The Decision to Medicate

Five Rules for Treating ADHD in Children with Stimulant Medications

Successfully treating ADHD isn’t as simple as filling a prescription and living happily ever after. Getting ADHD meds to work to their optimal benefit requires trial and error, close monitoring, and patience. Doctors and patients offer guidelines for using stimulant medications safely and effectively.

ADHD treatment and medication tricks
ADHD treatment and medication tricks

Before Winnie Frable agreed to start her child with attention deficit disorder on an ADHD medication three years ago, she did a lot of reading — and agonizing. She worried about long-term effects stimulant medications might have on her 8-year-old son, as well as the insomnia and appetite loss the medication may cause.

“Ultimately, it came down to whether I wanted Christian to remember his childhood as being full of failure and antagonism due to his untreated ADHD,” says the Bethesda, Maryland, mom of three. “When I looked at it from this perspective, there was nothing else I could do.”

Although alternative ADHD treatments are used to manage attention deficit, research shows that pairing therapy with medication dramatically increases the odds of improving ADHD symptoms in both children and adults.

For children in particular, the results have been promising. In fact, according to the American Academy of Pediatrics (AAP), 80 percent of the children who use stimulant medications, either alone or combined with behavior therapy, increase focus and decrease impulsivity. What’s more, a study in the Journal of the American Academy of Adolescent Psychiatry suggests that, for children under age 10, medication alone may offer the best results. The majority of children who use medication report having increased self-esteem, fewer disruptive behaviors, and improved relationships with parents, siblings, and teachers. And adults with ADHD have seen similar results.

Contrary to what the word suggests, stimulants don’t excite or rev up those who take them. This class of medication works by normalizing chemical neurotransmitters in the brain responsible for regulating attention. And while no clinical studies have tracked the long-term safety of stimulants, doctors say that there aren’t any known disabling or lasting side effects. Ritalin, they point out, has been used for more than 40 years. Shorter-term studies, involving two-year follow-ups with patients using stimulants, have shown the drugs to be safe and effective.

(See a chart listing all the stimulant medications)

Making Meds Work

Successfully treating ADHD with medication isn’t as simple as filling a prescription and living happily ever after. Winnie’s pediatrician told her that it would take several weeks to fine-tune the dosage for her son, during which she’d be responsible for monitoring her son’s symptoms. Christian, like many ADHD patients, switched medications, starting out on Ritalin and moving to Concerta. There is no one right medication or dosage for everyone with ADHD. Prescribing involves trial and error. “Christian has done well on Concerta, except for the fact that he doesn’t seem to sleep as well,” says Winnie. “We’re trying to figure out whether it’s due to the drug, or if he’s just nervous about school.”

William W. Dodson, M.D., a Denver-based psychiatrist specializing in ADHD, wishes more parents and ADHD adults would be patient about side effects. “There’s a tendency for people to throw up their hands at the first difficulty instead of working with the physician as they would with the treatment of any other disorder,” says Dr. Dodson. “Getting ADHD meds to work to their optimal benefit requires patience.”

Here are five key steps for using stimulants effectively, as well as advice on managing some potential side effects.

Rule #1: Find a doctor who will closely monitor your or your child’s medication.

This is critical to your success on medication. According to a study published in the April 2004 issue of Pediatrics, researchers who observed the therapy outcomes of 579 children with combined-type ADHD concluded that those who were closely monitored showed the greatest improvement in their symptoms.

For parents, The AAP suggests starting out with a general pediatrician to deal with ADHD. But if your child has a comorbid condition, such as depression or a learning disability, or if she doesn’t respond to initial drug therapy, a parent should consider seeking specialized care, says Andrew Adesman, M.D., director of developmental and behavioral pediatrics at Long Island Jewish Medical Center and North Shore University Hospital in New York. In these instances, a developmental pediatrician, child neurologist, or child psychiatrist can offer a deeper working knowledge of the newest medications and more experience with drug therapy, as well as the time available to work with your child.

Carol Fitzgerald of Warren, New Jersey, says that it took a visit to a neurologist to determine why her son wasn’t responding to Ritalin. “It turns out that Gregory also has a mild form of Asperger’s syndrome,” says Fitzgerald. “He explained that we also needed to treat the mood changes associated with this condition.”

While the frequency of visits during the startup phase of a medication may vary from office to office, your doctor should be willing to see your or your child at least every two to four weeks during the first couple of months. These informative meetings will enable you to discuss how the meds are working, whether there are noticeable or troubling side effects, or, for children, if the medication is affecting height or weight. A doctor should always measure your child’s height and weight during the initial office visit and then at evenly spaced intervals — once a month, perhaps — afterward.

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 patient needs, explains Roy Boorady, M.D., senior director of the Psychopharmacology Service at the Child Mind Institute. At some point, though, the dose will be increased, but the patient 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 someone will respond to medication — nor is weight. That’s because each person 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., the former 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, patients 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 patient’s response to the medication and how long it works — and adjusts it upward if necessary.

