For instance, your child might be experiencing new stressors or changes, such as a taking a new class or attending a new school, Dickstein said. Also, as kids get older, they encounter more challenging demands, such as harder classes and assignments, he said.
“Younger kids function pretty well on long-acting stimulants.” But kids in middle school and high school need medications that extend to homework time, he said. Timing of medication is important to consider.
Has your child grown?
As kids grow, the doctor might need to increase the dose of their medication to adjust for weight changes. “[T]here is not a standard way to pick the ‘right’ dose based on weight so you have to titrate to symptoms while monitoring for side effects,” Dickstein said.
Is it ADHD?
“It’s always good to re-evaluate the diagnosis,” Dickstein said. “ADHD is stable over time. If you have it, you always have it.” Thus, your child’s doctor may conduct another comprehensive evaluation to make sure ADHD is the appropriate diagnosis.
Is there another disorder?
Sometimes, the reason treatment stops working is because your child might be struggling with another disorder, such as an anxiety disorder or depression, which can worsen daily functioning. For instance, depression can severely compromise a person’s cognitive and motor skills, said Olivardia, a clinical instructor in the department of psychiatry at Harvard Medical School.
According to Dickstein, “a new anxiety disorder or depression would warrant either adding psychotherapy or potentially treating with an SSRI or both, depending on how severe the issues may be.”
Substance abuse also might be an issue for older kids, making it important to assess for.
Is it an adherence issue?
If a child’s symptoms worsen suddenly, it might be because they’ve stopped taking their medication, Dickstein said. (This may happen with adolescents, in particular.) If that’s the case, find out why they’re missing their dose and work on continuing treatment.
Is there a physical illness or injury?
It’s also important to assess for and rule out physical illnesses and injuries such as concussions, Dickstein said.
Changing Medications for ADHD
If your child doesn’t have any other disorders besides ADHD and symptoms are still present after a dose increase, then the next step may be switching from one stimulant type to another (such as switching from methylphenidate to amphetamine) or adding a non-stimulant (such as guanfacine) to augment efficacy, Dickstein said.
Behavioral Interventions for ADHD
Your child may be participating in various behavioral interventions, depending on symptoms, Olivardia said. For instance, “Social skills and assertiveness training is beneficial for kids who are impulsive and have trouble with interrupting others and being physically or vocally intrusive.”
Time management training teaches kids structure and organization. Relaxation and mindfulness strategies help kids focus and improve their anxiety, he said. Interventions also target healthy habits such as getting enough sleep and exercise.
“A behavioral treatment is judged as ineffective if after much repeated practice and earnest participation you do not see a positive change in symptoms.”
But that doesn’t mean stopping the treatment right away, he said. Again, it’s important to pinpoint the specific factors that are contributing to the worsening symptoms. Sometimes, the contributing factors may be outside of treatment, such as “stress at school or sleep deprivation.”
Other times, the treatment might need tweaking. For instance, it’s possible that your child needs some novelty in the intervention, Olivardia said. He gave the following example: “If someone is engaging in deep breathing exercises and it suddenly stops working, it may be that the client needs to change the scenery in which they do the breathing exercises. Or instead of picturing themselves at a beach, they need to change the mental visualization. It could sometimes be a subtle factor that can shift a treatment.”
In order to be effective, behavioral therapy has to be “concrete, consistent and heavily practiced.” Also important are “having a high degree of accountability and a reward system.” Consider if any of these parameters have changed. For instance, maybe the reward system works well and needs to be replaced.
Every child is different and complex, so it’s important to consider all variables – such as the family, school and community environments – when tailoring treatment, Dickstein said. It’s crucial for parents to have a collaborative relationship with their child’s treatment team and be clear on the symptoms being treated. It’s also crucial to have ongoing monitoring to make sure the treatment is actually working.
Dickstein suggested checking out these additional resources from the American Academy of Child & Adolescent Psychiatry:
- The ADHD resource center offers information on treatment and other important facts.
- This paper discusses practice guidelines.
- This “Pocket Card” includes treatment algorithms (but has a fee).