The American Academy of Pediatrics reports that at least 80% of kids with ADHD will respond to a stimulant medication. And it is great when a child newly diagnosed with ADHD does well on the first medicine he is prescribed, whether it is Ritalin, Adderall XR, or Concerta, etc.

Treating a child who doesn't respond to a medication or who has side effects can be more difficult.

Does he need a higher dose?

Does he need a lower dose?

Does he need a different medicine?

Those are all important questions to consider when evaluating a child with ADHD who is doing poorly.

You might also think about whether or not he really has ADHD. Could he have a learning disability instead?

Could he be depressed or have bipolar disorder?

Or could he have ADHD and another comorbid disorder, like depression or a learning disability.

Poorly Controlled ADHD

Here are some common scenerios that doctor's see that can help you figure out why your child with ADHD isn't doing well.

John is a 9 year old in 4th grade who has always struggled in school, especially math. He has trouble paying attention, but doesn't get distracted in activities outside of school. He was diagnosed with ADHD, inattentive type after a quick 10 minute visit with his pediatrician and was put on Concerta 18mg. After a few weeks of this not helping, he was increased to 36mg, but still had problems in math.

An observant teacher wondered why he was doing well in reading and spelling and mostly just struggled in math. She suggested that he might have a learning disability, which was confirmed after testing by the school psychologist. The Concerta was stopped and he instead attended math resource classes and began to do very well.

Although many children have both ADHD and a learning disability, it is also possible that children with attentional problems just have a learning disability and don't need mediction for ADHD.

Shelly is also in 8th grade and was diagnosed with ADHD, inattentive type when she was in the 4th grade. She had previously done very well on Concerta 36mg, but has started to struggle in math class. Her teacher also suspected a learning disability, but testing was normal.

Her Pediatrician thought that the problem was that she wasn't getting enough medicine, as math was her first class in the morning, especially considering the way that Concerta works. Unlike Adderall XR, which gives a child half the dose in the morning and another half later in the day, the delivery method of Concerta only gives about 20% of the dose in the morning, with the rest being distributed throughout the day. So for a 36mg Concerta tablet, that would mean that she is only getting about 8mg first thing in the morning, which might not be enough. In this case, increasing her dose to Concerta 54mg gave her a higher initial dose and helped her pay attention in the morning.

David was recently diagnosed with ADHD, combined type and worsened after being started on Adderall XR 20. He was irritable and moody, wasn't eating and had trouble sleeping. His doctor suspected the dose was too high and he did much better after being decreased to a 10mg capsule.

Sammy is also irritable and moody after being started on Adderall, but he is on short acting Adderall and he takes it in the morning and at lunch. Unlike David, he does great all day at school, and doesn't become irritable until 4-5pm in the afternoon. In this case, the problem is likely that he is having a 'rebound' as the Adderall is wearing off. A small afterschool dose might be helpful for Sammy, or he might do even better on a long acting, once a day medicine, like Adderall XR.

Jenny was recently diagnosed with ADHD and had no improvement on her starting dose of Concerta 18. As per AAP guidelines, the dose was slowly increased, first to 27, then 36 and finally 54mg. At the higher dose, she still couldn't pay attention and began having headaches and trouble sleeping. She was changed to Adderall XR and had the same problems. She was finally changed to Strattera and did great.

In cases like this, it is important to remember than only about 80% of kids will respond to a stimulant. Strattera, a non-stimulant medication, may be a good choice for these children in whom stimulants don't work or cause too many side effects.

John had been doing well on his stimulant for years, but he recently began having trouble sleeping and was very irritable during the day. His mother suspected he was on too much medication, but lowering the dose didn't help. Further evaluation by his Pediatrician revealed that John was depressed. He was put back on his regular dose of stimulant and an anti-depressant was added. In this case, his Pediatrician put him on Remeron at bedtime, which help his depression and also helped him sleep.

Laura was on Adderall XR 20, just like her older sister but she was still having trouble paying attention. Her father was resistant to raising the dose, since her sister was doing very well on the same dose and she was older and weighed more. After her Pediatrician explained that stimulant doses usually don't depend on the child's weight, she was increased the Adderall XR 30 and did very well.

These scenerios help explain some of the different things to consider when a child with ADHD isn't doing well. Some kids need a lower dose, some a higher dose, and some need different treatments all together.

A child psychiatrist and/or child psychologist might also be helpful if your child isn't doing well.

Remember that many doctors, especially child psychiatrists, use higher than recommended doses of stimulants. This might mean that a child takes 2 Adderall XR 30 capsules or 2 Concerta 54 tablets. Although high doses, these usually do well and the AAP does state that 'the best dose of medication is the one that leads to optimal effects with minimal side effects.'

Also, when changing medicines, keep in mind that doses of Adderall are generally half that of Ritalin or Concerta. That doesn't mean that Concerta is stronger, but simply that it is more potent. So if your child is on Concerta 54 and is being changed to Adderall XR, the comparable dose would be the XR 30 capsule.

And Strattera doesn't equate to Adderall or Concerta at all on a mg to mg basis. So a teen on Strattera 80mg isn't necessarily on more medicine than a child on Concerta 54 or Adderall XR 30.

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