A conversation about ADHD

Listen in as I talk about ADHD. I even throw in several stories from my own experiences in parenting a child with ADHD.

I was recently interviewed about parenting a child with ADHD. I encourage parents of kids with ADHD to listen.

As a pediatrician I have the benefit of seeing many families affected by ADHD, and that has helped me to be a better parent. It has also given me support when things don’t go well because I know I’m not alone.

If you’re feeling frustrated with parenting, especially when it’s related to those issues common to kids with ADHD, I encourage you to listen.

I hope that you will feel like you’re not in this alone. 

Topics discussed:

  • What is ADHD?
  • How is ADHD diagnosed?
  • Co-existing conditions
  • Things that are mistaken as ADHD
  • Ways to manage symptoms other than medicine
  • How symptoms of ADHD change over time
  • And more!

Listen:

For More Information:

Developmental Age in ADHD

Supplements for ADHD

Medications for ADHD: Starting out and titrating

Remembering Medications

Medications: Types and side effects

Alternative Treatments for ADHD

Genetics of ADHD

What does brain imaging tell us about ADHD?

Brain function 101: Why medicines help ADHD

Developmental Age in ADHD

I’ve been asked what the single best parenting tip I’ve gotten as the parent of a child with ADHD is. After a lot of consideration, I’ve decided that it involves setting expectations. When we re-frame things that are appropriate for their developmental age, it alleviates so many fights and frustrations. These expectations can vary if they’re on medication at the time, how much sleep they’ve had, and more.

What is developmental age?

Kids with ADHD have a delay in brain development that affects the ways they organize, process, and act upon information.

Chronologic age

We typically measure a child’s age by how long it’s been since they were born. This is their chronologic age.

We assume that kids will be able to understand more complex ideas and master new tasks as they get older. There are certain milestones that are associated with various ages, such as a social smile by 2 months or walking by 15 months of age.

Developmental age

Your pediatrician will ask developmental questions at routine well visits to be sure your baby is on track.

These questions help us to identify if your child is developing at a normal rate or if there is a delay. At some ages there are specific standardized developmental screening tools to be administered.

As long as a child meets expectations, their developmental age and chronological age match. If they are delayed, we can give a developmental age to help identify their stage of development.

We know that ADHD is one cause of delay of areas of the brain that are important in executive functioning. At this time there are no standard screening tool recommended at all well visits to assess this development. It is important to bring up any concerns from home or school with your physician.

What are executive functioning skills?

Executive functions are the things we use to help us use and act upon information.

Understood is a great resource for many things related to learning, attention, and behavior. They have a great page about what executive functioning problems look like at different ages – from preschool to high school.

But my child’s smart, not delayed!

Being delayed in executive functioning areas of the brain is not the same as being academically delayed or having a low IQ. Parts of our brains grow at different rates.

Even your child that excels in certain areas can be delayed in others.

A child who can do math several grades ahead of classmates might not be able to remember something as simple as turning the homework in the next day.

Another child who reads grade levels ahead might not be able understand why a certain behavior is considered undesirable.

A child who is gifted in the arts can struggle significantly remembering all the things that must happen to get ready to leave the house in the morning on time.

It’s easy to get angry at kids for having missing assignments, when they forget to brush their teeth, or when they’re always running late. It can be difficult to help kids understand why they cannot blurt out answers or tell others what to do or how to do it.

Negative feedback leads to increasing problems

Unfortunately, kids with ADHD often hear negative feedback when they fail to do what’s expected, which can lead to rejection sensitivity.

Kids often develop unproductive ways to buffer the negativity that follows their failures. They can act out, become the “class clown,” decide to stop trying because of the fear of failure, and more.

It is now recognized that kids with ADHD have a delay in brain development that affects the ways they organize, process, and act upon information. #executivefunction #adhd #adhdkcteen

Setting expectations

I’m asked all the time how to set expectations with kids, especially those with ADHD.

It’s understandably difficult to parent when your child, who otherwise looks and acts like kids of the same age, doesn’t have the same abilities in areas of focus, organizing, prioritizing, completing tasks, and self care issues.

Visible differences are easy to spot

When kids look different due to a genetic or physical condition, it’s easy to see what accommodations are needed.

If a child has an obvious trait that makes it difficult to do a task, we modify our expectations. A wheelchair bound child would never be expected to run upstairs to grab something.

Invisible differences still exist

For those who look “normal” but are neurodevelopmentally different, it’s easy to fall into the trap of setting an expectation based on the typical expectation for their age, not their level of development.

A child who has problems with working memory might also struggle to run upstairs to grab something. It’s not a form of defiance when they go upstairs and forget what they’re supposed to be getting or when they don’t return because they get distracted by something else.

Many kids are simply not there yet.

They can’t act their age because that part of their brain is not at that stage.

Most will get there, but it takes them longer.

Set appropriate expectations, and when they struggle, show patience and help them learn. This is much more effective than setting the bar too high, resulting in punishments and anger.

Delays of executive functioning

Dr. Richard Barkley has shown that kids tend to develop executive functioning skills about 30% slower than neurotypical peers. This adds up to about 3-5 years at most ages.

This might mean that your 12 year old might struggle doing what another 12 year old has already mastered. They might only be able to handle things expected of an 8 year old.

Set expectations according to skills, not age

The single tip that helps de-stress parenting more than any other that I’ve heard is to adjust expectations by skill.

Chronologic age is less important when deciding what a child is capable of and what they’re ready to learn.

this doesn’t mean letting them get by with anything…

As a child grows, you will watch their successes and failures.

You learn what they can and cannot handle. Help them with the things they cannot do while letting them do as much as they can.

