- 6 Steps to Take If ADHD Medication Isn’t Working for Your Child
- Know what “working” looks .
- Monitor your child’s medication and take notes
- Observe your child’s personality, too
- Consider adjusting or changing your child’s medication
- Explore other treatment options
- How to Know When a Different Drug or Dosage for ADHD Is Needed
- ADHD medication for kids: Is it safe? Does it help?
- What we’ve learned about methylphenidate
- What should parents do?
- ADHD medication: The bigger picture
- ADHD Medications Rarely Work Perfectly on the First Try
- Problem: ADHD Medication Doesn’t Work
- Problem: ADHD Medication Doesn’t Work All The Time
- Problem: ADHD Medication Causes Side Effects
- Parenting Problem: Your Child Resists or Refuses to Take Medication
- Problem: You and Your Partner Disagree About ADHD Medication
- Is Your Child’s ADHD Medicine Working?
- Treatment of ADHD in patients unresponsive to methylphenidate
- When your ADHD medication is not working anymore
- Infections and ADHD- symptoms
- ADHD medication isn’t working anymore
- ADHD medication is not working
6 Steps to Take If ADHD Medication Isn’t Working for Your Child
Most experts agree that ADHD medication is the most effective treatment for ADHD. But it doesn’t work for 20 to 30 percent of kids, according to the CDC. And even when there’s some benefit, parents may find that the ADHD medication is not working well enough.
Your child’s ADHD symptoms might subside at certain times of day but get worse than usual at other times. Or you may not be seeing the progress you expected to see after your child started medication. Here are steps you can take if ADHD medication doesn’t seem to be working for your child.
Understood is not affiliated with any pharmaceutical company.
Know what “working” looks .
The best way to gauge whether your child’s medication isn’t working is to know what you’d be seeing if it were working. The goal isn’t to “get rid of” ADHD symptoms. But you should see a decrease in the intensity of symptoms and in how much they disrupt your child’s life.
Monitor your child’s medication and take notes
One way to do this is by using an ADHD medication log. It helps you keep track of your child’s sleep, eating and behaviors. That information can help you start to identify patterns and pinpoint your concerns.
Are your child’s symptoms worse at certain times of day than others? Do they seem to get better after certain activities? Is your child’s impulsivity better, while focus is still a struggle? Asking yourself questions these allows you to figure out if the medication is helping a lot, a little, or not at all. And your child’s prescriber will need this specific information when you talk about next steps.
Observe your child’s personality, too
There are some side effects of stimulant medication that can affect personality. One is a “flattened affect.” This might look your child not wanting to socialize or becoming withdrawn and quiet. Other side effects might be changes in how your child reacts to things, poorer sleep, or increased tiredness.
Consider adjusting or changing your child’s medication
Talk to your child’s prescriber about what you’ve been seeing. Together you may decide to fine-tune your child’s dosage or try another medication altogether.
Keep in mind that ADHD is genetic. Tell your child’s prescriber if there’s a family member with ADHD. If that person takes ADHD medication that’s effective, your child may respond well to that medication, too.
Explore other treatment options
You and your child’s prescriber may decide that ADHD medication isn’t the best fit for your child. Or you may want to try other treatments in addition to the medication. Behavior therapy can be helpful for many kids. Certain lifestyle changes may be beneficial, too.
worked as a classroom teacher and as an early intervention specialist for 10 years. She is the author of The Everything Parent’s Guide to Special Education. Two of her children have learning differences.
Stephanie Moulton Sarkis, PhD
is an ADHD/ASD expert and a best-selling author.
How to Know When a Different Drug or Dosage for ADHD Is Needed
PhotoAlto/Antoine Arraou – Brand X Pictures/Getty Images
Medications for treating symptoms of attention deficit hyperactivity disorder (ADHD) can be very effective for children, making it easier for them to pay attention in school, maintain friendships, and basically navigate life.
But sometimes, it's hard to determine the right medicine and the right dosage, with the best results and the fewest side effects.
With some careful adjusting, however, it's almost always possible to find a medication and a dosage that works.
The most commonly prescribed ADHD medicines are Adderall (amphetamine and dextroamphetamine); Ritalin (methylphenidate ); Focalin (dexmethylphenidate); and Concerta (methylphenidate extended-release tablets).
