ADD-ADHD Treatment: 7 Essential Tips for Finding the Challenging Bottom of the Therapeutic Window

First learn the basics of how medications work

ADD stimulant medications have certain easily recognized characteristics regarding how they work. If you understand those characteristics, you can adjust the medications correctly; if you don’t, you simply won’t do it right, and the entire treatment process becomes significantly problematic. Too often, medications are widely distributed based on an *ADD/ADHD diagnosis* rather than specifically treating the *person* with the ADD/ADHD challenge.

I liken this haphazard process of medication adjustment to stepping back and throwing a bucket of paint at a barn door that needs painting, rather than taking a fine brush and covering the edges, specifically the details. With ADD drugs a *custom job* is required at the beginning and at each subsequent drug review. This article discusses the 7 Essential Tips on how to recognize and correct the Therapeutic Window Bottom.

First consider the therapeutic window

The *Therapeutic Window* is just what it says on the tin; the window is the space, the place in time and the correction of symptoms in which the stimulant medication clinically works best, – the exact dose, the expected effectiveness of that specific product with that specific person. All products have characteristic features, they are metabolized, burned, at different rates in different people. The way we evaluate that window is by recognizing the top, the bottom, and the sides. We work to make sure that all bases are covered correctly and that the drug is working at the maximum expected level of performance.

One key point of observation with the Therapeutic Window Fund: the drug is an underdose. The top is too much, the bottom is not enough.

7 tips for finding the bottom of the therapeutic window: So what does the bottom look like?

1. Obvious Bottom: Medications [Meds] They have no effect: “Below background” means that the drugs are simply not working: no effect, no focus or improvement in attention, no delayed impulsivity or hyperactivity is going crazy, the mind is constantly worried, avoidance and procrastination with projects remains clearly intact. Inadequate can be measured both at the end and at the beginning of the day. Is there an AM start, how long is it in the afternoon? If you cannot answer any of these questions, the dose is usually insufficient.
2. Sketchy Bottom: Medications Not Working Enough: Duration of Efficacy [DOE] not suitable: All stimulant medications have an expected duration of less than 24 hours. Marking the specific duration is essential to get the best out of each medication. Vyvanse and Daytrana win the DOE race at 12-14 hours, Adderall XR is next at 10 hours DOE, Concerta and Focalin run 8-10 hours if dialed in effectively, Metadate CR and Ritalin LA right at 8 hours , – the break lasts only part of the day with Adderall IR [Immediate Release Tabs] lasting about 5-6 hrs. Ritalin IR has a maximum duration of 4 hours. None of the short acting doses of IR last past noon without significant side effects, such as: superfocus in the afternoon and a hard crash around 1-2 PM. It is important to be completely accurate about the DOE’s expectations for each specific drug.
3. Inaccurate bottom: The apparent “bottom” is really the top: the drugs appear to “don’t work” but are actually dosed too high. The inability to concentrate, hyperactivity, and impulsivity are caused by too much medication, not not enough medication. How to tell the difference? This will be another article, but for now think: emotional dysregulation: angry, sad, irritable, disrespectful, or high.
4. Insufficient fund – the goal for the day must be set correctly: drugs are not marked for the whole day, but simply “to go through work or school.” This problem has been with us since long before the 1960s, it’s Paleolithic, and it just doesn’t address the ‘fascinating hours’ of 4-8 pm New drugs can cover the whole day, school and work are no longer the same. only objectives. Family life, nighttime, and general cognitive management throughout the day have become important treatment targets with new medication alternatives.
5. The Cycling Bottom with IR: The IR Bottom – If immediate release [IR – Short Acting ] Medications First Choice – If RI medications become first choice for whatever reason, as managed care often does not consider the “compliance goal” important to support [in spite of multiple references in the literature], the fund is often overlooked with the focus on the economy. If IR medications become an absolutely necessary option, then responsible regular use throughout the day to avoid the inevitable cycles of ups and downs becomes an essential goal, even if you have ADD.
6. Missing a fixable background – Neglecting the PM background target: Specifically target spell hours at the beginning of treatment: PM time is not targeted properly, and if the extended-release drug has a DOE of 8 hours, then a short-acting IR trim is essential for nighttime, and essential to accurately dial in the expected DOE IR at night. Just because it’s evening time doesn’t mean the day is over.
7. Uneducated client haze: Client cannot see the background or is not actively involved in the background search process: if the ADD client is not involved in the process, if the conversation is only with the parents, if the discussions remain unclear objectives regarding the Upper, Lower and Lateral Therapeutic Window from the start, medical checkups become an avalanche of misinformation and guesswork. With stimulant medicines precision is possible, it’s fun, and you need to be organized from the start. Predictable results can become the rule.

The window concept provides a different and more specific way of adjusting stimulant medications that makes the whole process more “insightful”.