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ADD: General Medication Questions

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ADD: General Medication QuestionsWhich medications work best?
There's no single answer to this question. In most patients, stimulants emerge as the drug of choice, but in others they don't work at all. Even within these categories, the responses of individual patients can be very different, often for no discernible reason. One child may do fine on Ritalin but not Dexedrine; for another it may be just the reverse. One may experience troubling side effects while his classmate has no such side effects.

How, then, do doctors know which medications to use?
Unfortunately, there's no good way to predict the response to a type of medication or a dosage schedule. So don't be surprised by some degree of trial and error as you try to get it right.

Each medication has its pros and cons, and we'll look at each of them in turn later in this chapter.

Are generics equivalent?
In my experience, no--especially the generic equivalent of Ritalin. If your health care prescription plan restricts you to certain medications, you may have trouble getting brand name Ritalin covered. Different plans have different rules, but if you encounter this problem, it's sometimes possible to win an exception if your doctor documents that the generic medication wasn't effective or files an appeal with the insurer.

How soon can I expect to see results?
With stimulants, you can see some changes in behavior very quickly--even with the very first dose. Other types of medications typically take longer to start working. Antidepressants, for example, may require up to three weeks before effects are noticeable. However, with all of these medications, you should see definite changes within a couple of months.

What should I do if the medication isn't working?
About 25 percent of patients don't respond to the initial medication, or have too much trouble with side effects to stay on it. But there's good news: Patients often do well with another medication of the same type. So, for example, if Ritalin isn't helping your child, ask your doctor to consider switching him or her to Adderall or Dexedrine, and vice versa. If the stimulants don't work, ask the doctor to consider other classes of drugs instead. Also, combinations might work where single medications don't.

If medication isn't making a difference after a reasonable period of time, there's no reason to continue the same treatment regimen in the hope that it will eventually improve. Schedule an appointment with your child's physician to look at how the treatment should be modified.

Here's what you and the doctor should consider:

• The medication--another drug or class of drugs may work better.
• The dosage--if you're not seeing improvement, the dosage may need to be increased or the timing of the doses changed; if side effects are a problem, consider reducing the dosage, either temporarily or permanently.
• The diagnosis--if medication isn't proving effective, take another look at the diagnosis. Your child may have an ADHD mimicker--a different condition whose symptoms resemble ADHD.
• Comorbid disorders--as we've seen, problems such as learning disorders or anxiety often go hand in hand with ADHD. If, for example, your child has a comorbid learning disorder, you won't see much progress if you're only treating the ADHD. That doesn't mean you should stop treating the ADHD and focus only on the LD; you need to treat both.

Page 2Does medication really help my child get better grades in school?
While it's clear that medication has a powerful effect on classroom behavior, some researchers have questioned whether they improve learning as well. In other words, does medication simply help ADHD children be less disruptive in class, or does it actually improve their performance on things like book reports and math exercises? That's an important distinction, because it raises the issue of whether medication primarily benefits the child or the teacher.

While there are conflicting studies on this issue, the bulk of the evidence suggests that medication does in fact improve both behavior and academic performance. For example, a 1993 study published in the Journal of the American Academy of Child and Adolescent Psychiatry looked at specific areas of academic performance and found that medication helped about 75 percent of ADHD children improve to the point that their performance was essentially the same as that of non-ADHD children.

Can medication interfere with learning?
Yes, it can--which is why it's so important to monitor closely the child's school performance after medication begins. For example, in some cases stimulants cause children to become isolated and withdrawn. This may make it hard for a child to set priorities and move from task to task. These effects seem to be dose related, so the way to manage them is by reducing the dosage or trying a different medication.

The dosage my child is using doesn't control her ADHD all the time. Does it need to be increased?
Inconsistent control is usually a matter of when it's given, not the size of the dosage. For example, Ritalin's clinical effects may last as little as two hours, so even the standard twice-a-day regimen creates peaks and valleys of control throughout the day. Longer-acting Dexedrine often gives better results, but with any medication you may see variability.

That's why it's important to tailor the dosage schedule for your child's individual circumstances. For example, one common problem comes up with children who have a long bus ride to school. If they take their Ritalin with breakfast, they'll be fine on the bus, but the medication may start wearing off in first or second period, and the period before a second dose at lunchtime will be a complete loss. If the child can be relied on to take his medication, I often suggest that he take it when he gets off the bus at school, so that the peak effects will occur when they're most needed.

How will the doctor determine the right dose for my child?
Mostly by clinical experience, along with some degree of trial and error.

