Patient 1: Joey
Age: 6 years, 9 months
Diagnosis: ADHD combined type, severe
Presenting symptoms and complaints
Joey has no prior diagnosis and who just started kindergarten. At the first 6-week progress report, his kindergarten teacher requested a parent–teacher conference because Joey seemed hyperactive and had difficulty with focusing on tasks. There were many times when he would be disengaged from the rest of the class and could not follow directions from the teacher even though the instructions were simple and age appropriate. The kindergarten teacher felt very strongly that his parents arrange for an appropriate evaluation and hence the psychiatric evaluation.
Despite a clear explanation of the diagnosis of ADHD, and a review of treatment options, the parents were especially reluctant and hesitant about the use of psychotropic medications. The parents were naïve about ADHD and the mother admitted to struggling with the notion that their son was somehow “defective” and needed medication intervention. It was at this point that his child psychiatrist suggested that they try a liquid stimulant as it would afford the parents the opportunity to gradually titrate the medication from a very small initial dose to an effective and optimal dose.
Initial treatment plan
Joey was started on amphetamine extended-release oral suspension and an initial variable dose prescription was written as follows:
Amphetamine extended-release oral suspension (amphetamine extended-release oral suspension 2.5 mg/ml) |
Sig. 1 ml to 4 ml po q am |
Quantity: #120 ml |
Joey’s parents were given very clear and detailed instructions to try an initial dose of 1 ml every morning for 4 days and to increase/titrate this dose by either ½- or 1-ml increments every 4 days but not to exceed the prescribed limit of 4 ml. The parents were also informed that there was a good likelihood that they will see a positive response somewhere between 2 to 4 ml and to stop at that effective dose once they could detect or notice a positive difference. They were also informed that if they saw a detectable response earlier, perhaps at 2.5 ml, 3 ml, 3.5 ml, or even 4 ml, to remain at that effective dose, instructed not proceed further, and certainly to not dose beyond 4 ml.
Follow-up
At the 1-month follow-up appointment, Joey’s parents reported that they followed the instructions carefully and found Joey’s “effective sweet spot dose” at 3.5 ml/day. They were most happy and relieved to report that Joey’s functioning in class had improved considerably and that his kindergarten teacher was pleased with his progress and that he was now able to participate along with the other children in the class. The parents were also grateful that they had been allowed to participate actively in his treatment and that they had been involved in a shared decision-making endeavor for their child in finding the optimal dosage for their child.
Patient 2: Lisa
Age: 9 years 3 months
Diagnosis: ADHD inattentive type
Presenting symptoms and complaints
Lisa is a 4th grader who was initially diagnosed with ADHD when she was in the 2nd grade. Despite Lisa’s efforts to concentrate and stay focused, she often day-dreamed, could not stay on task and was very easily distracted. Her teachers reported that she frequently performed below her academic potential. Despite having been treated initially by a pediatrician and then later by a child psychiatrist, the mother felt that Lisa had not responded well to any of the medications that had been tried and that they caused unmanageable side effects. Lisa had been tried on more than six different ADHD medications, but with limited benefit. Furthermore, during the initial assessment the mother admitted that she had a general mistrust of stimulants even though she had read that these medications were safe and effective. The mother complained of dissatisfaction with the results so far and was concerned that Lisa was being overmedicated. She confided that she had considered resorting to the use of wellness products and herbal preparations to treat her child’s ADHD.
Following these admissions and disclosures by the mother, it became clear that the treatment failures thus far were related to the mother’s own fears of the use of these medications. Lisa’s psychiatrist suggested that the mother try a liquid stimulant so that the she (the mother) could adjust and customize the dosage and discover for herself the least amount of medication necessary to provide an effective dose to improve her child’s problems with inattention.
Initial treatment plan
Since Lisa had last been on a daily morning mid-range (20 mg) dose of dexmethylphenidate HCl, a variable dose prescription of methylphenidate extended-release oral suspension was started as follows:
Methylphenidate extended-release oral suspension 5 mg/ml |
Sig. 4 ml to 8 ml po q am |
Quantity: 2 × 600 mg (150 ml) bottles |
The mother was advised to start with 1 ml and increase the dosage by ½ or 1 ml increments every 3 to 4 days until she found an effective dose that improved her daughter’s ability to focus and pay attention. The mother was also advised that there was a good likelihood that Lisa would respond somewhere between 6 to 8 ml and that she could stop at any dosage as long as it did not exceed 8 ml.
Follow-up
Both Lisa and her mother returned for the 1-month follow-up appointment with a glowing report that Lisa had responded well with 6.5 ml of methylphenidate extended-release oral suspension and that it was an effective dosage point that did not cause any adverse side effects. The mother was most grateful for having been invited to share in the decision-making process of her daughter’s treatment. The mother herself had discovered the “best” dosage for her child while at the same time achieving a high level of comfort by controlling a medication that she had feared and did not trust previously.