The Treatment of ADD--Every Case is Different, Part 2
by P. Louis Theriot, M.D., F.A.A.P.
January 16, 2006
In my last column I wrote about seventh grade Josh who was taking Concerta for his ADD. It was determined that he was taking the medication, a long-acting form of Ritalin, too early in the morning. The effect was wearing off by lunchtime and he was having trouble in his afternoon classes. The remedy was a simple one: his dose was given later in the morning, and this worked quite well.
Erica's case is different. She is a freshman in high school and was diagnosed with having ADD in the fourth grade. Though she does have attention deficit disorder her main problem is pure inattention. The trouble lies in staying focused and on task. She has been described as a daydreamer, but does NOT have impulsivity or hyperactivity.
Erica is a bright young lady with well-above average intelligence. That is why her ADD was not diagnosed until a relatively late age. Kindergarten through third grade was gotten by on sheer intelligence and she was always at the top of her class. In fourth grade the work became more abstract and voluminous. Then she just fell apart. When Ritalin was tried she did not have a good response. Instead of wiring her or acting as a stimulant, it simply did nothing for her.
Since the diagnosis was made Erica has flourished academically on Adderall XR, a long-acting form of Dexedrine. As she has grown and gone through puberty the daily dose of Adderall XR has increased modestly. She has done well in school, graduating with the highest grade point average in the eighth grade class. She was excited about high school, and looked forward to being a member of the cross-country team.
In mid-October Erica's mom made the appointment to discuss her medication dose. Mom seemed very frustrated about her daughter's work habits, especially her homework. "Erica used to be such a hard worker, almost compulsive about the homework. She would come home from school, change her clothes, have a snack, and sit down to do all of her work without me even saying a word. Now she comes home and either plops in front of the TV or gets on the darn computer. I ask if she has any homework, and she tells me she'll do it later. When 'later' comes its like pulling teeth to get her to do her work. And when she does, it is sloppy. It's like she is a different person," her mom lamented.
Both Erica and her mom agreed that she was doing fine in class. Her mom met with the teachers and they all had wonderful things to say about her. She was a bright child, did her work in a timely manner, and was a pleasure to have in class. Why, then, does one hour's worth of homework take almost three hours to complete...and a lot of cajoling and, at times, yelling?
Similar as in the case of Josh in last month's article, I think that Erica's problem has to do with timing. We all agree that her current dose of Adderall XR is correct for her at this time. This is corroborated by reports from Erica's teachers. The medicine is working fine during the day. In junior high Erica had no commitments after school. She would come directly home after dismissal, have a short break, then sit down and do her work independently. The morning dose of Adderall XR apparently did not wear off until later in the afternoon. This afforded her the ability to be focused and on task throughout her homework period.
Now that she is involved in cross-country, she is getting home between 4:30 and 5:00. After a shower she retreats to her room. Every night it is the same mantra. "Erica, why don't you start your homework before dinner?" her mom pleads. Instead she is found either on the computer "chatting" with friends, or absent from her desk with books open. There she is, in the family room, watching TV. The work that would have taken her no more than an hour to complete in the past is drawn out until ten or eleven o'clock each and every night. "Is this just being a teenager?" her mom asked in a pleading voice.
I told mom that I wasn't quite sure at this point. But it seemed to me as if there was a major change from last year that might be significant. In junior high Erica was able to come home and do her homework right away. The morning dose of Adderall XR was "still on board" and had not worn off. This allowed her to be focused to do her work in a timely manner. Now that she was running cross-country and not getting home until much later, the morning dose had completely worn off by the time she had taken a shower. Her inattention and easy distractibility was in full swing, interfering with her ability to do the work. She was not being oppositional or difficult; it was simply her ADD that was unchecked by that time. She truly had no control over this. I assured mom that it must be frustrating for Erica because she is such a good student.
We worked out a plan to take all of this into account. Erica's main problem was her homework, which she had on Monday through Thursday. On these days Erica was to take a dose of Dexedrine when mom picked her up at school. This short-acting form of Dexedrine should dovetail in with the morning long-acting dose and essentially cover her through the homework. In other words, the Adderall XR should last until late afternoon. On days when she had homework, Dexedrine would cover until later in the evening, allowing her to be focused and on task to complete the work. Since there was no schoolwork on Friday's or weekends, the Dexedrine dose would not be necessary.
Both Erica and her mom were anxious to start the program. I wanted to see them in a week; if this was going to work, a noticeable response would occur immediately. Erica's mom called me by mid-week to cancel Friday's appointment. She said, "I cancelled because I don't want to waste your time. This was CLEARLY the answer. We are both so excited." The first day they tried the Dexedrine, Erica got home, took a quick shower, sat down and finished her homework BEFORE dinner. Considering that this might have been a fluke, the same thing happened the next night as well. Erica was pleased because she could get her busy work done before dinner, and then study for tests and reviewing after dinner. What's more, she is usually finished with everything by 8:00 p.m. which affords her ample time to "chat" with friends on the computer. THIS, I'm afraid, is part of being a normal teenager.
Erica and Josh, from the last column, have ADD and are very responsive to their medication. For different reasons, they were having problems with their work. In Josh's case, his morning dose was given too early and wore off by lunchtime. The remedy was a simple one. Have him take his dose as late as possible before school. In Erica's case, her morning dose was working perfectly well. But, because of her after school commitment, the morning dose had worn off by homework time. It would not be possible to give her dose later in the morning; it just wouldn't last long enough. So, the answer for Erica was to give a short-acting form of her medicine on days that she had homework. This worked beautifully.
As was stressed in the case of Josh, when treating ADD every case is different and must be treated on an individual basis. What works well for one 15-year-old high school freshman won't necessarily work well for another.
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