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Medication Treatment for ADHD: The Importance of Ongoing Monitoring
Many experts agree that there are at least 2 important problems with how medication treatment for ADHD is provided to many children today. First, when medication treatment is initiated, there is frequently no systematic procedure used to determine the optimum dosage for each individual child. Rather than collecting systematic ratings of children’s functioning from parents and teachers on a range of different doses, physicians typically start a child on the lowest possible dose, obtain only anecdotal feedback on the child’s behavior, and elect to maintain the first dosage that seems to be effective. In many cases, this is unlikely to be the dosage that would provide the greatest improvement in a child’s functioning.
A second important problem is, even when the maintenance dosage selected is appropriate, there is often little ongoing effort made to systematically monitor how a child is doing over time. As a result, adjustments to medication -- or to any other type of treatment the child is receiving -- are not made, and symptoms that were being managed effectively at one time begin to significantly interfere once again with a child’s functioning. The extent to which ongoing monitoring of medication treatment is required is highlighted by another paper to come out of the MTA study (Vitello, B. et al., 2001. Methylphenidate dosage for children with ADHD over time under controlled conditions: Lessons from the MTA. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 188-196.)
In the MTA study, 289 of the 7- to 9-year-old participants with ADHD were assigned to receive medication treatment -- either alone or in combination with intensive behavioral interventions. To determine the best medication and dosage for these children, an initial titration trial was conducted in which children’s functioning at school and home was compared when receiving different doses of medication (all children began with methylphenidate, the generic form of Ritalin, and a full range of doses was tested for each child) or a placebo. By comparing parent and teacher ratings on each dosage to the placebo, the researchers sought to determine the optimum dosage for each child.
When no clear benefits were obtained for any dosage of methylphenidate tested, or if adverse side effects were apparent, a similar trial was conducted with another type of stimulant. Using this strategy, a clearly optimal medication regime was identified for approximately 90% of the participants. For the vast majority of children (79%), good results were obtained on at least one of the methylphenidate doses tested. For another 11% satisfactory results were provided by the second stimulant used (dextroamphetamine, the generic version of Dexedrine.) For other children, the response to placebo was so robust that they were not continued on medication after the titration procedure.
After medication treatment was implemented, careful monitoring was conducted of it’s ongoing effectiveness over the next 13 months. Each month, information was obtained from each child’s parents and teacher about key ADHD symptoms, functioning at home and school, and possible side effects. If these reports indicated adequate control of symptoms and no side effects, the child continued on the current medication regime. If reports indicated that symptoms had emerged that were causing impairment, or if possible side effects were reported, the medication regime was changed. This could involve either increasing the dosage to obtain better symptom management or lowering the dosage in an effort to eliminate adverse effects. Overall, this careful monitoring was intended to insure that no child remained on less than optimal treatment. This was done even though an extremely careful procedure had been used initially to determine the best dosage for each child. (Note: More detailed information on the medication treatment used in the MTA study can be found here.)
This procedure enabled the authors to examine several important issues related to medication treatment for ADHD. First, how does the optimal medication and dosage identified by a careful initial titration trial compare to what is required over the course of treatment to maintain optimal management of ADHD symptoms? Second, how soon into treatment do medication adjustments typically need to be made and how frequently do these tend to occur? Finally, does gender or the presence of other conditions (i.e. Oppositional Defiant Disorder, Conduct Disorder, or anxiety disorders) impact the need for medication changes during ongoing treatment?
Results
How does initial medication and dosage compare to what is required in ongoing treatment?
Of those children for whom an optimal medication treatment regime was identified by the initial titration procedure, only 17% continued on the same medication and dosage throughout the entire 13-month maintenance period. The remaining children all experienced at least one change in drug or dosage during this period.
Of the children for whom methylphenidate was the medication on which maintenance began, 12% needed to be switched to a different drug during maintenance in order to promote optimum symptom management. For the children who remained on methylphenidate, at the end of the maintenance period, 29% were on the same dose, 41% were on a higher dose, and 18% were on a lower dose. Overall, daily dosage required increased from an average of 30.5 mg/day at the beginning of maintenance to an average of 34.4 mg/day by the end. (Note: In the MTA study, children received 3 doses per day so these amounts were divided across the 3 doses with the third dose being half the amount of the first 2.) As you might expect, those who began on a low dosage were likely to have it increased. Doses for those starting on high doses (i.e. 35 mg/day) tended to decline.
Eleven children who had started on medication were no longer on medication at the end of the study, presumably because side effects had emerged. Of the 32 placebo responders who did not begin the maintenance period on any med, all but 4 required medication at some point during maintenance.
How soon into treatment do medication adjustments typically need to be made and how frequently do these tend to occur?
Three months into the maintenance period, 56% of the children had already had their medication or dosage changed. The average amount of time to the first dose change was between 4 and 5 months. Across the entire maintenance period, the average number of changes required for each child was just over 2, but some children required as many as 10 medication adjustments. Of the total medication changes made, 62% involved increasing the dosage of the current medication, 31% involved decreasing dosage, and only 7% involved changing types of medication.
Does gender or the presence of other conditions (i.e. oppositional defiant disorder (ODD), conduct disorder (CD), or anxiety disorders) impact the need for medication changes during ongoing treatment?
About 20% of the children in the MTA study were girls. On average, girls remained on doses that were approximately 20% lower on a mg/kg basis than boys. The time required to the first medication change, or the number of changes required over the maintenance period did not differ between boys and girls. In addition, the presence of other disorders in addition to ADHD was not related to dosage at either end of titration or maintenance, the time to first change, or the number of changes required.
Summary And Implications
The results of this study make it clear that, even when extreme care is taken to determine the optimal medication treatment regime for a child with ADHD, changes in that regime are likely necessary to maximize the ongoing management of symptoms. If one simply continues to maintain a child on the initial regime that seems best, it is very unlikely that the child’s symptoms will continue to be managed as effectively as possible.
In my opinion, the importance of these results cannot be overstated. Without careful ongoing monitoring, and adjustments to treatment made when indicated, most children with ADHD are simply not going to do as well as they otherwise could. Although the focus of this study was on the monitoring and adjustments required to medication treatment, it is important to emphasize that careful monitoring is essential regardless of what type of treatment, or combination of treatments, a child is receiving. One simply cannot assume that an initially positive response to any treatment will be maintained consistently over time. Instead, it is necessary to carefully track how a child is doing, and make modifications to existing treatment(s) when it becomes evident that symptoms are no longer being managed as effectively as they need to be. Although some children will continue to have problems regardless of the modifications made (see article above), the likelihood of maximizing a child’s ongoing success is certainly increased when this approach is followed.
Note: This article originally appeared in Attention Research Update, an online newsletter written by Dr. David Rabiner, a Duke University psychologist and former member of CHADD's Professional Advisory Board. You can learn more about Attention Research Update and sign up for a free subscription at www.helpforadd.com.