You may already be aware that the dosage of many medications, including antibiotics, cold medications, and other over-the-counter drugs, is determined by a child’s weight. This is not the case with stimulant medications.
Just as individual children respond differently to different stimulants, each child requires a different dosage that cannot be predicted in advance. The best dosage for a child with ADHD is the one that achieves the best possible results without troublesome side effects—not the minimum dose that leads to any level of positive response (even though in the past this has been a fairly common practice among physicians). Because the dosage is determined by how well it works, and because it varies so widely among children, your child’s pediatrician may need to adjust the dosage a number of times before finding the best level.
Your child’s pediatrician may choose to start with a low dose, and progress through a series of dose increases, monitoring the results by feedback from you, your child, and her teacher. Often rating scales are given to parents and teachers to organize their observations concerning each dose. In general, you and your child should see your pediatrician in a face-to-face follow-up visit by the fourth week of medication use to review your child’s response to the medication, including its effects on core symptoms, to monitor any side effects and check her blood pressure, pulse, and weight. Many physicians use rating scales like the Vanderbilt Scales to organize parents’ and teachers’ observations.
Also remember that you have already targeted specific behaviors that you hope to see improve with medication management. Ideally, your child’s pediatrician will review these with you, and will also ask for teacher input regarding these targets in the form of a phone call or written report, perhaps supplemented with standardized behavior checklists. A good way to organize these reports is to set up a daily “report card” that can track teachers’ observations about each target. The more objective these reports can be—for example, how many times in a halfhour period a child blurts out answers without raising her hand, or how many math problems were completed correctly in a 15-minute period—the better. These report cards can then be brought into the doctor’s office for review.
Once your child’s doctor has reviewed any changes in your child’s core symptoms and target behaviors, the medication dose can be gradually adjusted upward until the best results are achieved. Again, your doctor may not stop increasing the dose when you first notice a positive result, but will likely continue to increase it until there is no further improvement. If a higher dose produces side effects or no further improvement, the dosage can be reduced. This gradual method of arriving at the proper dose (titration) can minimize some of the initial side effects that might have occurred if he had started with the higher dose from the beginning.
In some cases a particular stimulant will have little effect. If this is the case with your child, a second stimulant can be tried. If 2 or more stimulants fail to be effective (an uncommon occurrence), a review of her diagnosis may be in order—or a switch to an alternative medication plan that includes one of the non-stimulant medications.
Many parents become concerned that the frequent dosage and medication changes (particularly as the medication is being started) may mean that their child’s pediatrician does not know what he is doing. On the contrary, the only way to know how effective stimulant medications will be is to try a given medication and review changes in an organized way over a period. So expect medication changes until you and your child’s pediatrician arrive at the most effective medication and dosage for your child.
Stimulants are available in short-acting (about 4 hours), intermediate- acting (6–8 hours), or extended-release (10–12 hours) forms, making the dosing schedule of your child’s medication quite flexible. Your child need not be limited to only one form and, for example, you may choose to combine short-acting forms with intermediate-acting or extended-release forms to create a schedule that best suits her needs.
Many children prefer to take a longer-acting preparation (8–12 hours) before leaving for school in the morning because this makes it unnecessary to take any medication at school (so that their classmates will not even know they are taking it). If your child has after-school activities that cause her to put off doing homework until after the longer-acting medication has worn off, she may want to use an additional short-acting dose at that later time. In this case, she could take an 8-hour dose in the morning before school and another 4-hour dose half an hour before beginning her homework in the evening.
Some college students prefer 4-hour medications because they can schedule these doses for the times during the day when they most need the medication. Again, think of stimulants as helpful tools, like glasses—children can use them at the times of day when they need to focus or achieve other target outcomes, and may prefer not to use them at other times. Just as with glasses, continuous coverage throughout the entire day with minimal side effects would be ideal, and researchers are presently working toward this goal.
Some physicians suggest taking “medication holidays”—stopping medication on weekends, during summer vacation, or over other longer periods when they feel the child needs them less. These breaks may speak to a desire of parents or children to minimize the use of stimulants, but there is no reliable evidence indicating that the breaks are helpful or necessary from a medical point of view. In many cases, families find that continuing the medication schedule outside of school hours and school days helps family relationships by supporting better listening skills and helps the more hyperactive and impulsive child better enjoy social experiences such as scout meetings, church activities, and sports.
The dose of your child’s medication should be increased until optimal results are achieved without significant side effects. Only a small number of children who are introduced to stimulant medication in the systematic way we have described—and who follow their medication schedule consistently—will find side effects too intrusive. Any side effects that do occur are likely to be mild, and most can be relieved by adjusting the dose or schedule of medication or by switching to another stimulant.
While each medication can potentially create side effects in some children, there is no way to predict which child will experience side effects with any one medication. One child may experience side effects on dextroamphetamine (Dexedrine) but not methylphenidate (Ritalin), for example, while another may report opposite results. Again, the only way to find out is to try a stimulant and monitor the results.
Side effects caused by stimulants tend to occur early in treatment and are generally mild. The most common side effects include a decreased appetite, stomachaches, headaches, difficulty falling asleep, jitteriness, and social withdrawal. Rarely, children who are overly sensitive to stimulants or on too high a dose can become overly focused and seem dull. Other less common side effects include dizziness, rebound effect (increased activity, irritability, or sadness for a short time as the medication wears off), and transient tics (repetitive eye blinking, shoulder shrugging, etc) most common when a new stimulant is first taken. In some children with Tourette disorder stimulants may make their tics worse.
Your child’s pediatrician can help you manage most of these side effects through adjustments in dose amount or schedule, the use of alternative medication preparations, or occasionally by adding other medications. It is important to pay attention to the timing of side effects. For example, if your child seems irritable 4 hours after an intermediate-acting dose, this may suggest too high a dose of medication. If the irritability occurs 8 hours after an intermediate-acting medication, it may indicate a withdrawal or rebound effect.