All of these drugs are stimulants, which are thought to work by increasing levels of a neurotransmitter in the brain called dopamine. This chemical is associated with motivation and attention, among other things.
For many people with ADHD, stimulant medications both boost concentration and the ability to focus while at the same time curbing hyperactive and impulsive behaviors.
For the most part, ADHD drugs work. According to the ADHD treatment guidelines of the American Academy of Pediatrics (AAP), most children will respond to one of the stimulants.
When a medication doesn't work or causes intolerable side effects, the options are usually to adjust the dose, either up or down, or switch to another medication.
For example, if Adderall isn't relieving a child's symptoms or is making them cry a lot, then lowering their dosage or having them try one of the other stimulant medications may solve the problem.
A non-stimulant medication called Strattera (atomoxetine) is sometimes a good option for a child who isn't tolerating a stimulant. Some doctors also prescribe Strattera along with a stimulant, making it possible to lower the dose of the stimulant drug enough that it no longer causes side effects.
Other alternative medications used to treat ADHD include the medications Catapres (clonidine) and Tenex (guanfacine). These can be effective for impulsivity, hyperactivity, and sleep disturbances.
Sometimes if a child doesn't respond to two or three different stimulant medications and continues to do poorly, it may be that the ADHD diagnosis is wrong and that something else is causing the symptoms the child is experiencing.
In this case, the AAP advises pediatricians to evaluate the child's diagnosis again and also have the child tested for a coexisting condition such as depression, bipolar disorder, or a learning disability or behavioral problem.
If you have a child with ADHD, putting various medications and dosages to the test to find what will work for him can be frustrating for you both.
Don't hesitate to ask your pediatrician any questions you might have about effectiveness and timing (sometimes adjusting when the doses are taken can make a big difference).
Let the doctor know about any side effects you believe are associated with your child's treatment. Don't be afraid to push for changes. There are many options available.
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ADHD medication for kids: Is it safe? Does it help?
Follow me at @ellenbraaten, the MGH Clay Center
Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed psychiatric disorders, with prevalence rates around 3%-4%.
Medication is frequently used to treat the symptoms of inattention, impulsivity, and hyperactivity that are associated with the disorder. It’s a developmental disorder, meaning that the symptoms start in childhood, before the age of 12.
The symptoms can impair functioning in school and at home, and interfere with forming and keeping friendships.
I’m a psychologist and I don’t prescribe medication, but despite that fact, parents often ask me, “Should my child with ADHD be on medication?” followed by, “What are the downsides of medication?” and then frequently follow up with, “Aren’t there too many kids on medication anyway?” A study published last fall in BMJ can help parents and professionals with answers to these questions in terms of the drug methylphenidate, in particular.
Methylphenidate is the most commonly prescribed drug for ADHD worldwide. It’s known by a number of brand names, including Ritalin, Concerta, Metadate, Daytrana, and Quillivant.
Although it has been used for over 50 years to treat ADHD — and studies have found it to be effective in decreasing the symptoms of inattention, impulsivity, and hyperactivity — there had been no comprehensive, systematic reviews of the benefits and risks of this drug until this study.
What we’ve learned about methylphenidate
For the study, the investigators reviewed hundreds of papers that had examined the effects of methylphenidate for ADHD. Their analysis found that methylphenidate did improve children’s performance in the classroom.
In other words, teachers reported fewer symptoms of ADHD and better general behavior when kids with ADHD were taking the medication.
In addition, parents reported a better quality of life for the family when their children were taking medication.
On the other hand, there was some evidence that methylphenidate comes with the risk of side effects, including sleep problems and decreased appetite. These side effects are considered “non-serious adverse effects.
” However, if you’re a parent of a child who isn’t sleeping or eating, these may seem quite serious.
The good news is that there was no evidence that methylphenidate increases serious side effects, which would include life-threatening problems — that is, something that would require a hospital stay or result in a life-long condition.
What should parents do?
So what does this mean for parents trying to decide whether their child should take ADHD medication? First, they don’t need to worry about whether taking the most widely prescribed medication — methylphenidate — will cause serious, long-term problems. It most ly will not.
Second, because a fairly large percentage of kids who take methylphenidate (about 25%, this study) may experience minor and short-lived problems such as difficulty with appetite and sleep, parents should be prepared to see these effects in their children.
Knowing that issues such as these might be a problem, and that these issues may improve as a child adjusts to the medication, can help parents anticipate possible solutions — which can include, for example, having a big breakfast before taking the medication or lowering the dose if sleep is an issue.