SEt expectations and supports

One child can be expected to get dressed and brush teeth without reminders.

Another child of the same age will need a chart listing all the routine things that need to be done.

And yet another child of the same age may need reminders to look at the chart.

All of these same age kids can be smart and have good intentions, but they need different levels of reminders.

Recommended Video

I recommend this video to parents often. It shows very clearly what it means to parent a child who is delayed in executive functioning. Parents of kids with ADHD will most likely identify with it.

Pharmacogenetic Testing: Personalized Medicine

Pharmacogenetic testing involves testing a person’s genetics to find out how a certain drug would work in that person. Learn the pros and cons of this testing.

I’ve recently seen increasing numbers of parents who want testing to decide which medication to use for their child’s condition before trying any medicines. Many admit that they don’t know much about it and want to learn more. Pharmacogenetic testing involves testing a person’s genetics to find out how a certain drug would work in that person. While that sounds like it would be fantastic to know, it has many limitations. We’ll talk about the pros and cons below.

Traditional dosing of medicines

Before they can be approved to be used, drugs are tested in large groups of people.

Dosing schedules are determined based on safety and efficacy of the medicine, but this is in a group. It relies on information gathered from a mass of people, and majority rules. This means that whatever works for most people is what becomes the recommendations.

Although this works for most people, any individual can have a variation that is not seen with the large numbers in a group. We all know people that can’t tolerate certain medicines. In the past we use family patterns to help predict tolerability. If a family member (or especially if multiple family members) report that certain medicines require lower or higher doses to be tolerated and effective, then we use that in our decision making for prescribing medicines. Of course it isn’t a perfect way to do things, but it can help.

What is pharmacogenetic testing?

Pharmacogenomics is the study of how genes affect a person’s response to drugs. It’s a growing field that involves using what we know about the person’s genetic make up and how they will metabolize a medication. This can allow the prescriber to use certain medicines and not others, or begin with overall higher or lower doses than standard recommendations suggest.

It is personalized to a person’s genetic makeup, so it’s often called personalized medicine or precision medicine.

Many medicines work well for most people, but there are people who will metabolize certain things slowly, allowing the medicine to build up to toxic levels when dosed per standard amounts. Other people may require higher doses due to a very rapid metabolism. Some people should avoid certain medications all together. Knowing these dose adjustments and risks before even starting a medicine could be very beneficial!

Certain proteins affect how drugs work. Pharmacogenetic testing looks at differences in genes for these proteins. These proteins include liver enzymes that chemically change drugs. These changes can make the drugs more or less active. Even small differences in the genes for these liver enzymes can have a significant impact on a drug’s safety or effectiveness.

What are some uses in general pediatrics?

I’m limiting this discussion to uses that a general physician would use this type of testing. There are other uses for chronic diseases that are managed by specialists and beyond my scope.

Please realize that these are the commonly requested uses, not recommended uses.

ADHD

The most common time that I’m asked about this type of testing is for kids with ADHD.

Many parents are afraid of side effects of stimulants and have heard of other children who needed many adjustments of medication, both type of drug and dosing.

Starting a new stimulant medication can be frustrating, especially if it takes weeks or months to find what works. Parents would like to avoid that and start with the best.

Unfortunately the tests currently available do not predict which medicine will be most effective. They test how it will be metabolized.

Many people who show best tolerability for a certain drug may find that drug ineffective in managing their symptoms. This is due to many factors, but in the end still leaves us with the need to do a trial of various medicines to find the best one.

Failure to find a beneficial medicine based on these trials may lead to reassessment to be sure the diagnosis is correct. Proper diagnosis is not tested with the pharmocogenetic tests.

Anxiety and depression

Anxiety and depression medications are another type of medicine that has many options, and some respond to one better than another.

The traditional way to start is to look at family history (which is also a study of genetics, although included in the cost of your visit and doesn’t include a lab). Unfortunately, many people do not know of family member’s specific health details, especially what medicines they were on and what their reactions were.

When we pick a medicine, we start with low doses, and increase as tolerated and needed. If the first medication doesn’t work or isn’t tolerated, it is stopped and another is tried. This can prolong the time it takes to feel better, which is significant, and likely the reason people want a quick answer with a lab test.

Unfortunately, much like the ADHD testing mentioned above, the tests don’t predict which medicine will manage symptoms best. They only predict how they will be metabolized.

Should you get tested?

I am excited for the future of personalized medicine.

We may no longer need to try multiple medicines to be able to see which are better tolerated. Starting near the target dose, rather than starting at a low dose and titrating up, which prolongs the time it takes to get to an effective dose, would be welcomed in many people.

Unfortunately, I think psychopharmalogical testing is not yet for prime time.

The FDA agrees. They’ve sent out warnings that these tests should not be used to help choose a medicine.

Just because your body will metabolize a medicine more slowly or rapidly doesn’t predict if it will be effective to treat your symptoms.

It is still very costly and insurance companies resist paying for it. With high deductible plans, many people must pay the cost. With the new FDA warning, it is unlikely that insurance companies will cover the cost of these tests anytime soon.

It is being widely used in cancer and HIV patients and has helped to prevent significant side effects that often lead to hospitalization. From an insurance company standpoint, they’re saving money by covering the test for these purposes. From a patient standpoint, they have added security that they will respond well to the treatment.

For more:

Pharmacogenomics and Personalized Medicine By: Jill U. Adams, Ph.D. (Freelance science writer in Albany, NY) © 2008 Nature Education Citation: Adams, J. (2008) Pharmacogenomics and personalized medicine. Nature Education1(1):194

ADHD Medicines: Starting out and titrating

Can pharmacogenetic testing save time and money when choosing a new medicine? Personalized medicine is exciting, but is it ready for prime time?

