The ADHD Medication Stopped Working! How to Troubleshoot Treatment

The 100 billion neurons in your brain are always busy. A single neuron may deliver 12 messages in one-thousandth of a second by using tiny chemical impulses to leap over tinier gaps called synapses. On the other side, another neuron waits to receive the information. The brain chemicals powering the operation are called neurotransmitters — for example, dopamine and norepinephrine. This is where ADHD brains run into trouble.

The ADHD brain makes neurotransmitters just like everybody else’s brain, but often it does not release and reload the chemicals — primarily dopamine — effectively. Some messages do not make the link from one neuron to another, and that’s where attention and impulsivity problems arise. This is the specific problem that ADHD medications solve. Stimulants improve communication between neurons.

Is ADHD Medication Safe and Effective?

Studies show that ADHD medication safely and effectively improves communication between neurons in the ADHD brain. Amphetamine has been around since 1937, and methylphenidate since 1956. There are more research studies done on these types of medicines than on any other medicine you will ever take. A 1998 study by the American Medical Association¹ found that 90 percent of children with attention deficit hyperactivity disorder (ADHD or ADD) responded to at least one stimulant without any significant side effects if the drug is carefully fine-tuned by the clinician.

Most of the work of ADHD prescribers involves adjusting this titration, especially in the early weeks. In the process, we hear the following questions most often from patients:

The ADHD medication isn’t working. What to do?

“I don’t feel any different after taking this medication. Is it working?”

Insufficient symptom coverage points to one of two problems: You’re either taking the wrong class of stimulant or your dose is too low. Either way, weekly visits to your ADHD clinician are essential. At the outset, titration usually means slowly increasing the dosage of a medication, while monitoring to watch for symptom control and for individual sensitivities and side effects.

[Download This: The Ultimate Guide to ADHD Medication]

This is a sensible approach, but it works for only 60 to 70 percent of all patients. Why? The class of stimulant medication they’re taking — either amphetamine or methylphenidate — doesn’t work with their unique body chemistry. Studies show that only 38 percent of patients respond equally well to both stimulant classes; 26 percent do significantly better on methylphenidate; 36 percent do better on amphetamine.

In general, younger or newly diagnosed children do better on methylphenidates, as do those sensitive to stimulants. Usually it’s best to start with a small dose of short-acting methylphenidate to see if it is tolerated, and to gradually increase the dose to find the optimal dose for that individual. After a tolerable dosing range is established, a longer-acting form of methylphenidate, like Ritalin LA, Jornay PM, or Quillivant XR, might be tried.

Adolescents and adults generally do better on amphetamines, like Adderall, Mydayis, or Vyvanse. But there are myriad exceptions, and no one knows right off which class will work best. If an individual is sensitive to medications or to caffeine, perhaps start with a trial of methylphenidate before trying an amphetamine.

[Free Resource: ADHD Medication Tracking Log]

Should ADHD medication change your personality?

“Why does my child seem like a zombie since he started taking medication?” or “Why am I irritable when I’m on medication?”

If your child loses his usual sparkle, lacks spontaneity, and has no sense of humor when his medication is active, that probably means his dosage is too high, or that it’s not the right medication for him.

Likewise, if you or your child experiences irritability throughout the day or feels jittery and on edge — and if these feelings fade at the end of the day — that suggests the dosage is too high. These side effects also appear when a patient is taking the wrong class of stimulant, so clinicians should consider both dosage and class.

The “right” dosage of an ADHD stimulant is not based on a patient’s weight, age, or severity of symptoms. It is a matter of how sensitive your body is to this particular type of medicine and this particular dose. Sometimes that sensitivity remains constant within all methylphenidates or all amphetamines — and sometimes it varies from brand to brand, and from brand name to generic.

How can I adjust the ADHD medication so that it works at the right time of day?

“My child has no appetite during the day and his lunches come home uneaten” or “We struggle through homework and dinnertime because my child’s symptoms come back.”

These are different problems with a common root cause: a stimulant formulation that doesn’t work for your family’s schedule. The length of time it takes for a medication to kick in and its duration vary from one person to another. Careful titration and fine-tuning can avoid or eliminate most side effects and ensure coverage when you or your child need it.

For example, appetite for lunch is often reduced in the early weeks of starting a stimulant. Usually, but not always, that improves after a few days or weeks and is not a big problem. If it remains a problem, a lower dose or shorter-acting morning medicine may be needed. If appetite for dinner is persistently down from a long-acting medication, it may need replacement by a shorter-acting medicine.

If symptoms return in mid- to late afternoon because a longer-acting medication wears off too early, a small “booster dose” of short-acting stimulant may be added in mid-afternoon to provide late afternoon or early evening coverage for homework or extracurricular activities. If a late afternoon “booster” is used, it should be timed carefully to provide the needed coverage without its interfering with dinner or bedtime.

