Using medications to improve behavior and enhance learning is both an art and a science; it requires close communication between everyone who works with the child. The dosage, frequency, and schedule for giving stimulant medications vary greatly from child to child. Here are some general guidelines.
1. Working out the right dose requires establishing whether the drug works, and what, if any, are the side effects. The usual dosage ranges from .3 to .8 mg/kg depending upon body weight. Your doctor will probably begin with a dosage of .3 mg/kg (a 5- to 10-mg pill in the morning) and, based on your charting and reporting, and that of the teachers, increase or decrease the morning dose, add a second late morning or early afternoon dose, or decide that your child either doesn’t need or doesn’t respond to that particular medication. Your doctor may increase the medication by 5 mg weekly until either the desired beneficial effect or undesirable side effects occur. If one stimulant medication does not work or is not tolerated by your child, your doctor may try another. This trial phase may take as long as six weeks. The second phase is monitoring the long- term dosing schedule, which may include increased doses during stressful situations and drug holidays when there is no school.
2. Some A.D.D. specialists feel that some children, and their parents, are “placebo responders,” which means they respond to the power of suggestion and get better with just about any therapy, or with a placebo (pretend) pill. For these children, a placebo trial may be useful. Some A.D.D. specialists recommend this first. Your pharmacist can make a look-alike placebo pill.
Don’t start the medication simultaneously with a major change, such as a move, a family upset, or a change of school. To gauge whether or not the drug is necessary, first give your child a chance to adjust to his new environment. On the other hand, if you know by past experience that your child falls apart during major changes, beginning the medication just before the event may help. It will, however, be more difficult to evaluate the results.
3. Give the first dose of medication on a Saturday morning or at the beginning of a school vacation, so you have an opportunity to observe the effects firsthand before the next school day.
4. To minimize the appetite-decreasing effects of stimulants, try giving the morning dose after breakfast or just before the child leaves for school, so it is likely to take effect by the time the child’s class begins. A few children may absorb Ritalin better on an empty stomach. This may, however, diminish their appetite.
5. The most noticeable effects occur around one to two hours after the medication is given. If your child is required to be at his best behavior or peak performance at a certain time, you can time the giving of the dose accordingly.
6. For medications given at school, give the child a reminder, such as a watch with an alarm that beeps at the dosage time.
7. Consult your doctor about drug holidays, weekends, school holidays, or school vacations, when you can skip the medication, or at least use a lower dose.
8. To avoid sleep disturbances, give the late afternoon dose earlier, lower the dose, or omit that dose entirely.
9. Some children do better if the second pill is given after the morning recess; otherwise, the last class of the morning is an academic disaster. If safety is a factor in the hyperactive, impulsive child who walks (or rather runs) home from school, a third pill may be given after the afternoon recess.
10. If your child experiences a rebound effect when the medication wears off, try “piggy-backing.” Give the next dose before the previous dose has worn off, usually three hours after the previous dose instead of four.
11. Resist the temptation to increase or decrease the dose if the child is having a particularly bad day. First, explore other causes unrelated to the effects of the drug that may have triggered his sudden change of behavior.
12. If your child’s appetite is diminished as a result of the medication, encourage her to eat large meals at the times of the day when the effects of the medication are wearing off. Offer your child nutritious foods frequently throughout the day.
HOW TO EVALUATE IF THE MEDICATION IS WORKING
After an agreed upon time by you and your doctor, and with the help of the following medication effectiveness chart, note your observations: Is the medication helping, hindering, or having no effect? Don’t be surprised if the teacher’s assessment on the effectiveness chart is different than yours. Remember, the teacher is observing your child’s behavior and learning when the medication’s influence is at its peak, but parents see their child mostly when the effects of the drug are wearing off. Your observations of the medication’s effects are more accurate on weekends and holidays. According to the doctor’s instructions, report your findings either by phone or in a follow-up office visit. Remember, the primary goal of drug therapy, or any therapy is not to eliminate problems, but to make them more manageable. Be sure the medication is actually improving your child’s behavior and/or learning, not just making him more convenient to have around.
THE A.D.D.-Q/MM (To Monitor Medication effectiveness) Instructions:
1. Teacher or parent fills in this questionnaire according to who is with the child.2. Complete questionnaire 2 hours after every drug dose – usually at 10 am, 2 p.m. and 6 p.m.
3. Do this for 2 days before starting medication and each day during the drug trial.
. .Name:____________________ Age:_____ Date: __________Medication: ____________ Dose: _______ Time: __________Time chart was filled out: _________________QUESTIONS: (check ‘?’ appropriate column if any example is true)Never or very rarelySome-timesA great dealAlmost always
- ATTENTION SPAN1. The child has difficulty paying attention to things other people want him to do.
2. The child seems to be day dreaming, almost “spaced out”, drifting into her own little world, oblivious to what’s going on and not paying attention to instructions.
3. The child doesn’t pay attention to details and often makes careless mistakes in schoolwork.
4. The child has difficulty following routines, such as getting ready for school, bringing homework home, getting ready for bed.
5. The child needs a lot of supervision to complete assignments (school work, chores), which require sustained attention.