Because people respond so differently and unpredictably to ADHD medications, it's difficult to say up front what the optimal dose should be for any given patient. In most cases, the initial dose should be at the low end of the range and then gradually adjusted upward to achieve the best response--an approach known as titration. Titration takes more work and a longer observation time than simply writing a "standard" dose. You have to wait to see the effects and possibly return to the doctor for several follow-up visits until the dose is right. But it allows the doctor to find the lowest dose that still produces the desired effects, thus reducing the risk of side effects.

How do you know when the dose is high enough?
A basic rule of thumb is to use the lowest dosage that produces an adequate response.

"Adequate" is, of course, often in the eye of the beholder. However, keep in mind that more isn't necessarily better. With higher doses, of course, the risk of side effects increases. But there's another, less obvious reason to keep the dosages low. Studies show that too high doses begin to interfere with the ability to do very complex and memory-intensive tasks, even though they control the social and hyperactive components of ADHD. Thus, while the child's classroom behavior seems terrific, the actual academic performance isn't at its full potential. In other words, the dose that's best at controlling behavior isn't necessarily the best at promoting learning. Lower doses can control behavior without interfering with higher-level processing.

Page 3Should the dosage be set based on weight?
Not necessarily--at least not for the stimulants. Weight is a starting point for calculating dosage, but not the whole answer. That's why two patients who weigh the same may end up with very different dosages.

For many medications, dosages are calculated based on body weight, so that a child weighing 50 pounds would receive one third the dose of a man weighing 150. But several studies of stimulants suggest that body weight doesn't always make a difference. For example, one study looked at how well different doses of Ritalin controlled symptoms of ADHD in a large group of children. When researchers looked at the dosages in terms of body weight, there was no clear pattern of which doses were most effective. But when they ignored body weight and simply looked at the dosages, the results were dramatic: The optimal dose was usually between 10 and 15 mg, regardless of the child's size.

Of course, that doesn't mean that every child will do best at this dosage, but it does suggest a good starting point.

This same general rule holds true for Dexedrine or other medications that we use to treat ADHD. In the final analysis, we are not treating a weight, but a person.

Should the dosage increase as my child grows?
Yes. Dosage will usually increase over time as the child grows through adolescence. It's important not to fall behind in the dosing. If the child outgrows the dose, she'll begin to lose her focus, and the symptoms of ADHD will re-establish themselves--often so gradually that you won't realize there's a problem at first. It's always preferable to head off these problems rather than trying to undo damage caused by loss of focus.

Are the effects of Dexedrine, Adderall and Ritalin the same?
No. Although all of these stimulants address problems of attention and focus, they're not completely interchangeable.

In about 70 percent of patients, they have similar effects. But other patients may respond to one of these drugs and not the others, or they may have unacceptable side effects with one and not another.

What's more, each drug has a "personality" in terms of how it affects the patients. In some, Ritalin acts like blinders on a horse, keeping them highly focused. It's almost as if Ritalin tells you, "You will pay attention." That can be useful, but the downside is that it leaves some patients feeling "flat," lacking zest. Parents sometimes tell me that their child seems "sad" on Ritalin, but it's not really sadness; it's more like their spirits are dampened. They don't feel quite themselves. That's one reason why many adolescents don't like to take Ritalin.

I've found that Dexedrine and Adderall often produce a more "natural" response in patients. Instead of forcing you to pay attention, it permits you to pay attention. Patients may not get the same tight focus as they do on Ritalin, but they're looser and more spontaneous.

However, Dexedrine and Adderall aren't tolerated by everyone. They don't provide the same degree of control over behavior. Also, in some patients they can produce an edginess and anger--sort of the flip side of the flatness we sometimes see in Ritalin.

The upshot is that there's no ideal treatment for everyone. For some patients, Ritalin is clearly the drug of choice; for others, it's Dexedrine or Adderall. The goal of treatment isn't to impose a one-size-fits-all approach, but to find out what's best for the individual.

What should I do if my child gets the wrong dose?
If you miss a dose, there's really nothing to worry about. Just give the next dose when it's scheduled. Don't double up to "make up" for the missed dose.

If you accidentally give your child too much medication, call your doctor. A double dose may cause short-term problems such as irritability, loss of appetite, and sleep difficulties. It's not likely to cause any long-term harm, but check with your doctor or pharmacist just to be sure. A major overdose--for example, if a younger sibling accidentally gets into the medication--can be much more serious. Call your doctor, your local Poison Control Center, or 911 immediately.