These are all things that can be discussed with a child’s pediatrician, and there are ways to cope with these issues once they are identified.
Finally, parents can be comforted by the fact that these medications can improve a family’s quality of life at home, a child’s general behavior at school, and result in fewer problems with attention, impulsivity, and hyperactivity.
ADHD medication: The bigger picture
This study doesn’t answer the question of whether there are too many children on medication.
Interestingly (and often surprisingly, for many people), other studies have shown that at least one-third and up to one-half of children with significant developmental and psychological problems go untreated.
That’s a lot of kids who need help, either through some sort of therapy, educational support, or (for some) medication. This study also only addresses one medication, although it is the one that is most popularly prescribed.
Deciding what treatment option to use when you have a child with ADHD isn’t easy. Medication isn’t the only option, as there are data that show some behavioral treatments that can help children with ADHD learn different skills are also effective.
In fact, recent studies indicate that a combination approach might be best. In other words, medication can help kids to get more non-medication treatments such as therapy and school supports.
When prescribed correctly by a medical doctor who understands and commonly treats these issues, the downsides of medication with methylphenidate probably do not outweigh the positives in most cases.
ADHD Medications Rarely Work Perfectly on the First Try
Taking medication is usually the first step in treating attention deficit disorder. But what do you do when the ADHD medication does not work? Or when ADHD symptoms grow worse? Or when you or your child experience side effects from medication?
Read on for solutions to common ADHD medication problems that adults, children, and their parents face.
Problem: ADHD Medication Doesn’t Work
When starting medication, some adults and parents claim that there is no improvement. The most common reason for this lack of response is an incorrect ADHD diagnosis.
Maybe your child’s behaviors are caused by an academic problem, such as a learning disability (LD) — maybe you suffer from a mood disorder or an anxiety disorder, not adult ADHD.
Many patients tell their doctor that they or their child can’t sit still or pay attention to everyday tasks. Without asking questions or conducting tests, the physician writes a prescription. The ADHD diagnosis is not that simple.
Specific criteria must be met before an attention deficit disorder diagnosis is made: establishing that the behaviors have been chronic (existed since early childhood) and pervasive (at home, at work, at school).
In some cases, the ADHD diagnosis may be correct, but the prescribed dosage may be incorrect. Determining the right dosage is not age or body mass, but on how quickly the medication is absorbed into the bloodstream and passed into the brain.
A 250-pound adult may need 5 mg., while a 60-pound child may require 20 mg. Since the dose needed is specific to the patient, medication should be started low, at 5 mg. If no benefits are seen, the dose should be increased, by 5 mg.
, every five to seven days until the correct dose is determined.
Finally, many people with ADHD have additional problems, alongside their ADHD diagnosis. The most frequent are learning disabilities, anxiety disorders, mood disorders, anger control problems, or obsessive-compulsive disorder (OCD). Stimulants manage ADHD symptoms, but don’t address symptoms caused by related disorders.
[Free Download: 3 Essential (and 4 Frivolous) Components of an ADHD Diagnosis]
Problem: ADHD Medication Doesn’t Work All The Time
If mornings are difficult: Think about how you or your child act when you’re on ADHD medication and when you’re not. Most problems occur before the medication starts working or when the dose doesn’t last the full four or eight hours noted on the label.
To keep yourself or your child calm and focused in the morning, try to wake up an hour earlier than usual to take the ADHD medication. Then, go back to sleep.
For children, if going back to sleep is difficult, discuss using Daytrana, a methylphenidate patch, with your doctor.
Apply the patch to your child’s thigh while she’s asleep, and the medication will start to work within an hour. (If you do this, an earlier afternoon dose may be needed.)
If you or your child crashes in the afternoon: Maybe there is a dip in coverage around noon, and difficulties arise between 12 and 1. Maybe you begin to feel unfocused around 4 p.m., or completely wired and hyperactive around 8 p.m.
Play detective to determine when ADHD symptoms worsen. Maybe the four-hour tablet lasts only three hours with you or your child. Perhaps the eight-hour capsule you are giving your son is not releasing evenly.
Tell your physician when medication doesn’t work — and he can reconfigure the dosage schedule or change the medication.