Addendum: 10/3/19

The New AAP ADHD Guidelines were released this week.

Pediatrics October 2019, VOLUME 144 / ISSUE 4 From the American Academy of Pediatrics Clinical Practice Guideline

Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents

Mark L. Wolraich, Joseph F. Hagan Jr, Carla Allan, Eugenia Chan, Dale Davison, Marian Earls, Steven W. Evans, Susan K. Flinn, Tanya Froehlich, Jennifer Frost, Joseph R. Holbrook, Christoph Ulrich Lehmann, Herschel Robert Lessin, Kymika Okechukwu, Karen L. Pierce, Jonathan D. Winner, William Zurhellen, SUBCOMMITTEE ON CHILDREN AND ADOLESCENTS WITH ATTENTION-DEFICIT/HYPERACTIVE DISORDER                      

The authors specifically state that this testing is NOT recommended.

The available scientific literature does not provide sufficient evidence to recommend genetic testing for ADHD medication management. @pediatricskc

Developing Responsibility and Resiliency in Our Children

Our goal as parents is to have our kids grow up with responsibility and resiliency so they can leave our home. How can we accomplish that?

As the years go by, I have seen very bright kids struggle with life and average intelligence kids thrive. I often think about how parents could help their kids grow into independent adults or hinder that growth by trying to be a good parent. Good intentions aren’t always the best way to do things, and sometimes the best parents sit back and let kids figure it out themselves. In the end, our goal as parents is to have our kids grow up with responsibility and resiliency so they can leave our home. Our desire to keep kids safe can seem to conflict with the need to let them grow up.

Is it safe?

So often parents attempt to keep their kids safe in the moment, but don’t consider what long the term implications are.

Parents want to keep their kids safe under their wings, at home or in a supervised activity. If their child is not directly in sight, they are at least within reach of a cell phone for immediate access.

Cell phone for “safety”

I often hear that parents buy a phone for their kids “for safety” purposes, but studies are showing the opposite. Cell phones lead to many dangerous situations for young kids and tweens. Smartphone use is associated with anxiety, depression, poor sleep, and more.

Bullying has always been a problem, but now it is more widespread. Kids can’t even escape in their own home due to social media.

Screen time takes away from playing outside, which contributes to obesity.

Smartphones also decrease the time spent interacting with people in real life and getting tasks accomplished. When kids spend excessive time communicating with their friends through apps, they miss out on real interactions that can help develop important social skills. Although it’s not a diagnosis yet, screen behaviors seem to be very addictive. Limiting time can become difficult when kids always carry a device.

Screens interfere with sleep. Sleep is critical to a growing brain and body, so sleep deprivation leads to many problems.

Inappropriate material is easily accessible online. Kids learn how to starve themselves and get encouragement for unhealthy behaviors. They share challenges that are very dangerous. Pornography and sex trafficking are huge issues.

Look into the Wait Until 8th movement for reasons to wait until 8th grade to give your child a smartphone. Gain support from other parents when your child says they’re the “only one” without one. Even teens recognize the problem.

Being out and about

If you never let your child visit a friend’s home or play outside, they will learn to be afraid outside their own home.

Many parents are afraid to let their kids walk to school. Realistically it’s a low risk that their child will become abducted, but a very real risk that the loss of exercise will impact their long-term health.

It’s rare in many neighborhoods to see kids outside playing. Some may be inside unable to go out because parents aren’t home. Others prefer to play video games. There are many at structured after school activities, which don’t allow for child-driven play and problem solving. If other kids aren’t out playing, the incentive for your kids isn’t there to go outside. It isn’t as fun to play alone. Talk to your neighbors to find times that their kids will be home and encourage outdoor fun at that time. This helps to build your neighborhood into a community!

Dr. Peter Gray shows how the decline of free play is directly correlated with dramatically increasing rates of anxiety, depression, suicide, and narcissism in children and adolescents. He discusses why free play is essential for children’s healthy social and emotional development. He also offers suggestions of how we can make this happen while keeping our kids safe. Take 15 minutes to watch it.

Playing sports

As Dr. Gray mentions, it’s the free play that seems to be important to help our kids develop resiliency.

Our kids consider sports their “play” time, but sports are directed by adults. Kids don’t learn what they need to learn about creativity, self motivation, problem solving, and all the other skills learned by kid-directed and kid-initiated play.

Overprotected kids

An article that I read years ago still resonates with me. The Overprotected Kid shows how parents try so hard to keep their kids safe that we sometimes prevent them from learning about real life.

The article is based on allowing kids to roam and play with things that haven’t been engineered to keep them safe. In our litigious society, that seems excessively dangerous to some. There are even stories of parents being turned into authorities for allowing their kids unsupervised time outside or even taking public transportation to school.

In my opinion, too many parents worry that kids aren’t safe when unsupervised. They forget what dangers lurk in too much supervision.

Where’s the right balance?

Building Snowmen from Snowflakes

Dr. Tim Elmore is a recognized speaker and author who focuses on building the next generation. Here’s an excerpt from his post, How to Build Snowmen from a Snowflake Generation:

Too often, our young give up due to “learned helplessness.” This happens, however, in both a surprising and sinister fashion. It’s all about control. Studies reveal that when the activities in their day are controlled by adults (and hence, not in their control), both their angst and hopelessness rise. The more we govern and prescribe the agenda, the less they feel hopeful and the more they feel helpless.

