“Everything was going fine, Doctor, until three weeks ago. The school started sending home notes about Billy disrupting the class and not completing his assignments,” Mrs. Lucas said.
“Is that right, Bill?” queried the boy’s pediatrician.
“I dunno,” he mumbled while avoiding eye contact.
“Well, Bill, you’re the only one who does know what’s going on,” the doctor countered. Bill shrugged his shoulders and picked up his Game Boy.
“Now Billy, the doctor is only trying to help. Talk to him…You see, Doctor, he just won’t get help, and besides, he won’t clean his room or do his chores either!” she accused.
“Mrs. Lucas, let’s focus on the school situation and leave chores out of the discussion for now. Bill, have you been forgetting to take your medicine lately?”
Bill looked up slowly and responded, “Yes, Doc. That’s it! I’ve been forgetting my medicine for the last month.”
“All the doses, or just the noon and 4 o’clock afternoon doses?”
“Just the noon and afternoon doses, Doc.”
“Billy, why didn’t you tell me? Doctor, I thought he was taking it. The school is supposed to give it at noon and the child care club at 4 o’clock.”
“You know, Mrs. Lucas, in middle school they depend on the student to take responsibility for getting the medication himself.”
“Billy, you’ve got to remember,” the mom advised. Bill gave a look to his mother that could stop a charging rhino at 50 paces, muttered something and looked down at the floor.
The doctor signaled Mom to remain quiet for a moment and addressed the boy directly. “You’re a smart guy. You don’t forget things usually. Why don’t you want to take your Ritalin at those times?”
“I don’t mind taking the medicine. I just don’t like going to the office to get it with all the weirdoes. I know I do better in school, but how would you like to go in front of your friends twice a day to take medicine for weirdoes?
Mom wanted to step in and say something soothing to her son. Fortunately she remained quiet and let the boy and doctor continue.
“I wouldn’t like that either. Do you get kidded a lot?”
“No, not really. I just feel stupid going there.”
“Don’t ever call yourself stupid. You know you’re a smart guy who simply has trouble paying attention.”
“I know. I just don’t want to stand out.”
“Do you think the medicine helps?”
“Oh, yes. I get work done faster and don’t get into trouble when I take it.” At that point his jaw loosened and he looked directly at the doctor. “Isn’t there a medication that I wouldn’t have to take at school? Maybe something I could take before school and when I get home?”
The scenario is reenacted many times a week at my office. There is much to learn from it and now something we can do directly to alleviate the problem.
As a parent we want to soothe the anger and hostility in our children. Sometimes we forget that they are no longer little babies, infants or toddlers. We approach them from the standpoint that we can make everything better, put them on our lap, stroke their head and make all the problems dissolve. Unfortunately, by the time the child gets into middle school that approach is neither longer effective nor appropriate.
What Bill needed was understanding of his basic reason for not taking the medicine. He knew the medicine helped him. It wasn’t that he didn’t want to take it. He just didn’t want to have to parade in front of his classmates twice a day to receive it.
Prior to the advent of Adderall, useful long-acting forms of stimulant medication were not available. There were sustained release medications, but they were inconsistently absorbed. The effect could not be relied upon on a day-to-day basis.
With the development of the multisalt preparation of amphetamine, (i.e., Adderall) we were given a medication that could be administered two times per day, eight hours apart. This allowed the child to take no medication at school. He could take it in the morning and when he got home; therefore, avoiding the nasty trip to the nurse’s office. Adderall proved to be extremely effective for those patients who therapeutically benefited from amphetamines. Unfortunately, not all patients respond to this medication. Therefore, Ritalin had to be used as the “every four-hour” preparation. Thus, the advantage of taking a medication before and after school in the privacy of home was lost.
In August of 2000 a time-release capsule that administers Ritalin over a twelve-hour period was approved for prescription use. For most patients this allows them to take the medication in the morning. They benefit from the effect over the next twelve hours without having to take any doses during school time.
With the advent of this long-acting form of Ritalin, namely Concerta, we now have an extremely useful preparation. The beneficial effects of the stimulant can be maintained over a twelve-hour period for most patients. This includes the school day with enough time to complete all their necessary academic work and essentially get them to bedtime.
I currently have over 70 patients using Concerta. It has worked extremely well and has been free of serious negative side effects. Since these capsules can not be broken into smaller doses there are some patients whose weight and metabolism preclude the use of the sizes manufactured. They cannot benefit from this much needed form of stimulant medication.
For those who are successfully maintained on amphetamine, the Adderll preparation has likewise proven effective. Unfortunately, as the children become adolescents, they begin skipping the second dose, which leaves them uncontrolled during their homework hours. To overcome this handicap they are developing a 12-hour Adderall preparation. With the advent of Concerta (Ritalin), and Adderall (amphetamine) we are able to offer these children and adults a source of medication that allows them to get the benefit of the stimulant medication discretely.
Notice in the interchange between the doctor and the patient, there was an avoidance of accusatory terms in addressing the fact that he didn’t take the medication. You can see by Billy’s words that he wasn’t proud of the fact that he was avoiding the medication. He simply did not want to go through the humiliation of having it administered by the school nurse.
As a parent we tend to be more aggressive and accusative when our children don’t follow directions which we feel are better for them. As a physician I realize that one can get more cooperation simply by trying to understand why the patient doesn’t take the medication. The issue can then be addressed directly without the patient being accused of disobedience.
The other thing you will note in the scenario is that his parent brings in other problems that dilute the focus of the discussion. The mom said that in addition to not taking his medication, he also doesn’t do his chores or clean his room. This is not relevant to the discussion. Although these subjects may be important to the harmony of home life, they should not be brought in at this time. When a very touchy subject is being discussed, one that is very critical to the success of his school experience, other problems should be avoided. Focus on the main topic.
When stimulant medication is working well for the ADD patient and suddenly it seems to stop working, don’t assume that the medication is being taken and for some reason is not working. More likely the child is skipping doses.
The doctor does not jump on Billy and ask, “Why aren’t you taking the medication?” Instead he says, “How often have you forgotten to take it?” Forgetting to take the medication is one thing. Deciding he does not want to take it is an offense against the direction of his parents. He knows it places him at high liability for punishment and trouble. While trying to gain the information, parents should be advised to approach it from the standpoint of the child forgetting instead of directly wanting to violate a rule. Once it is determined that it is forgotten, you will be able to understand “why”. The child truly did not forget, but volunteered the decision he did not want to go to the nurse’s office to take it. He realized the medication was good for him and was somewhat struggling with his conscience whether to take it or not.
This scenario is a common occurrence in my office. The usual outcome since we have the consistent time release medication for amphetamines and Ritalin has been handled much more easily. Prior to these long-acting medications it proved to be a real problem in trying to overcome the patient’s reluctance to go to the nurse’s office.
As informed parents what can we glean from this article?