Question:

My daughter is 11 years old and has been on various adhd medications for the past five years. She currently is taking 72mg of Concerta and suffers from ADHD, inattentive type. We have been told that some children build a tolerance to this type of medication and it no longer works, it is her doctor's concern that she is one of those kids. She is a bright, intelligent child, and does well in school as long as her attention span is stable. What options do we have if she builds a tolerance to this medication?

Thanks, Anne

Dear Anne,

This is an excellent and interesting question. My answer will probably surprise you and your daughter’s physician. I should first, for that reason, tell you that I was a part of the treatment phase of a very large multidisciplinary study on the treatment of Attention Deficit Disorder. Several of my close friends are child psychiatrists who are considered national experts on the treatment of Attention Deficit Disorder. I checked with one of them before writing this response to make sure that my answer was consistent with the latest research and thinking on the use of medications in treating Attention Deficit Disorder.

The idea of “tolerance” to stimulant medication in treatment of Attention Deficit Disorders is not generally felt to be valid. There is no evidence that, if prescribed properly with adequate dosage and clear response to begin with that the medication positive effect will “wear off” after a period of usage.

That being said, there is a “placebo” response to all medication and that can wear off over a time. The only way that one can know for sure that symptoms are responding specifically to the medication is to do a blind study with child, parent and teacher not aware of the treatment being placebo or active medication. All involved would report on their observations without being aware of a child taking the active medication or not. Stimulants particularly lend themselves to this type of observation since they wear off relatively quickly and there is little or no harm in taking them one day and not the next. The study that I participated in did such a study to determine most appropriate dosage for each child treated with medication during the study.

The “placebo effect” is real and benefits a surprising number of individuals and symptoms. It may be the reason that it appears that medication effects are wearing off for your daughter.

The second very complicated part of your question is concerning the whole diagnosis of Attention Deficit Disorder, primarily inattentive type. The diagnosis of Attention Deficit Disorder of any type is made by checking intensity of symptoms. With hyperactivity and attending difficulties and impulsivity, particularly starting early in life, the diagnosis is a little easier to make. However, when one looks at symptoms of inattentiveness, there is mainly one basic symptom that one evaluates.

Unfortunately, too often number of problems can cause a child to be inattentive and these factors are not considered. A few of these that are prevalent are anxiety, depression or learning difficulties that cause a child to have trouble understanding what is expected of them or have difficulties with an academic task. Many of us have difficulties attending to things that we do not understand or that are very difficult for us. It is particularly important that these other causes of difficulty attending be explored, particularly in an individual with primarily inattentive types of attending disorder. These other causes usually are approached and treated differently than a primary attending disorder.

I hope that this answer will clarify your daughter’s situation. There are many different medications for attention difficulties as well as for anxiety and depression.

I would be glad to answer any new questions that this response might generate.

Kay S. Browne MD