Further, learned helplessness promotes irresponsibility. Kids feel little responsibility to work because it’s “not up to them.” I believe most middle class students assume that if they make a mistake, some adult will swoop in and rescue them. While this may feel good, it hinders development. Feeling that outcomes are in their control gives them a greater sense of hope and ownership.

Established generations must slowly encourage and even insist on giving them control of the “agenda.” This is the only way to build ownership, engagement and responsibility. It requires trust and flexibility, since young people may not perform to our standards. We must decide what we want most: perfection or growth.

He goes on to say:
What message do you suppose it sends a student when the adults in his life continue to swoop in and save him whenever something goes wrong? While it may feel good at first, it communicates: “We don’t think you have it in you to solve this problem. You need an adult to help you.” Consequently, these young people don’t feel like adults themselves until somewhere between ages 26-29. They can remain on their parents’ insurance policy until age 26. In one survey, young adults reported they believe adult-life begins with “having their first child.” Today, this doesn’t happen until long after 18 years old. So while we give them the right to vote, they may have no concept of reality. Rights without responsibilities creates virtual adults and often, spoiled brats.
Teaching children responsibility is like teaching them to ride a bike. Offer less support and finally let go.

Growth Mindset

Did you know that success is not determined by intelligence? Our mindset, grit, and resilience are more predictive of success.

The good news is that we can all learn to have a growth mindset, which is a great start to becoming resilient. See my sister blog for more information on How to Get a Growth Mindset.

Success is correlated with a growth mindset more than intelligence. So how do you get it? It's not as difficult as you might think.
How to get a growth mindset.

A Bedtime Stimulant for ADHD?

Most parents of children with ADHD are familiar with stimulant medications. These include medicines in the ritalin and adderall family. There are many brands and formulations, but they are given in the morning and wear off at some point in the day. One of the problems is that when kids wake up, they are not medicated, which makes getting out the door a daily struggle. There’s a new technology that’s designed to allow medicine given at night to start working in the morning. This is different from the non-stimulant ADHD medicines that are used at night. Is a bedtime stimulant right for your child?

Disclaimer

As this was only recently announced and is not yet on the market, I have no experience in using this novel medicine. I wanted to learn about it and thought I’d share what I learn, but I am not promoting its use since I have no experience with it.

I want to caution people who it will take quite awhile before this will be covered on insurance plans and available for mainstream use. It’s good for parents to be aware of what’s in development, which is why I’m writing about as I learn, but you must talk to your own physician about what medications are right for you or your child.

Most of the information about the new medicine is from the company that is developing it, Highland Therapeutics. This is not an unbiased source.

Stimulant vs Non-stimulant medicines

You might know kids who have ADHD medicines that already work in the morning, so you might be wondering what benefit this new system offers.

The non-stimulant medications can continue to work in the morning. This new delivery system is for stimulant medicines. For many kids, the stimulant medicines simply work better for the majority of the daytime hours, even though they don’t last as long as the non-stimulants.

For more on ADHD medications, see ADHD Medications: Types and side effects.

New formulation of methylphenidate

The FDA has approved Jornay PM, a medication that uses a new drug delivery system for methylphenidate, one of the two main stimulants used for ADHD. The company that makes this, Ironshore Pharmaceuticals, is also working on one for amphetamine, but it has not yet been approved.

Jornay PM is expected to be available in the first part of 2019. This does not mean that your pharmacy will stock it or that insurance will cover it. I do not know how it will be priced, but typically new medicines are expensive.

Methylphenidate is the active ingredient commonly referred to as ritalin. For many years we have had short acting and long acting forms of ritalin to use for people with ADHD. The short acting medicines generally last 3-4 hours and the long acting last 6-12 hours.

The new formulation of methylphenidate in Jornay PM is designed to be given at night so that it begins to work in the morning. The time release will allow the child to fall asleep without any of the active ingredient taking effect until several hours later. The idea is to figure out the timing so that when the child wakes, the medicine is already taking effect.

Why is this needed?

Many parents of kids with ADHD know the struggle of getting out the door in the morning.

While many kids can be expected to follow the morning routine of getting up, eating breakfast, brushing teeth, and dressing, kids with ADHD often get lost in this process. Every day.

The distractibility is not their fault. Getting ready in the morning requires many steps. Anything that requires time management and organization is difficult for people with ADHD.

The medicines they take typically take to help with these functions take about an hour to take effect. They need this medicine to be able to stay on task and help with executive functioning skills, not just to do school work.

There are certainly things that can be done to help that don’t involve medicine.  Many kids benefit from putting clothes out and packing backpacks the night before. Charts with all the daily expectations can help kids visualize what needs to happen.

But they still struggle to stay on task without medicine. They often run late. Families fight despite the best intentions. When kids finally get out of the door, homework or needed materials are often forgotten. Self esteem is impaired with these daily struggles.

Many parents ask for help with morning struggles

Some kids have benefited from a non-stimulant for this purpose. Non-stimulants, such as guanfacine, clonidine, and atomoxetine, can be effective upon waking. Guanfacine and clonidine can help kids sleep as well, which is an added bonus to kids with ADHD, since many struggle with sleep issues. These medicines can be used alone or with stimulant medicines, but they aren’t effective for everyone.

Other parents have snuck into bedrooms to put a methyphenidate patch on their child so it starts to work before the child wakes. While this works well for kids that respond well to methylphenidate, they are very expensive and many families cannot afford them. Some kids don’t like wearing a patch or they get skin irritation from them.

How does this work?

Jornay PM uses a delivery system called DELEXIS. In this system the beads with medication inside resist water and dissolving.

The beads do not release any medicine immediately. They travel through the small intestine without dissolving for about 10 hours. When they reach a part of our intestine called the ileum, they are able to start dissolving.

