First learn the basics of how medicines work

Stimulant medications for ADD have certain easy-to-recognize features in how they work. If you understand those characteristics, you can adjust medications correctly; if you don’t, it just won’t do it right, and the whole treatment process becomes significantly problematic. Too often, drugs are widely distributed based on an *ADD/ADHD diagnosis* instead of specifically treating the *person* with the ADD/ADHD challenge.

I liken this casual 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 paintbrush and covering the edges, specifically the details. ADD medications require *personal work* at the beginning and at each subsequent medication review. This article discusses the 7 Essential Tips on how to recognize and correct Therapeutic Window Background.

First consider the therapeutic window

The *Therapeutic Window* is just what it says; the window is the space, place in time and symptom correction in which the stimulant drug clinically works best – the exact dose, the expected efficacy 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 the bases are covered correctly and that the drug is working at the maximum expected level of performance.

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

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

1. Obvious Bottom: Medicines [Meds] they have no effect: “Below background” means the meds just aren’t working: no effect, no focus or improvement in attention, no delay in impulsivity or hyperactivity is going crazy, the mind is constantly preoccupied, 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 does it last in the afternoon? If you cannot answer any of these questions, the dose is usually insufficient.
2. Vague Bottom: Drugs 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 from each medication. Vyvanse and Daytrana win the DOE race with 12-14 hours, Adderall XR is next with 10 hours DOE, Concerta and Focalin work 8-10 hours if dialed effectively, Metadate CR and Ritalin LA are right at 8 hours , – rest lasts only part of the day with Adderall IR [Immediate Release Tabs] lasting about 5-6 hours. 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: overfocus in the afternoon and a sharp drop around 1-2 PM. It is important to be completely precise about the DOE’s expectations for each specific medication.
3. Inaccurate bottom: The apparent “bottom” is really the top: It looks like the drugs “don’t work” but are actually too high a dose. Inability to focus, 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 bottom – the goal for the day must be set correctly: medications are not marked for the whole day, but simply to “get 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 sole 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 it’s immediate release [IR – Short Acting ] Medications are the first choice: If RI medications become the first choice for whatever reason, as managed care often does not consider the “adherence 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 fascinating hours early in treatment – PM time is not properly targeted, and if the extended release drug has a DOE of 8 hours, then a short action IR clipping is essential for the night, and essential to accurately dial in the expected IR DOE 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 are not clear objectives regarding the Upper, Lower and Lateral Therapeutic Window from the beginning, medical check-ups become an avalanche of misinformation and guesswork. With stimulant medications, precision is possible, it’s fun, and it needs to be organized from the start. Predictable results can become the rule.

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