Problem: ADHD Medication Causes Side Effects
Side effect: loss of appetite: While some ADHD medications suppress appetite, a healthy appetite often returns in several weeks. If not, try delaying the first dose until after breakfast. Lunch is often a bigger challenge.
A nontraditional lunch, such as a food supplement milkshake, Ensure, or a high-protein energy bar, might provide nutrients while appetite isn’t strong. To increase appetite at dinnertime, hold off on the 4 p.m. tablet until after dinner. If none of these suggestions work, ask your doctor for a referral to a nutritionist who has experience working with ADHD.
If your or your child’s appetite doesn’t return, talk with your doctor about switching to another stimulant or to a nonstimulant.
[Free Download: Routines for Morning and Night]
Side effect: sleep problems: Stimulants affect the area of the brain that induces sleep. Skipping the 4 p.m. dose may help — but not at the cost of symptoms becoming unmanageable. If you find that this is the case, try this experiment.
With your doctor’s permission, add an 8 p.m. four-hour tablet. A small dose of stimulant helps some ADHD patients fall asleep. If the experiment fails and you or your child still can’t fall asleep, your doctor might suggest Benadryl.
Many find that a small dose of melatonin helps with sleep.
Other side effects: Thirty to fifty percent of individuals with ADHD have a co-occurring condition.
In some cases, stimulant medication exacerbates these disorders or causes the disorders to become clinically apparent.
If you notice that you or your child becomes more anxious or fearful, unhappy, or angry on stimulants — but that the symptoms stop when you’re off the medication — talk with your doctor.
It is essential that emotional-regulation problems be treated promptly. A doctor will often prescribe a selective serotonin reuptake inhibitor (SSRI) to treat these disorders. Then the stimulant medication can be reintroduced without causing difficulties. Medication might be needed to address tic disorders as well.
Parenting Problem: Your Child Resists or Refuses to Take Medication
Educate your child about the medication he is taking: Don’t tell him it’s a vitamin pill. You will have a hard time building trust later, when he finds out the truth.
Explain what ADHD is and how it affects his life. Tell him how the medication decreases ADHD symptoms. Explain that he might experience side effects, but that they will be dealt with by you and his doctor.
Your child will be more cooperative if he participates in the process.
Problem: You and Your Partner Disagree About ADHD Medication
In the case of a child with ADHD, if one parent feels strongly that she shouldn’t be taking ADHD medication and expresses that to your child, there may be a serious problem. If the child has conflicting views about the benefits of medication, he might stop taking it or question why he has to take it.
If you’re an adult with ADHD and your partner doesn’t believe you need medication, it can create tension in your relationship or cause you to suffer difficulties in other areas of your life. Set up an appointment with your doctor to discuss the ADHD diagnosis and the value of medication with your partner.
[Top 10 Questions About ADHD Medications for Children… Answered!]
Larry Silver, M.D., is a member of ADDitude’s ADHD Medical Review Panel.
Updated on January 28, 2020
Is Your Child’s ADHD Medicine Working?
- How Long Does It Take?
- As Your Child Grows
It takes time to find the best treatment for your child’s ADHD. There are about a dozen drugs to choose from. Getting the right one at the right dose can be a long process of trial and error. You’ll need to keep a close eye on your child’s symptoms.
Before starting a new treatment, you and your child’s teacher can make a checklist of the symptoms and how strong they are. That will be your baseline.
After your child is on the medication for a while, you can each go through the list again. If a symptom isn’t as strong, the drug is probably helping with it.
Some things to check might include how often your child:
- Misses details or makes careless mistakes
- Gets off task
- Seems not to listen when spoken to
- Doesn’t follow directions or finish a task
- Can’t get organized
- Diss activities that take concentration
- Loses things
- Gets distracted easily
- Forgets things
- Fidgets and squirms
- Doesn’t stay in his seat
- Runs around when everyone else is seated
- Can’t play quietly
- Seems to be in constant motion
- Talks too much
- Blurts out answers
- Won’t wait his turn
- Interrupts others
It depends on the medication your child takes, and if it’s extended release or short-term.
Most kids with ADHD get stimulant medication, which helps nerve cells in the brain communicate. These drugs work quickly. Behavior can change within an hour.
They also leave the system quickly. Some formulas wear off in just 3-4 hours. The longest-acting can last 12 hours. So before doing a symptom check, you should know when your child last took his medication to make sure it’s in his system.