The medicine will be effective for many hours once it starts to be released. The delayed release layer starts to provide medicine about 10 hours after ingestion. Specific timing is affected by foods and drinks taken in the evening. It is recommended to be consistent with eating and drinking when taking this medicine.

Inside the bead deeper than the delayed release layer is an extended release layer. This releases the medication even later than the delayed release layer, to provide for many hours of benefit.

About 14 hours after ingestion starts the maximum concentration of medication levels. Absorption of the medication continues through the early evening.

Will it be right for your child?

All of this sounds great for the kids who need help from the first thing in the morning until later in the evening, but I will wait to see how it really works. We’ll all have to wait to see if it works as stated or not.

Will this new delayed medication delivery system benefit your child?
Will this new medication delivery system benefit your child?

 

 

Homework Battle Plan: Prepare Now!

Any parent with school aged children knows that homework can be a battle. Even good students can procrastinate, prefer to play, or have practice after school, leaving little time for homework.  Then there are the kids who struggle…

Student Responsibility

We all know that kids need help with homework. Sometimes parents help too much. Kindergarten projects should not look professionally done. Even when kids hate doing the work, they need to do it. If they cannot, you need to talk to the teacher to get the work scaled to what they can accomplish. Don’t do it for them.

Step back, one step at a time.

As kids get older, parents should offer less and less help.

It makes sense that young elementary school students will need help learning to organize their things and plan the appropriate amount of time to complete homework and projects.

If they are not asked to assume more responsibility over the years, many will never take over the tasks that they can be capable of doing.

The goal is that by the later half of high school teens can organize their work, schedule their time efficiently, and get it done without reminders. I know that sounds impossible for many kids, but if your senior is still needing you to nudge daily for homework, they will not survive when they leave home. Mommy isn’t there to remind anymore.

I’ve written before about what kids need to know to leave the nest if you want to think about all the things they need to be responsible to do.

How can you help your kids with homework without letting it become your problem? 

I am a firm believer that kids are the students, not the parents.

Kids need to eventually take ownership of their homework and all other aspects of school. Of course, for many kids this is easier said than done, but I hear all too often of college kids who have Mommy call the Professor to question a grade.

That is totally unacceptable.

Kids need to practice ownership from early on. Parents need to guide always, but manage less and less as the kids grow.

Not every solution comes from a cookie cutter mold. Kids have different personalities and abilities.

You know your kids best. Think how they work and what makes them tick.

All kids need the basics

Many parents underestimate the problem with missing out on basics: sleep, nutrition, and exercise.

If kids don’t get the amount of sleep they need, healthy foods, and regular exercise, they will not be as successful academically.

After school have a set time for kids to eat a healthy snack and get a bit of exercise. Both help make homework time more productive!

I have blogged on this previously on this site and on a teen site about developing self confidence. I really feel that finding balance is important for everyone for mental and physical health and success.

Find the right solution

Kids have different problems with homework at different times, and they each deserve their own solutions. 

Not one of these “types” fits every child perfectly.

Most kids have more than one of these qualities, but tend to fit into one type best.

Procrastination:

There is always something more fun to do than work.  Kids will put off overwhelming tasks or big projects because, well, there’s a lot to do.

Don’t just ask what homework they have due tomorrow, but also if there are any big projects due in the near or later future. See if they can estimate how much time it will take to do the project and help them plan how much to do each night to get it done on time.

Breaking big assignments or long worksheets into small pieces with short breaks in between can help kids focus. Use a timer for breaks or do a fun quick activity, like silly dance to one song.

Allow kids to have some “down” time after school for a healthy snack (brain food) and to run off energy. Limit this time with a timer to 30 minutes or so. The timer helps kids know there is an end point to the fun, and then it’s time for work. Play can resume when work is done correctly.

For more procrastination avoidance tips, visit Finish Tasks. It was written for teens, but has tips anyone can use!

Poor Self Confidence:

Kids who are afraid they won’t understand their homework might fear even starting.

They might blame the teacher for not teaching it correctly.

Some might complain that they are stupid or everyone else is smarter.

They blame the class for being too loud, causing distraction and therefore more homework.

Or they might complain of chronic headaches or belly aches due to anxiety.

All of these are problems with a fixed mindset. Many kids suffer from the negativity of a fixed mindset, but you can help them learn to have a growth mindset.

Praise kids when they do things right and when they give a good try, even if they have an incorrect answer. Praising effort builds their resilience and growth mindset. If you focus on the outcome, they develop a fixed mindset, which is associated with less success overall.

Be honest, but try to think of something positive to tell them each day. When they don’t meet expectations, first see if they can see the mistake and find a solution themselves.  Guide without giving the solution. Then praise the effort!

Find their strengths and allow them to follow those. If they are poor in math but love art, keep art materials at home and display their projects with pride. Consider an art class.

Remember to budget time. Over scheduling can result in anxiety, contributing to the problems.

Perfectionist:

While the desire to do everything right has its benefits, it can cause a lot of anxiety in kids. These kids think through things so much that they can’t complete the task. See also the “poor self confidence” section above, because these kids are at risk for feeling they are failures if they don’t get a 100% on everything. They can have melt downs if the directions don’t make sense or if they have a lot of work to do.

Help with organization

Help your child learn organizational techniques, such as write down assignments and estimate time to do each project. Plan how much time to spend each day on big projects and limit to that time. Help them review their progress in the middle of big projects to see if they are on track. If not, have them establish another calendar and learn to review why they are behind.

Watch for self-blame

Watch for self-blame when things don’t go well. Is it because one step took longer than projected, they were invited to a movie and skipped a day, they got sick and were not able to work… This helps plan the next project and builds on planning skills. Use failures as growing experiences, not something to regret!

