1. Health

ADHD Medications Not Working

Question of the Week

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Updated January 26, 2008

Q. I have a wonderful little boy who is now 9 years old. He has already been diagnosed with ADHD. We have tried all the typically prescribed drugs, i.e. Ritalin, Concerta, Strattera, Adderall... many. We tried Adderall first about 2 years ago and it seemed to make him cry a lot. Ritalin seems to work a bit, but his appetite was nil. We have tried Strattera, but it really has not been addressing the "hyper-ness" and excessive talking. We switched back, this time trying Focalin, hoping not to suppress his appetite as much as with Ritalin, but he instantly dropped around 15 pounds over the summer.

He comes home from school and will sleep until dinner, then goes right back to bed at times. He does wake up extremely early in the mornings on his own. When he was first on Ritalin, he had a horrible time sleeping. They added Remeron at night to assist the sleep and appetite.

My son is very bright and does well with grades, but we need to nail his "HYPER-ACTIVITY"!!!! He is struggling with socializing. He means well and is very sensitive. Can you please suggest a drug that we might attempt to use to just mellow him out across the board?? It is really getting out of control. Please help!! Jill, Columbia, SC

A. When they work well and don't cause significant side effects, all of the ADHD medicines can be helpful in controlling the main symptoms of ADHD.

Unfortunately, some children do have problems with side effects, especially appetite suppression that is commonly seen with stimulants. And these medicines don't always work.

Stimulants for ADHD

When they don't work, the options are usually to adjust the dose, either up or down, or change to another medication. For example, if Adderall was making your child cry a lot, then a lower dosage might have relieved that side effect.

According to the American Academy of Pediatrics ADHD treatment guidelines, 'at least 80% of children will respond to one of the stimulants if they are tried in a systemic way.' And 'children who fail to show positive effects or who experience intolerable side effects on one stimulant medication should be tried on another of the recommended stimulant medications.' So if Adderall isn't working or is causing too many side effects after your Pediatrician has adjusted the dose, then it is reasonable to try Concerta or Ritalin.

The AAP also recommends that when children with ADHD 'fail 2 stimulant medications,' then they can 'be tried on a third type or formulation of stimulant medication for the same reason.'

Strattera

Strattera is also a good option for a child who isn't tolerating a stimulant. Although it didn't work for your child, it may be that he was on too low a dose. The American Academy of Child & Adolescent Psychiatry, in their Guidelines to Managing Attention Deficit Hyperactity Disorder, mentions an off-label maximum dosage of 1.8mg/kg, which is higher than the FDA approved 1.4mg/kg that many doctors use.

Some doctors also have begun prescribing Strattera with a stimulant, often being able to use a lower dose of the stimulant so that it isn't causing side effects.

Other ADHD Medications

Also keep in mind that there are some alternative medications, which are not approved by the FDA, but are often used to treat ADHD. This includes the medications Clonidine (Catapres) and Guanfacine (Tenex). The AACAP describes them as being effective for impulsivity and hyperactivity and sleep disturbances. Since you describe your main problem as his hyperactivity and he likely has sleep problems, since he is taking a nap after school, one of these medications may be good option for you, either alone or with a stimulant.

ADHD Treatment Failures

If a child continues to do poorly and doesn't respond to 2 or 3 stimulant medications, the AAP considers that to be a treatment failure and that the original diagnosis of ADHD should be evaluated. So instead of ADHD, maybe the child has a learning disability or behavioral problem causing his symptoms. The AAP also recommends that these children have further evaluation for a coexisting condition, which might include a learning disability, depression, bipolar disorder, etc.

Behavior therapy with a child psychologist or other mental health therapist might also be helpful for your child.

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