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Attention Deficit Hyperactivity Disorder

Dosage of Adderall Rx 20mg

01/25/2008

Question:

My boyfriend`s son is 7 years old and was recently put on Adderall, for ADHA, after another medicine was doing the trick. The child`s mother says that the doctor told her that he did not have to take the pill on days that he wasn`t in school, such as weekends and breaks. His behavior is worse than it has ever been when he is not on the pill. He is so tender hearted that it is hard to tell him he is doing something wrong. I do not think that the pill can be thrown around and taking every once in a while. Should he take the medicine on a regualr basis, or can it just be taking when he goes to school? I believe that it is harmful to go with out the medicine in his system and them have him take it and then quit again. Is doing this going to hurt his body?

Answer:

There are many reasons for a doctor changing or adjusting medications for ADHD, and it is not clear what the reason was in this case. Common reasons include side effects, time-action effects (medicine wearing off at the wrong time of day), new information about the risk of a certain medicine, unsatisfactory benefit, regression after initial benefit, or even relative expense. The important thing is to keep notes on the effect of each medicine and dose so that a knowledge base about the individual patient's response if built up to guide future treatment.

Adderall XR is one of the most popular medicines approved by the FDA for treating ADHD, but individuals vary in their response to the wide array of possible medicines: some individuals respond better to one while others respond better to another. There are two respectable schools of thought regarding consistency of medication. One is that it should be given every day on a schedule that is effective during all waking hours. The other is to medicate only on days and at times when the person needs to perform, such as during school time, homework, and other activities requiring good concentration/attention. Many doctors fall between these extremes. I prefer using the method the family feels most comfortable with based on the individual patient's symptom profile.

If a youngster has problems only with academic work on school days and does not like to take medicine, then he/she needs it only on school days, perhaps only during school hours and/or homework. If a youngster is difficult to like when unmedicated, then he/she should take it daily all day to salvage the social and family relations. If he/she keeps getting in trouble on the Little League team for not paying attention to the ball or coach, medicine should be used on Little League days.

There are also two schools of thought regarding dose: one is that the dose should be titrated up to optimal benefit as long as side effects are not too bad, and the other is just to take the edge off the problem and use other treatments and support to achieve a satisfactory result. It has been shown in several studies that combining medication with behavioral treatment (systematic reward system, daily report card, structuring of activities, parent and teacher training in use of behavior modification, etc.) can give as good or better results with a lower dose of medicine compared to a higher dose of medicine alone. Because side effects depend on dose, the combination of a lower dose with behavioral treatment should relieve side effects.

The dose of Adderall XR mentioned in this case is a medium dose. Some patients respond well to lower doses and others need higher doses to get any benefit. There seems to be a U-shaped response curve for each individual, in which there is an optimal dose (different for each person), and above or below that dose has less benefit.

A neglected area related to medication is nutritional support. All the FDA-approved drugs for ADHD interfere with appetite. With reduced appetites, kids get pickier in their eating choices and parents, worried about their weight loss, may be inclined to allow them whatever they are willing to eat. The result is often a terribly imbalanced diet lacking some essential nutrients. The brain can only function optimally in an environment of good nutrition. Neurotransmitters are made from ingested proteins using ingested vitamins and minerals as necessary co-enzymes. The brain itself is made up of molecules derived from food. Deficiency of any essential nutrient can cause mental symptoms. Therefore some assurance of daily replenishment of vitamins and minerals as well as protein is essential. Nutritional strategies include eating a good breakfast before the medication takes effect in the AM and a wholesome bedtime snack after it wears off in the evening. In some cases a commercial milkshake-like drink with the daily requirements of vitamins and minerals is advisable, which can also provide some protein and calories. Nutritional support should be discussed with the patient's doctor along with dose and schedule of medication.

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Response by:

L Eugene Arnold, MD, MEd L Eugene Arnold, MD, MEd
Professor Emeritus of Psychiatry
College of Medicine
The Ohio State University