First Learn the Basics of How Medications Work

Stimulant medications for ADD have certain easy-to-recognize features regarding how they are working. If you understand those features you can adjust medications correctly; if you don't, you simply won't get them right, - and the entire treatment process becomes significantly problematic. So often medications are broadly scattered upon an *ADD/ADHD diagnosis* rather than specifically treating the *person* with the ADD/ADHD challenge.

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

First Consider the Therapeutic Window

The *Therapeutic Window* is simply what it says; the window, is the space, the place in time and symptom correction that the stimulant medication clinically works best, - the exact dosage, the expected effectiveness of that specific product with that specific person. All products have characteristic features, they metabolize, they burn, at different rates of speed in different people. The way we evaluate that window is by recognizing the top, the bottom and the sides. We work to make sure all the bases are covered correctly and the medication is working at it's maximum level of expected performance.

A key point of observation with the Bottom of the Therapeutic Window: the medication is an insufficient dosage. The top is too much, the bottom is not enough.

7 Tips on Finding the Bottom of the Therapeutic Window: So, what does the bottom look like?

1. Obvious Bottom: Medications [Meds] have No Effect: "Below the bottom" the means the medications simply are not working: No effect, no focus or attentional improvement, no delay in impulsivity, or hyperactivity is running wild, the mind is constantly worrying, the avoidance and procrastination with projects remains clearly intact. Inadequate can be measured by both the end and beginning of the day. Is there an AM onset, how long does it last in the PM? If you can't answer either of these questions, then the dose is, most often, insufficient.
2. Imprecise Bottom: The Meds Don't Work Long Enough: The Duration of Effectiveness [DOE] is not adequate: All stimulant medications have an expected, less than 24 hr duration. Dialing in the specific duration is essential to get the best out of each med. Vyvanse and Daytrana win the DOE race with 12-14 hr, Adderall XR is next with 10 hr DOE, Concerta and Focalin both run 8-10 hr if dialed in effectively, Metadate CR and Ritalin LA are both right at 8 hr, - the rest last only a portion of the day with Adderall IR [Immediate Release Tabs] lasting about 5-6 hr. Ritalin IR is 4 hour max duration. None of the IR- Short Acting doses last past noon without significant side effects such as: overfocused in the PM and a hard drop around 1-2PM. It's important to be completely precise on the DOE expectation of each specific medication.
3. Inaccurate Bottom: The Apparent "Bottom" is Really the Top: The meds look like 'they aren't working,' but are actually too high in dosage. The inability to focus, the hyperactivity and the impulsivity are caused by too much meds, not insufficient meds. How to tell the difference? This will be another article but for now think: emotional dysregulation: Mad, Sad, Irritable, Disrespectful, or Stoned.
4. Insufficient Bottom: The Target for The Day Must Be Set Correctly: The meds aren't dialed in for the Entire Day, but rather to just "get through work or school." This problem has been with us since much before the 1960s - is paleolithic - and simply does not address the 'bewitching hours' of 4-8 PM. New meds can cover the entire day, school and work alone are no longer the only objectives. Family life, the evening and overall cognitive management throughout the day have become important treatment objectives with the new medication alternatives.
5. The Cycling Bottom with IR: The IR Bottom - If Immediate Release [IR - Short Acting ] Meds are First Choice: If IR meds become first choice for whatever reasons - as managed care often does not consider the 'objective of compliance' important to support [in spite of multiple references in the literature], the Bottom is often overlooked with the focus on economics. If IR meds become an absolutely necessary choice, then responsible regular use through the day to prevent the inevitable cycles of up and down, becomes an essential objective - even if you have ADD.
6. Overlooking A Fixable Bottom - Neglecting the PM Bottom Target: Do Specifically Target the Bewitching Hours at the Outset of Treatment: The PM time is not targeted adequately, and if the extended release medication has a DOE of 8 hr, then a trim of short acting IR is essential for the evening, and essential to dial in precisely for the expected IR DOE in the evening. Just because it is the evening time doesn't mean the day is over.
7. Uneducated Client Fog: The Client Can't See the Bottom or is Not Actively Engaged in the Bottom Search Process: If the ADD client is not engaged in the process, if the conversation is just with parents, if the discussions don't set clear objectives regarding the Top, Bottom and Sides Therapeutic Window right from the outset, the med checks become a suffusion of misinformation and guesses. With stimulant medications precision is possible, is fun, and should be arranged from the outset. Predictable outcomes can become the rule.

The window concept does provide a different, more specific way of adjusting stimulant medications that makes the whole process more 'illuminating.'

"Bottom Line" By following simple guidelines and the metaphor of the 'Therapeutic Window' you will be more able to adjust dosing correctly, and effectively - so you and yours don't feel like treatment failures. I invite you to sign up now for the early bird special set of gifts for my new book "Fixing the ADD Madness: A Patient's Guide to Stimulant Medication Details," over at - And enjoy the bonus gift on the thank you page for signing up early -- simply to express your interest in the book: a 1200 word article on The 10 Biggest Problems With ADD/ADHD Medications, and a 17 min audio review of the article. At CorePsychBlog you can also sign up to keep posted on upcoming ADD/ADHD teleseminars and other training opportunities to further understand ADD medication challenges.

Author's Bio: 

Child, Adolescent and Adult Psychiatrist, Psychopharmacologist, Systems Medicine Specialist, SPECT Brain Imaging Specialist, Certified by the Nuclear Regulatory Commission.