Amphetamines release medication in a variety of ways: Adderall XR, for example, releases half of the capsule’s face value at a time. If you’re taking 10 milligrams of Adderall XR, it’s like getting five milligrams followed by another five milligrams three to five hours later. Mydayis releases medication in three phases, which some patients say results in a relatively steady and even feeling over most of the day. Vyvanse offers a flatter curve, dispersing medication more steadily for six to 12 hours, on average.

Methylphenidates also come in a variety of forms of release: Concerta releases its medication in three stages over 10 to 12 hours. It releases some medicine off the coating immediately. The inside includes a polymer substance that absorbs water inside the gut, then expands and pushes out methylphenidate from a tiny hole (see “Brand Name vs. Generic” below to learn about various versions of Concerta). Daytrana is a transdermal patch worn on the skin that releases medication evenly for about 9 hours. Focalin XR, which is basically Ritalin with one of the isomers removed, lasts about eight hours. (It tends to be twice as potent, milligram for milligram, as regular methylphenidate.) Jornay PM is a new medication taken at night; its thick outer layer delays the release of medication for 10 to 12 hours, so patients should wake up with full symptom control that lasts evenly through the day.

Can anxiety and ADHD be treated at the same time?

“Can I use a stimulant to treat ADHD with coexisting anxiety?”

There is a myth that using a stimulant with a patient with anxiety will always make that person more anxious. A recent review study proved this idea to be false. For most people with anxiety and ADHD, carefully dosed use of a stimulant makes their anxiety symptoms no worse — and may improve them.

If a stimulant does have an adverse effect, you will see anxiety increase quickly, but you may be able to adjust the dose to reduce it. If that does not work, the prescriber may suggest a second medicine, perhaps guanfacine or an SSRI like sertraline or fluoxetine, to reduce the anxiety.

When should I change ADHD medications?

“Should I switch to another med?”

If you’re experiencing side effects, but are still early in the process of adjusting ADHD medications, it does not make sense to change the medicine unless those side effects are uncomfortable and persistent. First ask: “How long has this problem been going on?” Most small side effects go away within days or a few weeks. They can often be dialed down by adjusting the dosage.

Then ask yourself: “Are there benefits to the medicine, along with the side effects, or are there only side effects?” When you first start a medicine, it’s not unusual to say, “Oh, it was wonderful. I felt much better and able to focus.” And then the next day or two, it doesn’t work. Usually, what that means is you’re almost at the right dose, so you bump it up just a bit more.

Sometimes a medicine just stops working. If you have tried slowly increasing the dosage and that doesn’t work, maybe it’s time to switch. You might be able to go back to the original medication if you take a break from it for a month.

What can I do when ADHD medication causes negative side effects?

“Why is my child extremely irritable in the after-school witching hour?” or “Why do I become very anxious as the med wears off?”

If a stimulant has not caused adverse effects during the morning and early afternoon, but the person gets very restless or very irritable or too serious as the medicine is wearing off in mid-afternoon or early evening, it is likely that the medicine is dropping off too fast and the person is “crashing.” Usually such medication “rebound” clears within an hour or two, but it can usually be prevented by prescribing a small dose of the short-acting version of the same medication to be taken shortly before the usual rebound time. That may reduce the long-acting dose at a more gradual rate.

If a stimulant is causing excessive irritability, restlessness or seriousness throughout the day, a dose reduction is probably needed or a change of medication may be required. A person should be able to be his or her usual self while taking these medications.

However, if the person tends to be too restless or irritable even without any medication, a trial of guanfacine, starting with a small carefully adjusted dose, may be helpful. Also, the clinician should consider whether the person has a co-occurring disorder, such as a mood disorder, rather than or in addition to ADHD.

Do ADHD medications affect sleep?

“Why is my child restless at night and not sleeping?”

Many children and adults with ADHD have chronic difficulty falling asleep, even without taking stimulant medication. For those individuals, it may be helpful to start with a small dose of guanfacine administered an hour or two before bedtime, and to consider adding a stimulant once the sleep problem is stabilized.

How can my doctor help me titrate my ADHD medication?

“My doctor is not an ADHD expert. How can I work with him or her to titrate my medication?”

Let the prescriber know what problems you’re seeing, what time of day they occur, and how long they typically last. Did you have a headache only the first two days you were on the new medication, or did it persist? Use a daily log to track symptoms and side effects meticulously.

Also, report the benefits. And don’t assume that all changes in behavior are due to medication. Keep in mind your physical and emotional health as well.

Do ADHD medications cause dependency?

“Is stimulant medication a ‘gateway drug’?”