Build self confidence

Remember to give attention and praise for just being your kid. These kids feel pressure to succeed, but they need to remember that they are loved unconditionally.

If you notice they have an incorrect answer,  state “that isn’t quite right. Is there another way to approach the problem?”

Not everything is about the grade. Praise the effort they put into all they do, not the end point. Make positive comments on other attributes: a funny thing they said, how they helped a younger child, how they showed concern for someone who was hurt.

Leave the comfort zone

Encourage them to try something new that is outside their talent. Not only are they exploring life, but they are developing new skills, and learning to be humble if they aren’t the best at this activity. Help them praise others. Model this behavior in your own life.  

Co-dependence:

Helicopter parenting is a term often used to describe the parent hovering over the child in everything they do. This does not allow a child to learn from failing. It does not allow a child to grow into independence.

It involves the parent “owning” the homework. These kids call home when they leave the homework or lunch on the kitchen table for Mommy to bring it to school. They often grow up blaming everyone when things don’t go their way and Mommy can’t fix it. These kids don’t learn to stand up for themselves. They seem constantly immature with life situations.

Slowly give over ownership

Young children need more guidance, but gradually decrease this as they get older. Teachers can help guide you on age appropriate needs. There are kids who need more help than their peers. For example, kids with ADHD are often 3-5 years behind their peers in skills that involve executive functioning. Your 10 year old with ADHD might need the support typically given to 5-8 year olds, but that does not mean they should rely on you to the same degree year after year. They must also continue to grow.

Most parents must sign a planner of younger kids, but as kids get older the kids become more responsible for knowing what the homework is. Many schools now have websites that parents can check homework assignments, but be sure the kids own the task of knowing what is due too.

Have a place that children can work on homework without distraction (tv, kids playing, etc).

Advise, but don’t do it

Be available to answer questions, but don’t do the work for them. If they need help, find another way to ask the question that might help them see the solution. Get a piece of scrap paper that they can try to work through the problem. If they have problems with reading comprehension, have them read a few lines then summarize to you what they read.  They can take notes on their summary, then read the notes after the entire chapter to get a full summary.

Busy, busy, busy:

Some kids are really busy with after school activities, others just rush through homework to get it done so they can play.

Set limits on screen time

Set limits on how much screen time (tv, video games, computer time) kids can have each week day and week end.

If they know they can’t have more than 30 minutes of screen time, they are less likely to rush through homework to get to the tv or computer.

It used to be recommended no more than 10 hours a week for screen time, but newer guidelines are more flexible. This is because the quality of screen time can vary considerably and it is constantly changing. Many kids require screen time for homework.

The big thing is that kids need balance. They should still have the opportunity to play with friends in real life. Kids need exercise. They should learn to problem solve through interactions with friends. Too many hours on a screen diminish the time with real people and in active play.

Do it right

Ask kids to double check their work and then give to you to double check if you know they make careless mistakes.

Don’t correct the mistakes, but kindly point them out and ask if they can find a better answer.

Once they learn that they have to sit at the homework station until all the work is done correctly, they might not be so quick to rush.

Avoid overscheduling

If kids have after school activities the time allowed for home work and down time are affected. Avoid over scheduling, especially in elementary school.

Be sure they have time for homework, sleep, healthy meals, and free time in addition to their activities.  

Are the activities really so important that they should interfere with the basic needs of the child? Is the child mature enough to handle the work load?

It is generally recommended to allow kids to do up to their age in number of hours of extra curricular activities. A 10 year old can do up to 10 hours of extra curriculars per week. This means they really shouldn’t take dance class 3 hours a day 4 days a week. That’s too many hours. And remember it all adds up: sports, music lessons, scouts – don’t over schedule!

When they can’t sit still

Kids who are in constant motion can’t seem to sit still long enough to do homework. Be sure they have the proper balance of sleep, nutrition, and exercise or all else will fail.

Praise their efforts when they are successful.

Schedule breaks

Set a timer after school to let them play hard for 30 minutes, but then make them get work done.

Help little ones organize what needs to be done and break homework into several smaller jobs.

Set regular 5 minute breaks every 30 minutes so they can release energy. Set a timer to remind them to get back to work and compliment them when they get back on task.

For more organization tips, see this blog on finishing tasks..

Don’t require sitting still

Some kids do better staying focused if they can stand to work. If you have a table, counter or desk that fits their height when standing, let them use it. When standing helps, try to problem solve places that they can do it to help with productivity!

If your kids need movement, let them wiggle. Kicking the legs or constant wiggling helps some kids.

Fidget items can help, so let your child use them as long as they don’t become a play item that distracts.

If you have an exercise ball, let them sit on it. No ball? Try a pillow on a chair.

Time matters

If kids wait to do homework until evening hours, it might not be as productive and it can interfere with getting to sleep.

When we’re tired, we don’t stay as focused, so everything takes longer. We constantly need to refocus. We don’t learn as well, so studying is less effective.

If homework requires getting on a computer or tablet, the light exposure suppresses the melatonin level. Melatonin is needed to feel tired and go to sleep. If kids are on a screen too close to bedtime, they will struggle to fall asleep. Try to get them to do all work that requires a computer done first. Ideally all screens will be off at least 1-2 hours of bedtime.

I see far too many teens who stay up far to late studying. They need to find a way to start homework earlier if at all possible. I know this is difficult with work and extracurricular schedules, but that brings us back to avoiding over scheduling…

Kids with ADHD

Timing matters even more if kids need medicine to help them stay focused. Don’t let them try to do homework after medicine wears off.

