighed. This is the way that dosing was determined in the early studies that proved the effectiveness and safety of the ADHD stimulants 50 years ago. This was done in order to “protect the double-blind” of the study so that neither the parent nor the doctor knew whether the child was on medication or how much. Clinicians misunderstood and thought that this weight-based determination of the best dose was based on something when it wasn’t.
Just as nothing predicts in advance which molecule will be best for a given child, it turns out that nothing predicts the dose of medication either: not weight, height, gender, ethnicity, or the severity of symptoms. The dose is determined by how efficiently the medication is absorbed from the GI tract. People who absorb the stimulant medications efficiently have lower optimal doses than those who don’t.
In real life, the dose of stimulant medication goes up and down over time until the child gets to be about 16 years old. That’s when the GI tract has finally matured. The dose usually does not change again for the rest of the person’s life. The American Academy of Pediatrics recommends that the dose of medication be re-determined once a year, with the understanding that the dose can go down as often as it goes up. Most families do this right before school starts each year.