Substance use disorders are twice as likely in those with ADHD — but only if the individuals are not treated effectively with medication. The relationship between ADHD medication and substance abuse is an inverse one. The substance use risk in a person with ADHD who takes medicine drops down to that of his neurotypical peers. Stimulant treatment does not guarantee that no substance use problem will occur, but, if prescribed correctly, it can substantially reduce that risk.

Treatment of ADHD with medication usually reduces that risk during childhood and adolescence.

How can I time the dosage of my ADHD medications?

“My child can hardly function in the morning; it takes too long for her medication to kick in.”

Patients sometimes need to take a short-acting medication in the afternoon because their long-acting medicine wears off too soon. Others reverse this strategy because the long-acting formulation takes too long to kick in. For example, long-acting Concerta takes up to an hour to kick in; short-acting methylphenidate may begin working within 30 minutes. These could be used in concert, but the exact timing depends on a person’s body chemistry.

Jornay PM, which is taken at night, delays the release of medication for 10 to 12 hours, so that patients can experience full symptom control when they wake up. This medication helps some families avoid the cumbersome strategy of waking up their kids an hour early, administering their medication, then letting them go back to sleep while the medication begins to slowly kick in.

My child is experiencing side effects. How should I handle that?

“My child has developed a facial tic since starting her medication. Did the ADHD medication cause that?”

Motor tics, like blinking the eyes, or oral tics, like clearing the throat, do occur in a small percentage of patients. We can usually fix it by changing to another medication or adding guanfacine. Rarely does a tic mean that a child can’t tolerate a class of medication, or that she can’t tolerate any stimulant.

The Complete ADHD Medication Chart

Compare and contrast popular ADHD medications based on chemical compound, duration, delivery method, and medicine release schedule. For medication details, visit additu.de/review.

Stimulants

Non-Stimulants

Are there delivery options for ADHD medications other than pills?

“My child can’t swallow a pill!”

ADHD medications come as pills, liquids, capsules that may be sprinkled, and transdermal patches worn on the skin.

Medication Delivery Methods

Note: Brand Name Vs. Generic

Many ADHD medications are just as effective in generic form as in the branded version. However, there are exceptions. For example, two of the three generic forms of Concerta were found by the FDA to not be equivalent to the branded Concerta. Currently the Patriot brand is reported to be the most effective generic for Concerta.

Note: This article is not intended to substitute for the expertise of your prescriber. Medication for each individual needs to be carefully selected and adjusted by a licensed prescriber who can consider all relevant characteristics of the patient’s health profile.

Thomas E. Brown, Ph.D., is a clinical psychologist who served on the clinical faculty of the psychiatry department of Yale Medical School for more than 20 years. He is now director of the Brown Clinic for Attention and Related Disorders, in Manhattan Beach, California. His most recent book is Outside the Box: Rethinking ADD/ADHD in Children. You can visit Dr. Brown at his website brownadhdclinic.com.

How to Treat ADHD in Children: Next Questions

1. What ADHD medications are used to treat children?
2. Is ADHD medication right for my child?
3. What are common side effects associated with ADHD medication?
4. What natural treatments help kids with ADHD?
5. What if the medication stops working?
   • How long will it take to get the medication and dosage right?
   • How do we know the medication is working?
   • When is it time to switch medications?
   • What should I do if my child stops taking their medication?
   • How can we solve medication rebound problems?
6. How can I find an ADHD specialist near me?

The Clinicians’ Guide to Treating Complex ADHD from Medscape, MDedge, and ADDitude

• What should I consider when developing a comprehensive treatment plan for ADHD?
• What medications and other approaches should I turn to as first-line treatments for ADHD?
• How can I decide which ADHD medication to prescribe first?
• What challenges and side effects should I anticipate from ADHD medications, and how should I address them?
  • How can combination therapy — using a simulant and a non-stimulant medication — improve symptoms with fewer side effects?
  • Stimulant use is associated with an elevated risk for sleep problems. How can clinicians address this side effect?
  • How can clinicians improve medication adherence in children with ADHD?
  • When should a patient switch to a different medication and/or dosage?
  • How can clinicians improve medication adherence in adults and adolescents with ADHD?
  • Free Webinar: How to Optimize ADHD Medication: Strategies for Achieving Better Symptom Management
  • Free Webinar: Why Adults with ADHD Abandon Medication — and How to Improve Treatment Outcomes
  • Free Webinar: How to Optimize Stimulant Treatment for Children and Adults
• How can I improve treatment outcomes for patients with ADHD and comorbid diagnoses?
• What dietary, behavioral, or other complementary interventions should I recommend to patients with ADHD?
• How should I follow up with patients with ADHD, and what should we discuss during these checkups?

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