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Adjusting Stimulant Doses




This discussion is mostly about the short acting stimulants Ritalin, Equasym, and Dexedrine. The newly available long acting preparation, Concerta XL, contains the same drug (methylphenidate) as Ritalin but, because it is long acting, it does not require, nor allow for, the same degree of fine tuning.

NOTE: These suggestions are to be taken as guidelines only They do not, and should not, be taken as medical advice for your or your child, and no liability can be accepted for any harm that might result from you relying on this information. Any dosage adjustments you make must be done in consultation with your doctor.

What doses does the medication come in?

Ritalin (methylphenidate) – 10 mg

Equasym (methylphenidate) – 5, 10, & 20 mg

Concerta XL (slow release methylphenidate) – 18, 36, & 54 mg

Dexedrine (dexamphetamine) – 5 mg

In terms of effectiveness, 10 mg of methylphenidate (MPH) is about the same as 5mg of dexamphetamine (DEX). In other words, one tablet of Ritalin is about the same as one tablet of Dexedrine (although it does not last as long). In this discussion we assume that you are starting with the standard size tablets of either 10mg of MPH or 5 mg of DEX. If you are using a different dose of tablet you must adjust the instructions accordingly.

How do I use the medicine?

Because the medication is only short acting, your child will normally need to take two, three, or maybe even more doses each day. Also since the dose needed is different for every child, it usually takes two or three weeks of trial and error to find the ideal dose and timing for your child. Since you (and the teachers) are in the best position to monitor the medicine, you are also the best one to do the fine tuning to find the right dose. After carefully adjusting the dose a few times you will begin to understand how the medication works for your child. The following is a short guide to get you started:

1) Start your child on half a tablet before school, and (if older than 5) another half tablet at lunch time (you will have to arrange this with the school)

2) After a couple of days check with the teachers to see if there has been any improvement, or any side effects.

  • If the behaviour/concentration are much improved through the day and the evening, stay at this dose.
  • If there are mild or moderate side effects, continue at this dose for a few more days and then check again. Normally the side effects will improve over the first few days.
  • If there are only minor side effects, and there is little or no improvement in behaviour/concentration, try increasing the dose to one tablet in the morning and lunch time. Wait a few days, and then check with the teachers again. You can continue to increase the doses in this manner by half a tablet at a time, up to a maximum of 6 tablets per day (ie. 30mg of dex. or 60mg of methylphenidate.).

  • Remember that the medication will only improve the core symptoms – concentration, organisation, impulsivity – not any associated complications such as lying, smoking, stealing, depression, anxiety etc. These are problems you will need to work on with your key worker.
Table 1: Example of how dose adjustments might be done (remember every child is different):

DAYS

MORNING DOSE

NOON DOSE

4p.m. DOSE

OBSERVATIONS

1-3 ½ Tablet ½ tablet none no effect
4-7 1 1 none a bit better
8-12 1 ½ 1 ½ none good a.m., zombie p.m., worse at 4-5p.m. (rebound)
13- 1 ½ 1 ½ much better, some sleep problems.

3) You may notice that the tablets improve the problems for a few (2-4) hours and then the problems get worse than ever. This is called a rebound effect and is caused by the medication wearing off too quickly. The most common time for this is at 4pm just as they are coming home from school! Another time is just before the lunch time dose. If coming home from school and the evenings are a problem, try adding in a dose at 4pm (start with half a tablet and slowly work up). Remember that giving your child too much, too late, will probably cause problems with sleep, so take it slowly.

If the school reports that things are improved mid-morning and mid-afternoon (when the maximum amount of medication is on board), but they are having problems just before lunch, it may be that the morning dose is not lasting long enough to make it through to lunch time. Try increasing just the morning dose, and/or try bringing the noon dose earlier – for example to the 11.00 am break time. In this case you may also need to add in another dose at 2.00 or 2.30. It is quite common to start the day with a large dose, and then to top it up with smaller doses through the day; each dose does not have to be the same size.

If sleep is a problem, try cutting down the 4pm dose. On the other hand, if settling to bed is difficult because of late evening rebound, then a small evening dose may actually make things better rather than worse.

4) After you have increased the doses a few times you may find that there is no further benefit, and possibly there are more side effects or more problems with rebound. In this case you have probably gone past the ideal dose and you should decrease it again. If on occasion you do give your child too high a dose – do not panic! The medication is short acting and it will wear off. If you keep to the maximum of 6 tablets a day you will not do any permanent harm – but you may be up all night because he can’t get to sleep!

5) Sometimes children respond well to the medication for the first week or two, and then the effect seems to wear off. The first time this happens, simply increase the dose further. If it happens again, discuss it with your key worker.

6) Some children do not respond well to the medication, whatever dose is tried. If this is the case, it may well be worth trying the other stimulant instead ( e.g. switching from Dexamphetamine to Methylphenidate or vice versa). Discuss this with your key worker. Apart from the fact that dexamphetamine usually last an hour or two longer than the methylphenidate, the two are used in exactly the same manner. There is no difference between to two brands of methylphenidate, Ritalin and Equasym, except that that Equasym is available as 5mg and 20m g tablets as well as the standard 10mg. Note. the doses discussed above are based on the standard 10mg methylphenidate, and 5mg dexamphetamine tablets.

If you have any worries about the medicine or the dose – call your key worker. If there are any side effects that alarm you, simply stop the medication.

You may find it helpful to use the following table to record your dose adjustments

Time:         Comments
Step 1          
Step 2          
Step 3          
Step 4          
Step 5          

Remember, these are only suggestions. If you have any questions or concerns about the medication or possible side effects you should speak to your doctor.

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Dr. Noel Swanson, Consultant Child Psychiatrist and author of The GOOD CHILD Guide, specializes in children's behavioural difficulties and writes a free newsletter for parents. He can be contacted through his website on Expert Parenting Advice.

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