Josh is a seventh grader who came to me for a second opinion regarding his ADD. In obtaining the history from mom, it seems that Josh was diagnosed with having ADD in the third grade. He was placed on Concerta, which is a long-acting form of Ritalin. It literally turned his life around.
He is a bright young man who has inattention AND impulsivity as the main components of the ADD. His teachers thought that he might be hyperactive. But it was correctly determined it was his impulsivity-- blurting out answers, talking out loud, interrupting the class, never reading the directions-- and not hyperactivity that was getting him into trouble. Near the end of third grade his doctor put Josh on Concerta and the turnaround was dramatic.
He was doing beautifully in school, but in the sixth grade he started to have some trouble academically. It turned out that he had outgrown his dose of Concerta. When the doctor bumped up his dose minimally once again he was getting A's in academic work as well as citizenship. Sixth grade was easy for Josh, and he made the adjustment to junior high school quite well. He started seventh grade on the same dose of Concerta. I was seeing him on an urgent basis because he had just received mid-term progress reports and it seems that the wheels had fallen off.
"Thank you for seeing Josh on such short notice," his mom said sincerely. "But we have a crisis. I think the Concerta is no longer effective. Just look at his progress report. He's getting D in math, and that is his best subject. He is almost flunking science. Teachers say that he is cutting up in class and is very disruptive. He has been sent to the principal's office more times this quarter than he has in all of the previous six years. What about trying him on Adderall or Strattera? I've heard that these are pretty good for ADD. What do you think?"
After a lengthy discussion with mom, it was determined that Josh actually seems to do well at home on his current dose of Concerta. Saturday mornings when he plays soccer he is focused and not at all impulsive. The same holds true on Sunday mornings when they go to church. Why, then, is he having such trouble at school?
Josh was having trouble in math and science. Mom brought a copy of his standardized math scores and he ranked in the 93rd percentile at the end of sixth grade. Math should be a breeze for him, as it always had been in the past. What was going on? Something just didn't make sense.
Mom told me what Josh's classes were and what time he had them. School started at 8:10 a.m. every day. First class was P.E., followed by English/literature, social studies and then Spanish. He had a long lunch followed by math and science. As it turns out, Josh is doing fine in the morning subjects. He is getting A in English, B+ in social studies, and a solid B in Spanish. The comments noted by his morning teachers are that he is a "pleasure to have in class", is "on task", and "doing grade level work".
Looking at his after-lunch classes it tells a different story. The math teacher reports that Josh is disruptive, talks out of turn, and "has a hard time completing his class work". The science teacher made comments that while Josh does all right on the tests and quizzes, he is on the verge of failing because no homework has been turned in. This is shocking to mom. She faithfully makes sure that he does his work every night, checking to be sure that it is complete. The science teacher has made it perfectly clear to the class that the students are expected to put their homework on his desk at the start of every class. It is THEIR responsibility, and he is not going to remind them. Consequently, Josh had a quarter of the school year worth of science homework crammed in the bottom of his backpack. The work was done, just never turned in!
After discussing all of this with mom, it became clear what was going on. It seemed that the Concerta was working as it should, but there was a problem with timing. I asked if there was a recent change in the family dynamics or schedule. Mom thought for a minute. "This summer I did get a part time accounting job in the mornings. Our mornings are a bit different. Josh gets up at 6:30 a.m. and while he eats breakfast I give him his Concerta. At 7:00 a.m. I take him to my sister's house who gets him to school by 8:00 a.m. with his cousin. That allows me to get to work on time, but this is the only change in our routine," she added a bit perplexed. "Why should this make any difference?"
I told her it possibly could make all the difference in the world. While Concerta is a long-acting form of Ritalin, the effects are determined by how each individual metabolizes it. Just as the dose must be determined on an individual basis, each individual metabolizes the medication differently. Josh is on the correct dose of Concerta. However, it is not lasting through the early afternoon because he is taking it so early. The beneficial effects have worn off by lunchtime. This is evident by his performance in the morning classes as contrasted by the classes after lunch. This is also obvious by his behavior on Saturday and Sunday mornings.
I asked mom to have her sister give Josh his Concerta at 8:00 a.m. just as he was leaving for school, or have the school nurse give it to him after P.E. class. They opted to have his aunt give it just before school. This made sense to mom and she was anxious to try it the following Monday. I wanted feedback as soon as possible. She called me on Thursday. In a teary voice she said that both the math and science teachers had e-mailed her to say what a turn around they had seen in Josh. He was a completely different boy, and they were pleased at how well he was doing.
This account is not at all uncommon when dealing with a patient who has ADD. It is critical to remember that the dose of a medication for such a person must be made on an individual basis, just as the way the person metabolizes it. In trying to sort out the dynamics of the medication, it often boils down to getting a thorough and detailed history, and doing a bit of detective work.