The 10 Things to Do When Starting Your Child on ADHD Medication

As an integrative psychiatrist who’s treated behavioral, mental and emotional problems with drug and non-drug therapies for over 30 years, I always look to address a patient’s entire needs, and not just simply prescribe a drug and walk away.

ADHD patients are often affected by a lack of essential vitamins, nutrients, and neurotransmitters that everyone else take for granted.

But each ADHD patient is a unique individual—a person with a unique brain, unique genes, unique biochemistry and unique behaviors everywhere in their life. More importantly, they’re a person who requires an individualized treatment plan to control symptoms.

For my patients, that individualized treatment plan starts with tests to detect neurological, genetic, nutritional and metabolic imbalances. Here are 10 rules I always follow when starting a child on ADHD medication.

The 10 Things to Do When Starting Your Child on ADHD Medication

#1. DO start magnesium—immediately.

Nine out of ten ADHD children are deficient in magnesium, a mineral that supports nearly every system and organ in the body, including nerves and muscles.

A low level of magnesium is a setup for ADHD symptoms, like restlessness, lack of focus and sleep problems. A low level of magnesium also makes your child more susceptible to side effects from ADHD medication, like agitation, sleep problems, headaches and facial tics.

That’s why I strongly recommend you supplement your child’s diet with magnesium for at least 30 days before starting a medication. You may find her symptoms come under control. And even if they don’t, the magnesium will boost the effectiveness of the ADHD drug and help shield her from side effects.

#2. DO test for nutritional and biochemical imbalances.

ADHD medication can often cause nutritional deficiencies and biochemical imbalances as an unwanted side effect.

Some of these imbalances cause dopamine excess. And when the child takes a dopamine-boosting medication, his brain is flooded with dopamine, causing side effects like agitation, sleep problems, irritability and aggression.

The specific deficiencies and imbalances that tend to cause side effects are:

• magnesium deficiency
• lithium deficiency
• zinc-copper imbalance
• HPHPA, a metabolic byproduct of an overgrowth in the gut of the Clostridia difficile bacteria
• Food allergies or sensitivities, common in children 10 and younger

Fortunately, tests that can detect these deficiencies and imbalances are available from Great Plains Laboratory and many other labs. Unfortunately, they’re not covered by insurance.

If it’s financially possible, I strongly urge you to have your child tested for these deficiencies and imbalances before she starts any medication. If testing is too expensive, I recommend you supplement your child’s diet with magnesium, lithium, zinc and high-dose probiotics, using the guidelines in the Plus-Minus Plan.

#3. DO use genetic testing to help determine the right medication and dose for your child.

I order a genetic test for every ADHD patient—something almost always covered by insurance. This simple test, requiring nothing more than a swab of saliva from the inside of the cheek, tells me a lot about what kind and dose of medication is most likely to work best.

Specifically, I test to see if the child has either a Val/Val genetic variant (mutation) or a Met/Met variant in the COMT gene, which helps regulate the neurotransmitters dopamine and norepinephrine.

Both variants would point to more effective dosages and types of ADHD medication to take. If you’re considering medication for your child, talk to your doctor about ordering this genetic test. I consider it a must for making an effective treatment decision.

#4. DO start with a low dose, and slowly increase it over two to four weeks. Or decrease it, if there are immediate side effects.

A common prescriptive scenario: a physician starts a child on too high a dose of medication, the child has side effects, and the medication is quickly discontinued. A better scenario: start your child on a low dose of an ADHD medication.

If, after two weeks, the child doesn’t have any side effects but symptoms aren’t under control, increase the dose. If, after four weeks, there are no side effects and no response, increase to the standard dose.

#5. DO consider these effective stimulant medications.

I start many children at the lowest effective dose of a long-acting stimulant. My preference is Concerta, at 18 milligrams (mg) daily, or Vyvanse, at 10 milligrams daily.

Vyvanse comes in a capsule; you can mix the contents in a liquid, making it easier for some kids to take. Another advantage to this approach: you can put the contents in 8 ounces of liquid—and easily cut the dose in half (4 ounces) if the initial dose causes side effects.

#6. DO consider a non-stimulant medication for hyperactivity and impulsivity. 

If your child has hyperactivity-dominant ADHD, consider a non-stimulant medication, like Tenex or Intuniv (guanfacine) or Catapres (clonidine), all of which are FDA-approved for use in ADHD. In my experience, the non-stimulant Strattera (atomoxetine) does not have consistent results, so I don’t prescribe it.

Similar to stimulants, I start with the lowest possible dose and increase every 2 to 4 weeks.

The most common side effect of non-stimulant drugs is drowsiness. On the upside, that makes the drug helpful in ADHD kids who have trouble falling asleep. For children who are severely hyperactive, impulsive and aggressive, a combination of stimulants and non-stimulant Intuniv may be the best treatment.

#7. DO watch out for these common signs of a too-high dose.

If your child has an increase in heartrate or energy, or becomes irritable or anxious, or says her thoughts are racing—symptoms similar to what you would experience if you downed five expressos—it’s very likely the dose is too high.

#8. DO switch medications if there are side effects.

If your child has side effects, switch medications immediately—from one class of medications to another (for example, from an amphetamine like Adderall to a methylphenidate drug like Ritalin), starting the second drug about one week after you stop the first one.

If a child needs medications but has side effects, I always try two to three medications before I give up on medication as a treatment.

Unfortunately, there’s no way to predict in advance which drugs will cause side effects in your child—your friend’s child may have had stomach aches and sleeplessness on Adderall, but your child might be just fine.

#9. DO understand that some emotional “side effects” are the effect of the medication wearing off.

Some long-acting medications “act” for 6 to 8 hours—if you give your child the medication at 8 AM, it may start to wear off around 2 to 4 PM. A typical result: your child might be more emotional and sensitive for 30 minutes or so, crying or getting cranky for no apparent reason.

There are a few ways to deal with this very common but little-recognized problem. 

• You can talk to your doctor about switching to a longer-acting medication.
• You can give a short-acting medication an hour or so before the “withdrawal” period, as long as it doesn’t interfere with your child’s sleep.
• And you can respect your child, understanding that the withdrawal period probably isn’t the best time to ask him to clean up his room or do other challenging tasks.

#10. DO individualize monitoring.

To monitor whether or not a medication (or another ADHD treatment) is working, doctors, child psychiatrists and psychologists frequently use standardized checklists and scales.

Some of these tests can be helpful—particularly comparing a computerized Connors Continuous Performance Test (CPT) with checklists from parents, teacher and the ADHD child.

However, all of these standard forms have a big drawback: they’re standard, the same for everyone. And all ADHD children are not the same. Just the opposite: every ADHD child is unique, with his own unique set of symptoms and struggles.

Instead of standardized checklists, I recommend you personalize your checklist, identifying the symptoms that are the most relevant for your child and your family, and tracking those.

Medications Can Help Your ADHD Child

Please remember one thing, an effective plan to control the symptoms of ADHD has to be a comprehensive plan, taking into account all the factors that might be contributing to your child’s symptoms.

Many parents fear medication will harm their child or won’t work. But with the guidelines like these in my award-winning book, Finally Focused, you can be assured that the ADHD medication your child takes will be safe and effective—reducing symptoms, improving everyday functioning, and opening the doors to a happier, more successful life.

Yours in health,

James M. Greenblatt, MD
Founder, Medical Director, Psychiatry Redefined