They’re not focused and a little homework takes a long time, which is frustrating to the child. They also won’t retain as much information they’re studying and they’re more likely to make silly mistakes or have unreadable handwriting. If the medicine doesn’t last late enough in the day, talk to your child’s doctor.

Struggling despite help:

There are many reasons kids struggle academically.  Reasons vary, such as behavior problems, anxiety, illness, learning disabilities, bullying, and more.

Work with the teacher

If they are struggling academically, talk with the teacher to see if there are any areas that can be worked on in class or with extra help at school.

Can the teacher offer suggestions for what to work on at home?

Talk to your child’s physician

If kids have chronic pains or school avoidance, ask what is going on.

Depression and anxiety aren’t obvious and can have vague symptoms that are different than adult symptoms.

Bullying can lead to many consequences, and many kids suffer in silence.

If your child won’t talk to you, consider a trained counselor.

Talk with your pediatrician if your child is struggling academically despite resource help at school or if he suffers from chronic headaches or tummy aches. Treating the underlying illness and ruling out medical causes of pain is important. Depression, anxiety, ADHD, and other learning disorders can be difficult to identify, but with proper diagnosis and treatment, these kids can really succeed and improve their self confidence!

Be Prepared! Season 2 of “13 Reasons Why” Starts Soon.

The Netflix series “13 Reasons Why” came in like a whirlwind last year. With it came increased thoughts and attempts of suicide. I’m worried that Season 2 will have a similar contagion effect this year. I’ve already heard from many teens that they plan on watching it. Last year I saw many teens significantly affected by Season 1, so it was on my radar to watch “some time soon.”

When my 15 year old said she wanted to watch it but needed me to unlock her Netflix restrictions to be able to view all maturity levels, I knew I had to watch it sooner rather than later.

It hit me hard.

The Netflix series "13 Reasons Why" came in like a whirlwind last year. I'm worried that Season 2 will have a similar effect this year. Last year I saw many teens significantly affected by Season 1, and I'm hoping we can all be prepared more this year.
The Netflix series "13 Reasons Why" came in like a whirlwind last year. I'm worried that Season 2 will have a similar effect this year. Last year I saw many teens significantly affected by Season 1, and I'm hoping we can all be prepared more this year. I’m hoping we can all be more prepared this year to talk to our kids and teens about watching “13 Reasons Why” responsibly.

The show did a great job of getting me hooked. I binge watched most of the episodes over one weekend. I put off grocery shopping and other necessities. It was hard to stop watching despite the fact that it was hard to watch.

There was a lot of debate about whether or not Netflix was responsible in showing this series. The producers claimed they wanted to bring the issues to the forefront. Mental health experts argued that it sensationalized suicide. I can see both sides. It does bring the conversation to the forefront, but can also lead to increased feelings of depression and post traumatic stress.

I couldn’t stop thinking about it for several weeks. There was so much to process! And I’m a 40-something year old pediatrician mother of teens who has a lot of life experiences to help with the processing. I can’t imagine processing this as a teen. And for those who have a history of abuse, rape, or other traumatic life events, this series could really be traumatic to watch.

This blog was first attempted a year ago, but it was too fresh and I could not finish it. I went to it many times, but never could finish it. It’s been a year and now Season 2 is coming, so I thought I’d finally finish it it in anticipation of all the kids who will see the upcoming season.

What’s it about?

Season One was about a girl who committed suicide and left tapes to explain the 13 reasons why she did it. It left a number of issues unresolved, such as a victim dealing with rape, a shooting, a counselor who failed to help on an at-risk child, and more. Season Two is expected to tackle these issues based on the previews.

It doesn’t sound any less traumatizing to watch than the first season. They do have a website dedicated to helping people who are struggling and supposedly will have warnings and helpful resources with each episode.

No more hiding the subject.

Depression is a significant problem. We do need to discuss it.

Between 10-15% of teenagers have some symptoms of depression at any given time. We need to recognize and address it better than we do. Less than a third of teens with depression get help, yet 80% of teens with depression can be successfully treated.

It is recommended that all teens be screened for depression yearly. If your teen hasn’t been screened, schedule a yearly physical with his or her physician, and be sure they are screened at that visit with a standardized questionnaire.

Schedule a visit that is dedicated to discuss depression if you’re worried about depression. If your teen has significant risks for suicide, take action immediately.

Again and again in Season 1 there are opportunities for the teens to talk to an adult, but they don’t, which is too often the case in real life. It’s not that parents don’t ask. They do.

In real life and in the show, parents offer to listen, but kids don’t talk. You can argue that parents should push harder, but that usually tunes teens out even more. Having teens fill out a standardized questionnaire can help identify problems that might be missed at home and school.

Open the conversation.

Conversation is desperately needed. Our kids are exposed to much more than we were.

The internet allows them to research just about anything – and they can find inappropriate things intentionally or accidentally.

Rumors spread much faster than they did when we were kids due to social media.

Our kids are at risk of being photographed in compromising situations more than we were in the days of bulky film cameras and when video recorders were not in everyone’s phone.

This show could be a great eye-opener for parents of teens. The first season depicted teens getting drunk, struggling with relationships, drug abuse, abusive relationships among family and friends, sexuality, bullying, and rape. Maybe parents already know these things happen, but don’t realize how it affects their kids. Watching shows like this with your teens can help to start the conversation.

Teens hear about and see this stuff so we as parents cannot shy away from it. Whether they go to public schools, private schools or religious affiliated schools, they are not in bubbles. These situations and topics affect them in real life.

Watching shows that tackle controversial topics together (or watching separately but discussing) helps open a needed conversation. They need help processing all the “stuff” they encounter at school and online.