- IMPULSIVENESS6. The child fails to think before acting, does not think through what he is about to do or say; leaps without looking.
7. The child has difficulty waiting for a turn, (for example, interrupts others, blurts out answers before a question is completed.)
8. The child has difficulty waiting in line, sharing, and cooperating.
9. The child has difficulty waiting for rewards, delaying gratification. (She wants the toy, to go biking, and so on, NOW!)
- ORGANIZATION10. The child’s schoolwork, keeping things together, time-management, personal functioning, seems very disorganized.
- EMOTIONAL11. The child over-reacts to seemingly little things.
12. The child has difficulty adjusting to sudden changes in routines.
- ACTIVITY LEVEL13. The child’s activity level is inappropriate for the situation (e.g., has difficulty sitting still in class, church, during meals).
14. The child shows motor restlessness, fidgeting, squirming.
15. The child seems always on the go as if driven by a motor.
16. The child seems sluggish, lethargic and unmotivated,
TOTAL SCORE for each column:
.SCORE: (the total number of checks for each column multiplied by 0, 1, 2, and 3 respectively.)
x 0 = 0x 1= x 2= x 3 =Total
From: The A.D.D Book by Dr. William Sears and Dr. Lynda Thompson
STIMULANT MEDICATION FACTS 1. Ritalin (Methylphenidate)
- It is approved for six years of age and over.
- The usual dosage is one 10-mg tablet twice or three times a day. Begin with 5 mg two or three times a day and adjust dosage according to response. It is usually given at breakfast and lunchtime. There is a wide range of effective dosages, depending on the child’s individual response.
- Each dose may last approximately two to four hours and its action usually begins about 1/2 hour after administration. Times may vary according to a person’s metabolism.
- In some children Ritalin needs to be given about 1/2 hour before a meal. This is best for absorption, but it may suppress a child’s appetite, in which case the medication should be given with the meal.
- There is a longer acting form of Ritalin called Ritalin SR, for slow release (the usual dose is 20 mg), which begins acting about an hour or more after administration and acts for about six to seven hours. Half its active ingredients are supposed to be released when it is first taken and the other half after about four hours in the body’s system. The advantages of the long- acting Ritalin is the child can be given one dose at home before school, thus increasing the compliance, and he does not have the inconvenience and embarrassment of having to take the pill at school. Our experience with the longer-acting preparation has been disappointing. We find a lot of variability from child to child as to when it has its peak effect and how long the effect lasts. Also, it seems not to be as effective after a few months. With the slow- acting preparation, we find it’s harder to make judgments about how well it works and what the side effects are. We always begin treating the child with the regular, short-acting Ritalin. If compliance is a problem, we try the longer- acting preparation once we have worked out whether or not the child responds to Ritalin and what the best dose is for this particular child.
- The effectiveness of Ritalin in controlling targeted symptoms in A.D.H.D., such as high activity level, ranges from about 30 to 50 percent in three-to- five-year-olds and adults, and close to 70 to 80 percent in six-to-twelve-year- olds. Effectiveness appears to drop to around 60 percent in adolescents. All figures are only approximations. This must always be compared to a placebo response. A placebo will give a favorable response in the 20 to 39 percent range.
- For patients who have A.D.D. without hyperactivity the response rate is lower.
- It probably acts by increasing dopamine, norepinephrine, and serotonin neurotransmitters.
- Use among adults is increasing as awareness of A.D.D. in adults grows.
- More than 80 percent of the prescriptions written for stimulants are for Ritalin, or its generic equivalent.
2. Dexedrine (dextroamphetamine)
- It is approved for three years of age and older.
- This medication is given at about half the dosage level of Ritalin and may be used in younger children. The usual dose is one 5 mg tablet twice daily.
- The short-acting form lasts an hour or so longer than the short-acting Ritalin.
- Each dose lasts about three to five hours.
- There is a longer-acting form of Dexedrine called SR, for slow release (usual dose is 10 mg), which begins acting one to two hours after administration and acts for about eight hours. (In our experience, slow-release Dexedrine seems to have a more reliable effect than slow-release Ritalin.)
- It probably acts by increasing dopamine and Norepinephrine neurotransmitters.
3. Cylert (magnesium pemoline)
- It is approved for six years of age and over.
- The effect lasts about seven hours (in adults about 11 hours).
- It may take four to six weeks to notice the effects, unlike the immediate effects of Ritalin and Dexedrine.
- The starting dose is 37.5 mg given once daily in the morning and it is increased by 18.75 mg if necessary.
- Because this drug may produce changes in liver-function tests, tests are performed before the drug is started and redone at least every three months. The liver tests return to normal when the drug is stopped. Because of possible liver toxicity, this drug has been taken off the market in Canada.
- It probably acts by influencing dopamine neurotransmission.
- Cylert is a completely different type and class of medication than Ritalin and Dexedrine. The DEA places no restrictions on prescribing Cylert.
- It is approved for three years of age and over.
- It comes in 10-mg and 20-mg tablets. The starting dose for children six and older is similar to Ritalin.
- Initially, it may be given twice a day at intervals of approximately four to six hours. This will vary with different individuals.
- It is an amphetamine with sympathomimetic properties, and it acts as a stimulant.