• There is substance abuse. In addition to the potential problem of abuse of the stimulants described previously, other substances such as cannabis can sabotage the benefits of medications.
• There is over-reliance on medications as the sole modality of treatment. ADHD is best treated using a wide range of strategies. Nonpharmacological interventions such as exercise, good nutrition and sleep, parent behavioral training, organizational help, regular reading, screen time reduction, and school supports are critical components of a comprehensive treatment approach.
• There is parental psychopathology. In our opinion, this area is one of the most frequently neglected aspects of child mental health treatment and can have huge implications. ADHD in particular is known to have very high heritability (similar to height). If a mother or father shares the condition, their struggles can frequently contribute to an environment that can exacerbate the child’s symptoms. A pattern in which the ADHD symptoms are more prominent at home compared with school is one clue to look in this direction. When addressing parental psychopathology, it can be important not to come off as blaming the parents for their child’s problems, but rather to convey how challenging dealing with ADHD can be as a parent and how they need to be functioning at their highest mental level as well.
Of course, sometimes the medication truly is not working, and it is time to try something else.
Dr. David C. Rettew is associate professor of psychiatry and pediatrics, director of the child and adolescent psychiatry fellowship, and director of the pediatric psychiatry clinic at the University of Vermont, Burlington.