ADD: General Medication Questions

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Does medication really help my child get better grades in school?
While it's clear that medication has a powerful effect on classroom behavior, some researchers have questioned whether they improve learning as well. In other words, does medication simply help ADHD children be less disruptive in class, or does it actually improve their performance on things like book reports and math exercises? That's an important distinction, because it raises the issue of whether medication primarily benefits the child or the teacher.

While there are conflicting studies on this issue, the bulk of the evidence suggests that medication does in fact improve both behavior and academic performance. For example, a 1993 study published in the Journal of the American Academy of Child and Adolescent Psychiatry looked at specific areas of academic performance and found that medication helped about 75 percent of ADHD children improve to the point that their performance was essentially the same as that of non-ADHD children.

Can medication interfere with learning?
Yes, it can--which is why it's so important to monitor closely the child's school performance after medication begins. For example, in some cases stimulants cause children to become isolated and withdrawn. This may make it hard for a child to set priorities and move from task to task. These effects seem to be dose related, so the way to manage them is by reducing the dosage or trying a different medication.

The dosage my child is using doesn't control her ADHD all the time. Does it need to be increased?
Inconsistent control is usually a matter of when it's given, not the size of the dosage. For example, Ritalin's clinical effects may last as little as two hours, so even the standard twice-a-day regimen creates peaks and valleys of control throughout the day. Longer-acting Dexedrine often gives better results, but with any medication you may see variability.

That's why it's important to tailor the dosage schedule for your child's individual circumstances. For example, one common problem comes up with children who have a long bus ride to school. If they take their Ritalin with breakfast, they'll be fine on the bus, but the medication may start wearing off in first or second period, and the period before a second dose at lunchtime will be a complete loss. If the child can be relied on to take his medication, I often suggest that he take it when he gets off the bus at school, so that the peak effects will occur when they're most needed.

How will the doctor determine the right dose for my child?
Mostly by clinical experience, along with some degree of trial and error.

Because people respond so differently and unpredictably to ADHD medications, it's difficult to say up front what the optimal dose should be for any given patient. In most cases, the initial dose should be at the low end of the range and then gradually adjusted upward to achieve the best response--an approach known as titration. Titration takes more work and a longer observation time than simply writing a "standard" dose. You have to wait to see the effects and possibly return to the doctor for several follow-up visits until the dose is right. But it allows the doctor to find the lowest dose that still produces the desired effects, thus reducing the risk of side effects.

How do you know when the dose is high enough?
A basic rule of thumb is to use the lowest dosage that produces an adequate response.

"Adequate" is, of course, often in the eye of the beholder. However, keep in mind that more isn't necessarily better. With higher doses, of course, the risk of side effects increases. But there's another, less obvious reason to keep the dosages low. Studies show that too high doses begin to interfere with the ability to do very complex and memory-intensive tasks, even though they control the social and hyperactive components of ADHD. Thus, while the child's classroom behavior seems terrific, the actual academic performance isn't at its full potential. In other words, the dose that's best at controlling behavior isn't necessarily the best at promoting learning. Lower doses can control behavior without interfering with higher-level processing.