Our psychiatrist explained it to us by drawing a graph of blood levels. He showed how the medication dosage raises the blood levels and showed us the peaks and troughs you get with the doses spread out during the day. He then drew a horizontal line through the graph to show the required blood level we had to aim for. Whenever the blood level dropped below that horizontal line, the ADHD behaviour would return.
The thing was, WE could see how there had to be a fairly large initial 'loading' dose to get the blood levels up high enough so we didn't see ADHD behaviours. But then the levels would drop through the morning and regular small doses would be needed to maintain the dose. If the levels were permitted to drop, such as when one or more of these later doses were missed, then the blood levels would drop and the next small dose would still be too low to bring his levels back up to above that line.
So in summary - the first dose or doses in the morning are always a larger loading or priming dose and later smaller doses spread through the day are smaller maintenance amounts. It is all finely calculated to keep the total dose through the day as low as possible (we don't want to give our kids more drugs than we should have to) but still work without risk of the blood levels dropping too low and problem behaviours breaking through.
The wheels fall off when the medication regime is not followed.
We can try to put in failsafes, including printing out dosage timetables, setting all the arrangements in place that we can with whoever has custody of our child during that period, but it all comes down to a need to trust the people who are caring for our child that they will meet their obligations.
What really makes me angry - the attitude too often is one of, "It's not as if it's a serious problem like diabetes or epilepsy."
It shouldn't be any different - this is medication that has been prescribed by a specialist to treat a serious problem. The child suffers as a result, his education suffers, his self-esteem, often safety of the child and others also suffers. Why should we be expected to tolerate this?
When we went through this with difficult child 1 we had a series of problems. First we had union issues when the schoolteachers were all ordered by their union to refuse to medicate all children in the school on the grounds that it's not a teacher's job and it's too easy for things to go wrong. In our state we had no provisions made for school nurses or equivalent. Thankfully husband worked nearby so difficult child 1 had to walk from school to his dad's work to get his medications - three times during the school day. The principal was staunch to the union but sympathetic; her son, difficult child 1's best friend, walked with him. By the time difficult child 1 moved to high school the problem was resolved. I and other parents had been writing lots of letters and looking into the legal problems this was raising, including who was responsible for the damage this could cause. Yes, they were concerned at what could happen if the wrong child got dosed with the wrong medications, but what about the right kid not getting dosed? As I said, what if they failed to medicate a brittle diabetic? An epileptic?
By high school there was a staff member designated and trained for the task, as well as a lot of rules and regs. However, there was still an attitude of "the child has to learn some personal responsibility" and no chasing up of difficult child 1 when he failed to show for medications. Or there would be times he would show up for medications and the staff member would be away from her station (however briefly). If difficult child 1 missed his medications they did not chase him up, with the result that often he was not properly medicated during the day. In vain we complained, threatened, exploded and raged at the school. Finally we bought a very expensive watch for difficult child 1 which had multiple alarms. We set them so he could have an alarm to warn him of each required dose. This worked a lot better but there were still problems - teachers complaining if the alarm went off a few minutes early and interrupted her going over the end of the class, or again difficult child 1 cancelling the alarm while on the way to see the nurse only to find her not there and still not get dosed.
We finally had to solve the problem by getting his medications compounded for sustained release. It was the only way.
I'm still very angry about this issue, because it is part of the culture of "kids shouldn't be medicated for ADHD" because if your child has another more obviously physical health problem, then of course the schools will be supportive and medicate the child. But the schools still behave as if ADHD is a learned behaviour problem and all your child needs is to learn a bit of personal responsibility.
You have two choices:
1) Fight this legally. Point out that the school, in requiring your child legally to be in school, has a fiduciary duty of care to ensure that such needs as medication are dealt with, since they have removed the child form parental custody during the day. Good luck - this is a tricky one and won't win you friends, except form other parents and more enlightened teachers.
2) Find a compounding pharmacist and pay for private compounding of the medications so you can ensure that one dose in the morning will do the job.
It's not fair. You shouldn't have to do this. But your child is more important than fighting a principle.
Marg
