When a child starts taking psychoactive medication, success depends on several things. Obviously, it matters whether the treatment fits the symptoms. Do the problems he’s having respond to this kind of medication? Not as obvious, but just as important, is whether he’s getting the right dose.
The reason dosage is so important is that different kids can respond very differently to the same medication—even if they’re about the same age and weight, and have about the same symptoms. There’s no such thing as a standard or typical dose—there’s only a range of doses that have been shown to be effective for different children. And the range is surprisingly wide.
That’s why starting with a dose that’s right down the middle of the range isn’t a good idea. Even to two apparently similar kids, it’s likely to be too little to be effective for one, and way too much for the other. This can be frustrating to families. One kid might quit taking the medication because it doesn’t seem to work, and the other because it produces unpleasant side effects. They might blame the medication, but in both cases, the problem could be that they’re taking the wrong dose.
How do you know if the clinician treating your child is doing a good job figuring out the best dose for him? Here we’ll explain how doctors work with kids, and their parents, to arrive at the right amount of medication.
How to find the right medication dosage
The best approach to finding the right dose is starting at the low end of the recommended range and increasing in small increments at about weekly intervals, until an effective level is reached. The child’s response is monitored at each step. This process, called titration, takes weeks, or even months.
“My rule of thumb is that I start low and go slow,” explains Dr. Allison Baker, a child and adolescent psychiatrist. “Sometimes there’s pressure from the school or a parent to speed things up, but it’s important not to rush out of anxiety to get results.”
Some medications have side effects that kick in only at the beginning of treatment, and they’re harder to tolerate if the dose is pushed too quickly. For instance, the antidepressants called SSRIs can cause agitation at first, as the body and the brain adjust to the effects of the medication. A doctor can minimize these “treatment emergent” side effects by introducing the medication very gradually. “You don’t want the patient to say, forget it, this is making me more anxious,” says Dr. Baker, “and swear off this kind of medication before it’s had a chance to help.”
Parents’ role in the process
When a doctor is prescribing medication, parents should expect a clear explanation of the treatment options, and why one option is being recommended.
“I talk to parents broadly about the choices we have—different classes and types of medications we might use—and why the medication I’m suggesting is my first choice,” explains Dr. Ron Steingard, a child and adolescent psychiatrist at the Child Mind Institute.
Dr. Steingard emphasizes the wide variation in the way kids respond to any given medication, and explains that parents will be his partners in not only administering medication but arriving at the right dose for their child. At each step the observations from parents, the child, and sometimes the teacher will determine what comes next.
As Dr. Baker puts it, parents are essentially collecting data that the doctor will use to find the optimal dose. “That communication is crucial,” she adds, because “sometimes even a minor adjustment can be a game-changer.”
How long it takes to arrive at the best dose for your child depends on the class of medication that’s been prescribed. We’ll take a look at several classes, and what the process might be like for each.
Stimulant medications for ADHD (Ritalin, Adderall, etc.) are immediate-acting drugs. They don’t need to build up in the body to have an effect, so you see what you’re going to get from a given dose on Day 1. But it takes at least a few days to get a consistent reading of the response.
“We need to guard against the placebo effect, ” notes Dr. Steingard, “and other factors that could affect a child’s experience. Everybody has good days and bad days. Everybody gets a headache or a stomachache now and then—not everything that happens is an effect of medication. But if the response is persistent, we can attribute it to the medication.”
Dr. Steingard likes to introduce ADHD medication, and changes in doses, on Saturdays, so parents will have two days to observe their kids before sending them to school on Monday. That way they don’t have to worry that something unexpected or problematic might happen when they’re not around, as the new medication or higher dose kicks in.
While the medication dosage is being introduced, Dr. Steingard has both parents and teachers fill out a checklist about the child’s behavior every day. “I get the parents’ observations on the weekend, which I value highly, and then one to two days of feedback from the teacher,” he explains. “Then we get back in touch at the end of the week and make the next dose adjustment.”
Doctors may use different timetables for titration, but the principle is the same: there will be at least several days of reporting on the child’s response before increasing the dose.