Rule #3: Try medication 7 days a week, 12 hours a day.

Although some studies suggest that skipping medication on weekends — called drug holidays — may reduce side effects without increasing symptoms, the experts we spoke with disagreed. They say that the disruptive symptoms of the condition extend beyond the classroom or office. “ADHD is a life problem, not just an academic or workplace problem,” says Dr. Copps. “The appropriate treatment is as important to relationships and social competency as it is to academic and vocational endeavors.”

Taking medication that extends beyond the school or work day has many advantages, including increased focus doing homework and during after-work activities. For children, it’s not necessary to medicate during sleeping hours, but it helps if the medicine is active at bedtime.

Some doctors recommend combining a short- and longer-acting stimulant. According to some experts, some of the longer-acting medications last only eight or nine hours, not 12. Dr. Copps compensates for that shortfall by recommending that his patients take a short-acting Ritalin in the early morning or late afternoon.

Rule #4: Keep tabs on how the medication is working.

Parents can help the doctor arrive at the right dosage for their child by tracking the child’s response to the medication. A doctor should offer parents a structured way to monitor their child’s symptoms. Behavior rating scales are very effective.

The SNAP-IV Scale (named for the doctors Swanson, Nolan, and Pelham, who created it), for instance, can help parents assess a child’s behavior throughout the day and detect patterns and problems with medication. The scale gauges the frequency of 90 physical symptoms and emotional behaviors at home and in the classroom. A doctor can evaluate any troubling patterns and adjust the dosage or switch to another stimulant (or class of drugs) to correct them.

Adults can use the same patterns to detect problems with medication. If you notice that you becomes irritable and anxious at, say, 5 p.m. every day, for instance, your medication may be wearing off too soon. In this case, another dose might help. On the other hand, if anxiety and irritability occur a few hours after taking the medication, perhaps the dosage needs to be lowered.

For parents of ADHD children, the Conners’ Rating Scales-Revised (CRS-R) is another worthwhile tool. Each of the three versions — parent, teacher, and adolescent — comes in a short and long form. Dr. Boorady recommends that parents use the long form themselves and reserve the short form for their child’s teacher(s), who probably has less time to fill out the evaluation. “Whichever you choose, use the same form for all of the evaluations to ensure consistency,” he adds.

Rule #5: Consider diet and medications.

Diet can affect the efficacy of any drug. If you or your child is taking Adderall XR or Ritalin LA, for instance, a high-fat breakfast can compromise its effectiveness, delaying the drug’s absorption. Instead of the drug working within the usual 20 to 30 minutes, it could take one to two hours. Use common sense and avoid such high-fat dishes as a bacon, egg, and cheese sandwich; donuts; bagels with cream cheese; and full-fat muffins.

Similarly, drinks rich in ascorbic acid/vitamin C or citric acid (orange, grapefruit, and other drinks supplemented with vitamin C) may interfere with the absorption of Ritalin. Citric acid breaks down the medication before it has a chance to be absorbed by the body. As a result, some doctors recommend avoiding such drinks, as well as multivitamin supplements and high-vitamin cereals, an hour before and after taking the medication. Others disagree, claiming there’s not enough citric acid in orange juice or fortified cereals to warrant passing them up.

Some doctors insist that patients on stimulants also avoid cold/sinus/hay fever medications that contain decongestants (antihistamines without decongestants are okay); over-the-counter or prescription weight control medications; steroids, taken orally or injected; and asthma medications containing albuterol or theophylline. All of these may produce a mildly unpleasant “buzz.”

Carol Fitzgerald and her son, Gregory, now 14, have had many ups and downs in the nine years he’s been on medication. But they both agree it’s been worth the effort. “We’ve found something that enables my son to feel good about himself,” she says. “That, to me, is the most important thing in the world you can do for your child.”


Solving Side Effects from ADHD Medications

Loss of Appetite: Before an ADHD child starts drug therapy, it’s important for you and your doctor to determine a dietary baseline. During the first month, it’s common for appetite suppression to peak and, later, to normalize. If appetite loss is severe, request that your child be switched to a different stimulant or another class of medication.

Sleep Problems: Because ADHD itself can cause sleep difficulties, it’s not always clear whether the disorder or the medication is the problem. Again, it’s important to monitor your child’s sleep patterns before he starts medication. If a medication is causing insomnia, adjusting dose amounts and times can make a difference. Dr. Roy Boorady of New York University suggests that taking a medication a half-hour earlier in the morning can often help alleviate sleep difficulties. If sleep problems persist, your doctor might lower the dose or switch medications.

Facial Tics: While children with ADHD are at increased risk of developing facial tics — rapid eye blinking, nose scrunching, twitches — stimulants may also cause or exacerbate them. It can take several weeks, or, in some cases, months, for stimulant-associated tics to appear. Lowering the medication dose, switching to another stimulant, or another class of drugs can help.

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