Publisher's Note: While stimulant medication is widely used in the treatment of ADHD, it is certainly not without controversy. This article is intended to educate parents on one small aspect of the complex issue of medication – monitoring stimulant effectiveness. Dr. Parker calls for improved oversight and evaluation, and he provides a solution as to how physicians can do this. It is not meant to be a comprehensive report, but to raise questions and help parents have better-informed conversations with your child's prescribing physician.
At ImpactADHD, we see medication as one of the many treatment options available to parents, and encourage parents to make decisions that are best for your families. The effective treatment of ADHD relies on a wide range of interventions that change with the needs and age of the child. Dr. Parker's guidelines remind us that our children are constantly changing and growing, and our response to their ADHD must be flexible, as well.
Measure what is measurable, and make measurable what is not so. Galileo ~ 1615
I am on a mission to encourage well-informed, comprehensive care for ADHD. In my experience, while medication is the most common treatment method used, the ADHD medication process is not as effective as it could be. Fortunately, I believe that there is much we can do to improve the use of medication in the treatment of ADHD. Parents, in partnership with prescribing physicians, can improve outcomes for their kids with more attention to critical measurements and better medical communication.
As parents, you can improve ADHD medication management when you actively participate in a conversation with your medical professionals. Beyond the obvious attention and mood related behaviors -- beyond side-effects and “is it working” -- a doctor must look at how metabolic changes in the body influence the affect of medication. Parents are uniquely suited to provide this information.
Details matter for every evaluation and every medication check. Without data, using common sense is limited. We must use specific guidelines to understand how ADHD medications should work, and apply neuroscience principles to understand when they don't work - if not, guesswork rules.
Currently, within the medical community, there are no clear specific dosage strategy guidelines. This leads to widespread prescribing challenges and potential for stimulant mis-management. I see dosage problems and incomplete evaluations in ADHD stimulant management as an enormous, national problem. That is a paradox in the context of remarkable discoveries in contemporary neuroscience.
To begin to put an end to the guesswork, I propose the following five medical “rules” for stimulant evaluation in medication management. They are easily assessed, and can avert treatment failures or medication disasters.
As a parent, I encourage you to have this conversation with your prescribing physician, and encourage your child's doctor to broaden his/her evaluation of the effectiveness of medication. As an informed parent, you can help your provider more accurately prescribe the correct dosage of medication for your child.
Proposed Guidelines for Stimulant Medication Evaluation
1. Know Each Medication Duration Of Effectiveness [DOE]
Each stimulant medication is designed to last a particular length of time. Understanding the DOE for your child's medication, and reporting the actual DOE back to the prescribing provider, can assist the treatment team in assessing how effectively the treatment is working. For example:
- Amphetamines [AMP] short acting = 5/6 hr. DOE
- AMP XR = 8/10 hr. DOE
- Methylphenidate [MPH] short acting = 4/5 hr. DOE
- MPH extended = 8 hr. DOE
If the patient's DOE is actually longer than these times, the patient may be on too much medication; if the DOE is actually shorter duration, the patient may be on too little medication. Measurements do matter. You should observe the DOE on a regular basis, and report it to your provider at every medical visit so they can determine if dosage adjustments are needed.
2. Measure the DOE Every Medical Visit
At every medical visit, physicians should evaluate and adjust the effective dose of each stimulant medication by using the DOE. If the DOE is longer than expected, the dosage may need to be adjusted down, if it is shorter than expected, the dosage can potentially be increased.
3. Measure DOE Quarterly – Every 3 Months
The standard of care in the US for medication checks with stimulant medications is quarterly, about every 3 months. However, some pediatricians only check biannually or even annually.
As metabolic variables change -- that is, as people grow and diets change -- the way a person's body responds to medication changes. To assure good compliance, and to prevent adolescents' tendencies to manipulate their own dosages, quarterly medication checks work best. Less medical structure leads to a greater likelihood for self-dosing.
4. DOE Changes can Highlight Other Problems
Many factors can cause changes in the effectiveness of medications, including genetic, metabolic, and drug interactions. When unexpected problems arise, the DOE is an early warning sign. If medications aren't working as expected, it's important to understand exactly why.
Potential reasons for such problems are too numerous to cover here, but are often simple and can be associated with metabolic variables such as sleep, diet, nutrition, breakfast, etc. All of these variables require more careful investigation from both practitioners and patients. Medication checks should require a review of the DOE and each of these variables to assure proper medication adjustment over time.
5. Measuring DOE Reveals Underlying Co-Existing* Diagnoses
Problems with treatment often arise from undiagnosed or misdiagnosed co-existing conditions associated with ADHD. Many co-existing* conditions, from anxiety to depression, can alter medication effectiveness. Other seemingly unrelated medical issues may also contribute to treatment failures. If other factors are not considered, the problems can often result in an inability to take stimulant medications at all.
As parents, the importance of your role in medication management cannot be underestimated. Talk to your child's prescribing physician about how you can enhance his/her evaluation of the success of stimulant medication. Provide details on your child's DOE. If your provider does not seem receptive to this information, consider switching to a provider who is more willing to actively monitor the nuances of your child's medication. Active and involved parents can make a difference in improving outcomes for your kids, and decreasing the challenges with medication mis-management.
To better understand these and other insights regarding ADHD medications, consider sharing this information with your prescribing physician: New ADHD Medication Rules – Brain Science & Common Sense. For New Rules excerpts and reviews: http://adhdmedicationrules.com, and for a Dosage Video Playlist: http://bit.ly/dosevids
* The medical term for co-existing is comorbid.
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