With the start of September, all thoughts turn to . . . medicating our kids??? Well, as bad as that can sound to some, it IS time for the annual debate. A question for which there is no clear answer. Let’s examine several scenarios and I’ll give some suggestions . . .
We’ll start with an easy one . . . the very hyperactive and disruptive kid with focusing difficulties. This is kind of a no brainer. Despite what some detractors might say, these kids really, REALLY benefit from the use of medicine. There are always ways the school environment can get tweaked to help them, but, for most, they will have significant difficulties no matter what you do. It is important, in my book, to treat these kids aggressively with medication so that they can begin the year on a good footing. If they can get into patterns of good relationships with both peers and teachers, and get into a good pattern of classroom behavior and homework achievement, it sets the pace for the rest of the year. It creates a buffer to absorb difficulties that may crop up later in the year. It gives them some sense of self confidence that keeps the bar high for later expectations. As you parents out there know, the personality match between the teacher and the kid can have a huge impact on the quality of the year. If the teacher must act the strong-man to manage behavior early in the school year, the likelihood of the kid liking the teacher and feeling comfortable with him goes way down. That can sink the whole year.
How about those inattentive kids without behavior problems? This is one of those grey areas that requires clinical finesse. A lot goes into the decision about using medicine here. How difficult is it for the kid to stay integrated into the classroom experience? How much impact does the focusing issue have on knowledge acquisition and academic success? How important is the school year (eg, 11th grade is way more important than 7th grade). Is the medication well tolerated or does it cause significant side effects? I could go on and on . . . (as I said, this is a big grey area!). In thinking about what to do, I consider as many of these factors as possible. Most kids want/deserve a trial off medicine at some point in their academic experience. Taking all these factors into account is very important as is the timing of the trial off. For these kids without behavior problems, the start of the school year can be a good time, as long as their progress in school is carefully monitored and there is good communication between home and school. What you don’t want is for half the year to go by, the kid to feel completely lost, and THEN have the teacher give a call to let you know about your summer plans . . . summer school. As I mentioned above, a potential danger in this strategy is that a bad start can effect a whole year, even if caught early and with efforts put into recovery. The alternative strategy is to medicate early so that the child gets a good footing for the school year, and then stop the medicine. This, too, must be done carefully and communication between school and home needs to be good. Sometimes, we do these trials off without the teacher’s knowledge. It allows the teacher to be ‘blind’ to the condition and to give more unbiased reporting of events. It then falls on the parent to touch base with the teacher about academic and social progress. Since most kids with ADHD take stimulants medication that wears off at the end of each day, a change in ability to concentrate can be readily apparent to the teacher (and the parent during homework time).
A strategy I will use for these mid-year trials off medicine is to gradually reduce the dose that is given to a child (eg, Adderall 20 mg for a month, then 15 mg for a month, etc,). While more difficult to ‘catch’ the onset of difficulties, it does allow us to re-check the lower threshold for medication. This can be especially powerful in kids who are motivated, maturing, and learning better ways to manage their own time and their own tendency toward being distracted. It is always best to have a discussion about what the end-points will be that will trigger an increase in medicine. If these end-points are written down, it will allow for a smooth and non-traumatic transition back to medicine. The truth is that, for most kids, if they had trouble focusing and concentrating last year, they will have trouble this year. The question will be how much trouble, and how will they deal with it. Planning ahead for these contingencies will increase the chances for a positive outcome, whether or not it includes continued use of medicine.
If it is determined that medicine is still needed, it is also important to frame the re-start in a way that is not defeating for the child’s esteem. It is not that someone “failed” the trial off medicine. It is just that we need to keep the medicine in place for a while longer. Reassure both the parents and the child that another trial off the medicine should occur in the future. That the most important think is that the child does as well as he or she can in school, and that their experience of school be positive. Just like “every day is a new day” with the stimulant medicine . . . every year is a new year at school and it presents another opportunity to consider a trial off the medicine.
–Dan Hartman, MD