Non-stimulant drugs act differently. They need time to build up in your child’s system but their effects last for 24 hours. You may not see a difference for weeks, and it may take several more to fine-tune the dose.
If you think your child’s personality has changed or he seems irritable all the time, his dose may be too high, even if his symptoms have gotten better. Talk to his doctor.
Many parents find that after several years, the medicine that used to help their child no longer does the job. Older kids have more demands on their concentration, especially in high school. And they don't end with the school bell. Their day may include hours of homework, sports, or a job.
If his old behavior seems to be returning, tell his doctor. It may be time to increase the dose or try a different drug. They can also switch to a formula that lasts longer, or add another shorter-acting pill later in the day.
For some people, the symptoms of ADHD get better with age. At some point, your child may not need medication. Don’t try to check this by stopping the medication on your own, though. Talk to his doctor about taking a monitored break from the drug to see what happens.
American Psychiatric Association: “Parent’s Medication Guide: ADHD.”
Children and Adults with Attention-Deficit/Hyperactivity Disorder: “Managing Medication.”
National Institute for Children’s Health Quality: “NICHQ Vanderbilt Assessment Scales.”
American Psychiatric Association: “What Is ADHD?”
CDC: “Attention Deficit/Hyperactivity Disorder (ADHD).”
© 2018 WebMD, LLC. All rights reserved.
Treatment of ADHD in patients unresponsive to methylphenidate
R.B. is an 8-year-old boy with a history of attention-deficit/hyperactivity disorder (ADHD) that was first diagnosed at age 4 years.
When he was referred at age 8, he was in grade 3 but failing most of his subjects.
He was also found to have oppositional defiant disorder at home and at school and, despite normal intelligence, a substantial learning disability in expressive and receptive language.
R.B. first started stimulant medication at 5 years old: 5, 10 and finally 20 mg of methylphenidate taken in the morning and again at noon. The medication did not greatly alleviate symptoms; poor compliance (many doses at school were forgotten or missed) and poor coverage between doses were thought to be the reasons for the poor medication response.
The child then started long-lasting OROS methylphenidate. The hope was that the once-per-day formulation, reported to last 10–12 hours, would improve compliance since no medication needed to be taken at school and would provide better coverage.
Since the child was already on 40 mg of methylphenidate per day, the OROS methylphenidate was started at 36 mg per day and then increased to 54 mg per day (a high dose for a 6-year-old). Despite the high dose in the morning, the child continued to have a short attention span with disruptive, impulsive and oppositional behaviour at school.
In the late afternoon and early evening, he became very emotional, with frequent crying, marked irritability and many tantrums.
In light of the poor response and the side effects to high dosages of OROS methylphenidate in grade 1, the child was switched to atomoxetine (a non-stimulant) in grade 2. This medication was increased from 0.5 mg/kg to 0.8 mg/kg, 1.2 mg/kg and then 1.4 mg/ kg.
The emotional side effects of the OROS methylphenidate subsided, but the clinical effects of the atomoxetine in controlling ADHD symptoms were not great.
To achieve better symptom control, small dosages of short-acting methylphenidate were added, initially at 10 mg, and quickly raised to 20 mg in the morning and at noon.
Despite maximum dosages of atomoxetine combined with a fairly high dosage of methylphenidate, R.B. continued to have attentional, behavioural and learning problems at school and at home. He was referred to a special day program at the beginning of grade 3 and was gradually taken off all medications.
As part of the day program, a behavioural program combined with parent training was begun for his oppositional behaviour, and special tutoring and remediation in language arts was begun for his learning disabilities.
He also started a long-acting mixed amphetamine salt product (Adderall XR), initially at 10 mg per day and increased to 15 and then 20 mg per day.
The combination of Adderall XR at 20 mg per day, academic remediation and behavioural therapy proved effective, and he was gradually reintegrated into his regular classroom where he continues to do well.
This case illustrates several important issues. First, children with ADHD often have other comorbid conditions (e.g.
, 40% may have oppositional defiant disorder and 20% may have specific learning disabilities) that need to be addressed and treated, as stimulant medication is not ly to correct everything.
Second, although many individuals (45%) respond equally well to methylphenidate or amphetamine products, some (28%) respond preferentially to methylphenidate whereas others (17%) respond preferentially to amphetamines and about 10% respond to neither group of stimulants.
