FINDING WHAT WORKS, AT WHAT DOSAGE
MEDICATION AND ITS ALTERNATIVES
Medication is the treatment of choice for ADHD. This doesn’t mean that alternative therapies and behaviour management techniques can’t help. Any child, regardless of whether they have ADHD, would perform better in a structured, predictable environment than in a random, chaotic one. Studies have shown that the only lasting benefit for the core symptoms of ADHD (impulsivity, inattention and hyper-arousal) were achieved in conjunction with medication.
TRIAL AND ERROR
Doctors will generally first prescribe a stimulant, like Ritalin or Concerta. It doesn’t make sense to have multiple trials of the same active ingredient.
One trial of the best medication of each kind is enough to determine what works best for your child. Some medical professionals urge individuals to record their symptoms in a journal for seven to 14 days after the initial dose. It’s a useful approach for monitoring how the body reacts to the new medication and assisting the doctor in developing an acceptable and optimal pharmaceutical regimen. Therefore, you and your child should rate each medication on a scale of one to 10, with one being a nasty experience with no benefits and a lot of unpleasant side effects. Ten is the best result imaginable, with no ADHD symptoms and zero side effects. A six or below should be considered a treatment failure, and your doctor should be asked for an alternative. Seven is acceptable but the goal would be between eight and 10.
Due to some foods interfering with medication absorption, it can also be beneficial to keep note of everything that is consumed before and after taking the medication. For instance, Ritalin must be taken one to two hours before meals to achieve optimum efficacy with the minimum negative effects. Food and drink have a much bigger impact on the efficacy of medication than people would like to believe. Someone might assume that the Ritalin is not effective, while it could be that their intake of food or drink is competing with the Ritalin particles for receptor binding and absorption. This can lead to irregular uptake of medication and a lessthan-optimal effect.
Even though not all food competes with these specific medications for uptake, it is helpful to understand what food and drink to avoid when taking the medication.
MAKE IT EASY
Extended release formulations are preferred, as it is easier and more convenient to remember to take one tablet per day that releases throughout the day. It also allows for privacy for kids who might otherwise have to take a second dose at school. Additionally, extended-release medication do not have the sudden dips in medication levels that could leave children irritable or weepy in the course of the day.
INDIVIDUAL DOSAGE
Paediatricians are trained to prescribe a certain number of milligrams per kilogram of body mass, but there is no evidence that dosage is affected by size, age, gender, scale scores or severity of impairment. Dosage is affected by four factors: how it’s absorbed by the gastrointestinal tract, how efficient the molecule crosses the bloodbrain barrier, the rate at which medication
is metabolised and excreted in the urine, and whether the medication is taken with an absorption blocker, like vitamin C or citric acid (this is why tablets should not be taken with juice or soft drinks). Once your child’s prescription has been fine-tuned to their individual needs, they should experience optimal relief from their ADHD symptoms with minimal side effects.
Very few people (if any) will experience no side effects. This is merely because the ingredients in medications are foreign substances to your body. The body’s natural response is to get rid of this substance, until it becomes less foreign. Therefore, most (if not all) people will at least initially experience some degree of side effects. The key to finding an optimal individual dose is not to change the regimen or dosage continually until you experience no side effects, but to manage the side effects you can tolerate and to know when it is necessary to consult a doctor.
For example, palpitations (the sensation of the heart racing, pounding, fluttering or skipping a beat) and appetite loss are two of the adverse effects that the vast majority of people will experience invariably. As long as you can tolerate it, this should be fine. You have to adjust to the circumstances. This can be done by scheduling set times to eat, regardless of whether you feel hungry – to counteract the loss of appetite – or avoiding caffeine when you experience palpitations, as caffeine can also induce it.
SPOT A WRONG DOSE
The optimal dose might vary tremendously from one person to the next. The right medication at the right dosage should return a child to normative levels of functioning without side effects. If your child is feeling on edge or different in any way, the dose is either too high or too low. If your child experiences personality changes, or feels either over-stimulated or slowed down, the dose is typically too high and needs to be decreased. Doctors have traditionally been trained to give the highest dose that a person can tolerate. Research has shown that this “highest dose” is too high. The optimum dose is typically at least two dosage strengths weaker than this threshold.
The therapeutic index can be used to measure the safety and effectiveness of all medications. It provides a safety margin between the dose needed to produce a desired therapeutic effect and the amount that could cause undesired (and harmful) effects. Therefore it is desirable that the dose being used is lower than the upper limit of the therapeutic index, where harmful or undesired side effects outweigh the positive benefits of the use of the medication.
FINE-TUNING
Fine-tune the medication according to the symptom response. Doctors should educate their patients about how ADHD medication can alleviate the symptoms of the condition. Symptoms that respond to medication are procrastination, distraction, finding it hard to complete boring tasks, impatience, impulsivity and restlessness. Symptoms that are not significantly affected by medication include disorganisation, argumentativeness and oppositional behaviour. Stimulant medication has a fast onset of action, so the benefits and the side effects present within an hour. Should your doctor agree, the dosage can be changed from one day to the next, with immediate effect. Children who cannot communicate the effects of medication need a week between dosage adjustments. Ask your child’s teacher to give you feedback on their performance and behaviour in class to help evaluate whether the dosage is appropriate.
LOWEST POSSIBLE DOSE
Ask your doctor to fine-tune to the lowest possible dose. As your child grows, the dose will be increased to maintain the benefits of the medication, preferably with no or only mild, transient side effects. At some point your doctor will again increase the dosage and your child will report that there have been no noticeable improvements, unlike before. At this point, the previous dose is the very lowest dose that gives your child 100% of what the medication has to offer. If your child is over the age of 16, that dose should work for the rest of their life. Tolerance to the side effects of ADHD medication develops very quickly, whereas tolerance to the benefits is rare.
DON’T INCREASE TO BOOST DURATION
Accept whatever the duration of your child’s optimal dosage is. If the dosage is increased to achieve a longer duration, your child will be pushed beyond the “sweet spot” of the dose to the point where they start to have more side effects. It is not worth it, as the increase in how long the dose lasts is marginal.
LIMITATIONS OF MEDICATION
Although medication can deliver very positive results in terms of your child’s behaviour and performance at school and in the home, the decision to medicate a child should not exclude engaging with other non-medicinal treatments. Medications do not cure ADHD but they can help make children more receptive to educational and behavioural interventions. When the right medication and dosage have been found, parents, therapists and educators have a window of opportunity to establish and encourage behaviour modification strategies to improve learning, responsibility and social interaction.
NON-MEDICINAL STRATEGIES
To be fair, ADHD is not always a superpower. For those who haven’t managed to garner the right insight or support, especially early in life, it can lead to problems. Studies by the Yale School of Public Health have found that children with ADHD are 10% to 14% less likely to be employed as adults, and those who are employed earn 33% less than people who don’t have ADHD. Of course, many do struggle and need treatment, and in certain cases medication is warranted. But some parents feel the severity of their child’s symptoms does not warrant medication, or they simply choose not to medicate their children. Whether you choose to medicate or not, the following support structures and complementary therapies could enhance your child’s ability to remain calm and stay focused.