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An Important Problem with How Medication is Often Prescribed
Problems With How Medication Is Often Prescribed
Children's Size Does Not Predict Medication Response
The decision to place a child on medication is a difficult one for most parents and if you are going to have your child take medication, you want to be sure that he or she is deriving the maximum benefit possible. Unfortunately, a commonly used procedure that physicians employ to decide on the dose to prescribe - basing the dose on the child's body mass - appears to be problematic.
A recent study in the Journal of the American Academy of Child and Adolescent Psychiatry conclusively demonstrates that a child's size CAN NOT be used to determine what dose of medication the child should receive.
In this study, 76 children with ADHD received different doses of methylphenidate (i.e. the generic version of Ritalin). The doses used in the study were 5, 10, 15, and 20 mg. Children received each dose in for one week and also received a placebo for one week. Careful assessments of each child's attention, schoolwork, and classroom behavior were made during each week of the trial. Children, teachers, and adult observers who rated children's behavior were unaware of what dose the child was on each week.
The results clearly indicated that children's body mass WAS NOT related to their response to the different doses. Children's response to the different doses was quite idiosyncratic and the optimal dose for each child (i.e. the one that child did best on) was not related at all to the child's size. Thus, the commonly used practice of basing the dose a child is to receive on their weight is quite unlikely to yield the best possible dose for each individual child.
What procedure should be used, then, to determine the appropriate dose. The procedure used and recommended at leading ADHD treatment clinics around the country involves a careful trial that typically lasts for 3-4 weeks. During a 4 week trial, the child would be tried on 3 different doses. There would also be a placebo week. For a 3 week trial, two different doses and a placebo week would be used. Teachers are asked to complete ratings of ADHD symptoms, academic performance, and side effects at the end of each week. Similar ratings may also be completed by parents.
By comparing the ratings at the end of the trial, you can determine if medication really helped (i.e. did child do better on medicine than on placebo), what the best dose was, whether there were any possible side effects, and what problems may remain even if the medication was helpful. Once the optimal dose has been identified, ongoing monitoring of the child's behavior and academic performance is required to be certain that medication is continuing to provide necessary benefits and to determine whether any changes or adjustments to a child's treatment are necessary.
I offer a program that is used by many physicians to conduct this type of careful trial. If you are interested in learning about it just send an e-mail to me at addhelp@mindspring.com and type "medication trial procedure" in the subject line.
Let me also emphasize that after the optimal dose has been determined, it is really very important to monitor how the child is doing on an ongoing basis. The ADHD Monitoring System that you received with your subscription is a good way to do this (if you didn't get the monitoring system, send me your address and I will get it to you.)
The reason this is important is that a child's response to medication can change over time, and what starts out as being effective may be less helpful weeks or months down the road. Other things can be going on in or out of the classroom that can also make a child's symptoms more difficult to manage.
As a result, it is not uncommon for children who are receiving medication to still be having real difficulty because their symptoms are not being managed as effectively as they could be. For example, I saw a child last week who had been receiving medication for several years. Feedback gathered from his teacher, however, made it clear that his ADHD symptoms were still quite prominent despite the medication he was receiving.
Now, it may be that this is a child who won't do better on a different dose or a different medicine. The important point, however, is that had his parents been aware of how prominent his symptoms were, they could have tried to do something about it before more than a year had gone by. What was done could include trying alternative medications, trying a different dose, and OF COURSE, looking at additional, non-medical interventions.
In my experience, this is more likely to occur with children who have the inattentive symptoms only, and who do not display hyperactive/impulsive behaviors. This is because these children are often not behavior problems, in the classroom, and it is thus much easier for them to "fall through the cracks". Carefully monitoring how they are doing - and not assuming that no news is necessarily good news - will prevent this from happening.
By the way, I think the above applies just as fully for children whose symptoms are being managed via non-medical means. It is still critical to get regular systematic feedback about how prominent ADHD symptoms are in the classroom and how these are affecting the child's work and behavior. This will let you know whether the intervention being used - whatever it is - being effective, or whether changes and/or modifications are necessary.
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.