1 It is still unclear what predicts preferential response to one or the other stimulant. This preferential response should be kept in mind, so when children don’t respond well to methylphenidate, the first change in medication should be to amphetamines.
Had R.B. been tried on amphetamines earlier and had other needed interventions (e.g., academic remediation in the language arts, parent training, behavioural program) been established earlier, his problems may have been improved in grade 1 rather than grade 3.
The information in this column is not intended as a definitive treatment strategy but as a suggested approach for clinicians treating patients with similar histories. Individual cases may vary and should be evaluated carefully before treatment is provided. The patient described in this column is a composite with characteristics of several real patients.
Competing interests: Dr. Hechtman declares having sat on the advisory boards/ been a consultant for Eli Lilly, GlaxoSmith-Kline, Ortho Janssen, Purdue Pharma and Shire Canada.
Psychopharmacology for the Clinician columns are usually a case report that illustrates a point of interest in clinical psychopharmacology. They are about 500–650 words long and do not include references. Columns can include a bibliography which will be available only on the journal website and can be accessed through a link at the bottom of the column.
Please submit appropriate columns online at http://mc.manuscriptcentral.com/jpn; inquiries may be directed to ac.amc@npj.
When your ADHD medication is not working anymore
Is your ADHD medication not working anymore or has the medication made your symptoms worse? If so, you are not alone.
Medications can be very effective in treating ADHD symptoms but for a significant number of patients medications are not helpful.
In fact, as many as 30% of children with ADHD do not respond to stimulants or cannot tolerate the side effects. 1
And 1 in 3 adults with ADHD do not improve on medications. 1
ADHD can greatly impair a person’s relationships, career and day-to-day functioning. Individuals with ADHD have difficulty concentrating and focusing. They may exhibit impulsive behaviors, forgetfulness, aggression, irritability, impatience and have a low frustration tolerance. Managing these symptoms through medication and therapy is essential.
If ADHD medication is not working anymore, it could be due to several reasons: the dosage may be incorrect; adherence may be an issue; co-existing disorders may impede the medications effectiveness or the patient may have another medical condition producing ADHD- symptoms. (i.e., autoimmune encephalitis, seizures, thyroid disease, anemia).
Infections and ADHD- symptoms
Growing evidence also indicates that, in some cases, an underlying biological or physical cause (i.e. infection) can induce behaviors that mimic ADHD.
The association between certain infections and ADHD has been demonstrated in numerous studies. Toto et al.
concluded, “streptococcal infections and autoimmune reactions against the basal ganglia are more frequent in ADHD patients than patients in a control group.” 3
In some individuals, infectious pathogens, such as strep, coxsackie and herpes viruses, can trigger an abnormal immune reaction, resulting in behaviors that mimic ADHD. Patients with an infection-triggered autoimmune encephalopathy appear to have ADHD, but in fact, have a treatable autoimmune disorder.
How does this happen? The immune system produces antibodies to fight the foreign germ, but these antibodies mistakenly attack not only the germ but healthy cells in area of the brain known as the basal ganglia. This autoimmune attack causes brain inflammation and the onset of neuropsychiatric symptoms, such as impulsivity, hyperactivity, and concentration impairments.
A study by Giana et al. reports, “Increased levels of anti-basal ganglia antibodies and antibodies against the dopamine transporter” have been detected in patients with ADHD “supporting the role of the immune system in the disorder.” 4
ADHD medication isn’t working anymore
Patients with autoimmune-induced ADHD symptoms often complain that their ADHD medication isn’t working anymore or that it is making symptoms worse.
Identifying whether there is a biological cause involved (i.e. an infection) is important, since treatment focuses on immune-modulating therapies, rather than stimulant medications. And with proper treatment, patients can have a complete remission or substantial reduction of symptoms.
- https://www.medscape.org/viewarticle/458059_1 MedScape. Advances in the Treatment of Adult ADHD: Landmark Findings in Nonstimulant Therapy. Editorial. Margaret Weiss, MD, PhD; Robert Bailey, MD.
com/Article/FullText/489635#ref37 Leffa D, T, Torres I, L, S, Rohde L, A: A Review on the Role of Inflammation in Attention-Deficit/Hyperactivity Disorder. Neuroimmunomodulation 2018;25:328-333.
- https://www.ncbi.nlm.nih.gov/pubmed/22956712 Toto, M., Margari, F., Simone, M., Craig, F., Petruzzelli, M. G.
