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Attention Deficit Hyperactivity Disorder

Meeting A Doctor About Medication Dosages

11/28/2005

Question:

my grandaughter who was 6 yrs old when she was diagnosed with ADHD, and was given Adderall 10mg, to start with, within the year the doctor has increased her dose to 20 mg. without even seeing her in his office once. Aren`t younger children or even older children suppose to be at least seen in the office for visits for the doctor to see for himself how the child is doing on the medicine. It has been a year and he has not seen her, she has lost over 10 lbs, he just writes the prescription, after asking my daughter a few questions, who sometimes does not answer honestly..she is trying to use these pills without any behavior program, and there is a lot of stress in their family. My grandaughter told her mom she could not sleep, my daughter`s response was turn your tv. on go back to bed..everyone is so worried about the increases of the drug without the doctor seeing her, and the wt. loss, and how at times, my grand dauther,it is like she can`t control the movement of her limbs, they have to be moving..she was never that way before.. I`d like your opinion, is this the safe way to doctor a 6-7 yr old child..over the phone, for a year? this is a controlled drug ..how do you convince someone they need to take them to a doctor that will monitor the effects of the drug on the child. The teacher has no complaints, she is an excellent student this year, even made student of the month. when the mother was asked, why did you increase her medicine again, she stated.."how would you like spending an hour or two helping her with her homework every night". I asked if the teacher had complained about the child and she said no..it is a control thing going on at home, the mom doesn`t want to take time with the child..and the doctor doesn`t want to take time to see the child..how does someone advocate for this child? mom refuses behavior counseling, states it is useless.. any suggestions would be greatly appreciated.. concerned grandma

Answer:

What a hard and frustrating situation you must feel you are in! It is difficult to believe that your granddaughter's physician has not seen her at all and is increasing the dose completely based on her mother's description of things. However physicians are capable of mistakes just like everyone else. I have seen mistakes such as this made when a professional mistakenly feels they know a parent well enough or when they are unaware of the potential side effects of stimulant medications. Medications like the four-dexedrine salts (Adderall) your granddaughter is on are often extremely helpful when used for children who appropriately need them and who tolerate them well.

Let me address the various points you raise one at a time. As you read this, keep in mind I am writing about general situations. Since I know little about your granddaughter except the few things you wrote, I cannot tell you which, if any, of my responses clearly applies to her.

1) A 10 mg dose of four-dexedrine salts (Adderall), either short acting or long acting, is within a normal range of dosing for your granddaughter's age level, if she does have ADHD.

2) An increase from 10 mg to 20 mg of either short acting or long acting could also be within an acceptable range although I would more likely increase to 15 mg first then reevaluate. Additionally, 20 mg of short-acting is a fairly hefty dose for a six-year-old and generally calls for particularly close follow up, at least initially.

3) All children should be seen in the office for evaluation when they are put on stimulants. How often is variable but at least enough to feel confident the benefits outweigh the risks (as with all therapy). The "risks" we watch for include things like weight loss that continues after 6-8 weeks, inappropriately-slow weight or height gain (that may take months to see), worsening or new anxiety or depression, worsening or new tics, abnormal movements or obsessive/compulsive behaviors, worsening or new sleep disturbances, and emotional flatness.

4) Children on even non-controlled medications every day should be regularly monitored---it is not because they are controlled that we see children periodically. Each person is a unique individual and, as such, will respond slightly different than everyone else to any medication or supplement (or even food!). Often the difference is not noticeable or a problem at all, but one can never be sure without periodic monitoring. Children's responses to drugs are less understood than adults' responses and children generally do not have the ability to express what is happening as well as adults. These are some of the reasons we need to be particularly careful to see children regularly when using medications, especially early on.

5) The teacher's opinion is, as you clearly understand, very important. On the other hand, there are children with ADHD on stimulants, and some off stimulants, whose teachers say everything is fine even when the child would benefit from the medication both in their didactic learning (such as reading and/or math) and socially. Thus, it is important to note but not a defining point.

6) How homework precedes can say a lot about a student's attention problems. However, it can also go poorly if medication is not given at the right time, if there is a learning disability in addition to ADHD, if the student is too anxious, if the student has a very inappropriate diet, and so on. I do urge you to keep in mind, if you discuss this with her mother, that it can be very frustrating to do homework with a child with ADHD.

7) Now, the more difficult part---how can someone who sees things of concern going on advocate for this child? Although the staff and teachers at your granddaughter's school cannot share information with you for legal reasons and your granddaughter's doctor cannot for a similar reason, that does not keep you from writing to them or visiting them with your concerns. In fact, you can include a copy of this with your note if you wish to write them. Of course, that may not go over big in your family so you need to think through how that might be handled first.

If you can afford to, you might want to offer to pay for a few visits to a specialist in ADHD or a full evaluation in a specialty center for ADHD.

Through all this, keep in mind that your granddaughter's mother (and father?) may actually need a lot of support as well. If your granddaughter has ADHD she may be a real handful---particularly if her mother, like so many parents of children with ADHD, has attention, organization and/or impulsivity problems herself.

I wish you the best.

For more information:

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Response by:

Susan Louisa Montauk, MD
Formerly Professor of Family Medicine
University of Cincinnati