There’s no way to predict where a given child will fall in the range of doses that are effective for ADHD meds. “For instance, one child might feel awake, alert and productive at 5mg, and at 10mg he might feel his heart’s beating a little too quickly, like he’s had too much caffeine,” Dr. Baker explains. “Then I know that for him, 5mg is the sweet spot. But another child might feel nothing on 5mg, nothing at 10, and then at 15, he tells me, ‘Oh, now I see what you doctors were talking about.’ ”
SSRIs (Zoloft, Prozac, Lexapro, etc.) are thought to work by increasing the level of the neurotransmitter serotonin in the brain. Getting to the right dose of an SSRI takes much longer than ADHD meds because they have to build up in the brain to reach an effective level. Dr. Baker estimates that it takes 4 to 8 weeks, increasing the dose once a week.
Several days after each dose increase she schedules a check-in, by email or phone, to get feedback. “If the patient says ‘I’m really anxious’ or ‘I can’t sleep,’ I might adjust the dose right away. I don’t want the kid to have two weeks of misery until the next appointment.”
Dr. Steingard notes that while it takes a month to two months on an SSRI to get to a full response for depression, anxiety seems to respond more quickly. “We can often see the beginning of a response to anxiety in the first week or two.” One of the challenges of SSRIs, he adds, is that it takes so long to get to the therapeutic dose range that patients, and their families, may lose patience and judge the medication, prematurely, as a failure.
A group of medications called atypical, or second-generation antipsychotics (Risperdal, Abilify, etc.) are primarily used to treat psychosis in schizophrenia and bipolar disorder. But they are also commonly used to reduce extreme agitation and aggression in kids, whether it’s associated with a disruptive behavior disorder or a developmental disorder like autism. When children with autism take these medications, for instance, it isn’t to treat the autism, but to help with behavior that’s dangerous to themselves or others around them.
Because the antipsychotics have concerning side effects—weight gain, among other things—a prescribing doctor will want to start with the medication with the fewest side effects. But not all kids respond to all antipsychotics. Somewhere between a half and three quarters of kids will respond to a particular medication.
While it takes weeks for these medications to become effective in reducing the symptoms of psychosis, and months for the full benefit to kick in, they do have the immediate effect of decreasing agitation and minimizing anxiety, Dr. Steingard explains, so they are sometimes used on an as-needed basis.
Antipsychotics, too, should be introduced slowly, to minimize side effects. Each dose should be tried for one to two weeks before an increase. Building up an effective dose may take two to six weeks, depending on the choice of medication.
This class of drugs is used to treat bipolar disorder, which includes both manic and depressive episodes. Included in this class are lithium, the oldest medication used as a mood stabilizer, and another group called antiseizure medications (Lamictal, Depakote, etc.). Treating bipolar disorder is complicated because there are two goals: The first is to reduce the symptoms of mania while they are happening. The second is preventative: to diminish the frequency of manic episodes.
Because mood stabilizers are often not effective enough, alone, to manage severe, acute mania, antipsychotics are often prescribed alongside a mood stabilizer.
A child or adolescent with bipolar disorder is usually started on a mood stabilizer first, and that is introduced slowly, with the time it takes to reach the full benefit depending on the medication. In some cases, checking blood levels of the medication can be used to help guide treatment.
If a second medication is added to the mix, it should be done gradually as well.
Kids with anxiety who don’t respond adequately to the SSRIs and behavioral treatment may be prescribed other anti-anxiety medications called benzodiazepines (Ativan, Klonopin, etc.). For a child who is acutely anxious and unable to sleep, these medications can be introduced at the outset, along with an SSRI, and they may also be used on an as-needed basis for crippling anxiety like panic attacks.
Because they can sedate the child, Dr. Steingard notes, they should be used very cautiously. Titration should involve starting low, going slow.
Consider the whole child
Before any trial of medication, it’s especially important to recognize that many factors influence a child’s behavior, Dr. Steingard advises. Understanding what’s driving the behavior and making other changes that might have a positive effect are as important as pulling out the prescription pad.
Addressing other factors in a child’s life that could be generating problems means looking at stability and structure in the family, support in school, issues with peer relationships. “If a child has a learning disability, and is struggling in school, that can lead to avoidant behavior, and melting down in situations where he can’t do the work,” Dr. Steingard adds. “If you’re going to practice psychopharmacology, you need to think about the whole person, not just the symptoms in front of you.”