, Tafuri, S., & Margari, L. (2015). Antibasal Ganglia Antibodies and Antistreptolysin O in Noncomorbid ADHD. Journal of Attention Disorders, 19(11), 965–970.
- https://www.ncbi.nlm.nih.gov/pubmed/25468771 Giana, Grazia et al.
Detection of auto-antibodies to DAT in the serum: Interactions with DAT genotype and psycho-stimulant therapy for ADHD. Journal of Neuroimmunology, Volume 278, 212–222.
ADHD medication is not working
Welcome to a new column designed to provide practical advice regarding issues related to child mental health. It will be a joint effort, featuring contributions from several child psychiatrists working at the University of Vermont and the Vermont Center for Children, Youth, and Families.
While psychopharmacology will certainly be a part of many of the columns, all of us here feel strongly that medications should be only one part of a comprehensive family-oriented plan. We encourage you to submit questions that you would us address in future issues to [email protected].
A 10-year-old boy presents for a follow-up appointment. He was diagnosed by another pediatrician in the practice 2 months ago with attention-deficit/hyperactivity disorder (ADHD) and now returns to the office with continued symptoms and a complaint from the mother that medication “isn’t working.
” The boy was started on an extended-release preparation of methylphenidate at 18 mg to take each morning. The child is in the fifth grade and weighs 80 lb (36 kg). He lives with his mother and 8-year-old brother.
The father is no longer involved in the patient’s life, which puts added stress on the mother.
The diagnosis of ADHD was made by the pediatrician based upon the history, the child’s hyperactive and intrusive behavior in the office, and the results of a standardized rating scale that was completed by the mother, who now requests that the pediatrician “try something different.”
Many children and adolescents respond extremely well to ADHD medications. Some, however, do not, and the parental complaint that the “medication isn’t working” is a frequent expression heard in pediatrician offices across the country.
It is also one of the primary reasons a family is referred to a child psychiatrist.
In the course of performing hundreds of these consultations, I have found that there are several possibilities to consider before assuming the medication simply isn’t effective.
We will start with simpler problems and work our way toward more challenging reasons.
• The dose is too low. Methylphenidate often needs to be dosed over 1 mg/kg/day to be effective. If the patient reports minimal response to the medication while experiencing no side effects, an increase may certainly be reasonable.
• The medication is working but wearing off. Despite the advertisements of long-acting stimulants continuing their therapeutic effect for 10-12 hours, many children seem to lose the benefit of the medication much faster.
Gathering some data from the school or asking the mother about weekend mornings compared with evenings can be useful. If indeed such a wear-off is found, adding a dose of an immediate-release stimulant in the early afternoon may help.
• Symptoms are being caused by something other than ADHD. Hyperactivity due to exposures such as lead may not change your management of the symptoms, but certainly could necessitate other types of intervention. Chronic sleep problems and inadequate nutrition, especially when it comes to breakfast, also should be queried and can lead to problems with concentration.
• There is psychiatric comorbidity. Un many differentials in other specialties, psychiatric differential diagnosis is often a matter of “and” rather than “or.” Anxiety disorders, for example, can frequently masquerade as ADHD or be present in addition to ADHD. Oppositional behavior is also very commonly present with ADHD and suggests additional types of treatment.
• There is noncompliance. This problem can surface frequently in two ways. Older children may be responsible at home for taking their medications and forget or refuse to do so.
I often ask, “Are you taking the medication every single day?” Diversion is also a potential problem from the parents or for an adolescent.
Checking if the refills are occurring on time can provide a clue here, and some states have systems to check for duplicate prescriptions from multiple clinicians.
• Side effects are appearing as untreated ADHD.
Sometimes medications are the problem, not the solution, and a failure to recognize this phenomenon can lead to unnecessary and sometimes harmful polypharmacy.
Stimulants in some children can lead to increased agitation, anger outbursts, and impulsivity. Trying a medication holiday for several days can sometimes reveal the need to back off rather than add medications.
• Family is expecting improvement for non-ADHD symptoms. Asking what particular behaviors the family is hoping to improve can sometimes expose a situation in which parents expect change in non-ADHD domains.
Unfortunately, there is no pill to make kids respect their parents more or want to do their homework.
Being clear from the outset about what behaviors are and are not medication responsive can sometimes prevent this problem.