By DR KIM PEDLOW (GP interest neurodevelopmental disorder)
Do we need to advise ADHD patients to take the following medication continuously?
That is treatment with methylphenidate and dexamphetamine. This would include short-acting such as Ritalin, dexamphetamine, the longer acting preparations such as Ritalin LA, Concerta, Lisdexamphetamine (Vyvanse).
Unless there is a very good reason for occasional omitting, e.g. appetite suppression my recommendation is…..
YES………..We need to advise our ADHD patients to set and forget with their medications.
My rationale is as follows.
The major benefit of these medications is to improve sequencing. That is the link between prior, current and future action and thought.
Improving sequencing helps performance with the following
- academic endeavours
- social interaction
- family, friendship groups, personal relationships, organised activities
- self-assessment including predicting the affect one’s actions and words have on others.
- Assessing the motives and likely actions and words of others
I’m sure there are many other examples………………. In other words not just activities at school, particularly in the classroom..
I am in a privileged position of having watched ADHD families over 35 years at the practice and longer with family members. That is I look after children and adults as opposed to my paediatric and psychiatrists friends.
They tell me what causes most grief in later life is the difficulty with relationships, time management, their lack of reliability and so on.
Going on and off medication is problematic for the following reasons
- negative reaction from the group is likely when a person is sequencing and performing better one day and then not the next. It may go like this…’ Okay one day, all over the shop the next, I don’t have to put up with this, he/she seems like a bright enough kid, maybe they are doing it on purpose just swinging the lead, maybe it’s the parents, just need a good……..
- I can remember studies from 25 years ago pointing out that the school performance was not so good on a Monday when the medication was omitted over the weekend. Assume that is still considered valid.
- Reasons for omitting medication short-term, weekend, holidays and so on.
- Appetite suppression causing clinically significant weight issues.
- Trial on and off medication for effectiveness when there is uncertainty.
- Usually it is simply that the family has forgotten the tablets, forgotten to give them, shared care, shared parenting has forgotten to give the tablets or deliberately withholding due to lack of consensus amongst the guardians.
- Poor advice given by what I call the caring circle…… See below
- my professional network including psychologist, psychiatrists, developmental paediatricians tell me that there are some patients, probably mainly adults for which the following most likely applies………… Take a short break and the same dose of medication seems to work better when it is recommenced. Maybe a few days or a week.
my anecdotal feeling is that there are some patients who have those characteristics. I find it is always difficult to work out perceived from the reality. Comparing it to when we trial children on and off trying to ascertain effectiveness or not of stimulant medication and getting feedback from school. Frequently they will come back and say oh yes when we stopped Dexamfetamine or Methylphenidate things were terrible and when we started again things were fantastic. Not sure if this has relevance to a short break with adults. Maybe it is the contrast they are noticing.
I wish there was a better way of measuring it. A colleague was saying something similar that she had picked up from a conference that some cases do better if you stop for a while, not sure how long and then recommence.
I suppose I am sensitive and wary about this discussion which interpreted incorrectly might channel into a discussion as follows…………..oh well they habituate, it loses its effect, we need to keep ramping up the dose therefore maybe they are addicted to it. All of this is not true of course but can you see I am concerned some people might extrapolate. Some colleagues. Maybe the same ones that still tell people in Emergency Department please stop your dexamphetamine and you know you must tail it gradually over a month because otherwise you will get withdrawal symptoms. This is not correct of course but I still hear from time to time. Less so these days.