For more on bullying and suicide, see this comprehensive summary from Drug Rehab.

Warning!

It might be risky for people who have been sexually assaulted or have experienced trauma of any sort to watch this series and shows like it. I have seen some teens who suffered from post traumatic stress reactions after watching Season 1.

If you struggle with a history of assault or abuse, cautiously watch it with someone you trust. Stop if viewing becomes uncomfortable.

Things to discuss.

Of course I haven’t watched Season 2 yet so I can’t comment specifically on it. Common Sense Media has a short video on things to know and once the shows are available online, they will have more.

Some things that can be discussed from Season 1:

Social Media

Social media is a theme throughout the series. Kids send messages that spread to everyone at school several times. Cyberbullying is real. It doesn’t go away when kids go home, which is historically a safe zone, but there are no longer safe zones for kids due to the internet.

In the first season, a picture that can easily be mistaken for something it isn’t is shown to friends to brag (inappropriately) about a sexual experience (that didn’t happen) is shared by a friend (with minimal resistance). This of course causes the girl in the picture to be thought of as a slut and the guy as cool. This slut label lasts for months despite the fact that it isn’t true. There are several discussion points here:

Talk to your kids about never sharing pictures or words online that could be hurtful or embarrassing to anyone. Ever.

Talking to adults

There is a consistent theme in season 1 of teens not wanting to talk to adults. I have teens of my own so I know this is an issue regardless of how often parents try to connect.

It is a normal phase of life, but kids need to know that it’s important to talk to a parent or another trusted adult if any significant issues arise. I always remind teens that their brains aren’t mature until the mid 20s, so if they need advice, they need to ask an adult. Even very smart and kind teens can give bad advice because they just don’t know yet what the best advice is.

Alcohol and drugs

Each party these characters attend has what appears to be every teen drinking alcohol. This normalizes the use of alcohol. There is talk of not drinking and driving, but it is still not responsible (or legal) use.

Talk about how Jessica goes from occasional use of alcohol to regular use, even at school, as a means to deal with her emotions. As she becomes more depressed, she attempts to self medicate with alcohol and marijuana. This is not a healthy way to treat depression.

Teens need to know there are many healthier options to have fun at a party and more effective ways to address any depressed feelings. I have written more on teens and alcohol previously.

There is much more written about how alcohol and drugs can increase the risk of suicide on Drug Rehab.

Accepting responsibility

Use some of the show’s examples to highlight how individual choices and actions make a difference.

Jessica’s actions restrict her from cheerleading. She blames the coach, but it is her behaviors that are causing the coach to make consequences.

When a minor accident caused a stop sign to be knocked down, it led to a more serious accident. By not calling the police when the stop sign was knocked down, they indirectly lead to the death of a friend. It didn’t seem like such a big deal but actions have consequences.

Guilt

After suicide, many friends and family members feel guilty, but people who are suffering from depression and suicidal thoughts need professional help. Friends and family members should show love and support, but they are not capable or trained to help sufficiently.

Put a suicide hotline number in every phone.

Learn warning signs so you can help a friend if needed.

Rape and sexual harassment

There is a general theme of girls being objectified and sexually harassed at school. There are few students who seem to realize the seriousness of this.

We need to open the discussion of how to treat others with respect, not objects.

Sexual consent

Sexual assault and consent is an often misunderstood topic. While rape can result in physical trauma, it does not always cause physical injury or involve brutality. Victims do not always have bruises or obvious physical symptoms.

In Season 1 we learn that Jessica was raped and didn’t even know it due to alcohol. There are many instances of rape where victims blame themselves for not saying no firmly enough or because they lead someone on.

Victims are often blamed for dressing suggestively or flirting too much. 

People who have experienced sexual assault but have no physical trauma are less likely to report the incident to the authorities or to get proper healthcare related to the encounter. People who have had sexual assault are more likely to have symptoms that seem unrelated, such as headaches, chronic pain, difficulty sleeping, poor physical health, depression, and anxiety.

Discuss sexual consent with your kids and teens.

Resources

National Suicide Prevention Lifeline – 1-800-273-8255

National Sexual Assault Hotline. RAINN. Free. Confidential. 24/7.

Stop Bullying. Resources to help prevent bullying and cyberbullying.

Alcohol Addiction Center. Resources for alcohol misuse and addiction.

Suicide Awareness Voices of Education (SAVE) Toolkit on 13 Reasons Why.

Final Thoughts on ADHD Medicines

My last post was how to start and titrate ADHD medicines. Today I’d like to discuss more of the fine-tuning issues, such as what happens if medicine isn’t taken every day, how to remember it, what to do if parents disagree about medicine, and even how to plan for travel.

Time Off ADHD Medicines

starting ADHD medicinesOnce a good dose is found, parents often ask if medicines need to be taken every day. 

Stimulants work when they work, but they don’t build up in the body or require consistent use. (This is not true for the non-stimulants, which are often not safe to suddenly start and stop.)

Some kids fail to gain weight adequately due to appetite suppression on stimulants, so parents will take drug holidays to allow better eating.

Days off the medicine also seems help to slow down the need for repeated increases in dosing for people who are rapid metabolizers.

Drug holidays off stimulants were once universally recommended to help kids eat better and grow on days off school. Studies ultimately did not show a benefit to this, so it is not necessary. Some kids suffer if they are not on medications. Behavior issues, including safety issues while playing (or driving for older kids) can be a significant problem when not medicated. Self esteem can also suffer when kids are not medicated. 

Despite the fact that some kids need daily medicine, others don’t. When kids can manage their safety and behavior adequately, it isn’t wrong to take days off. Many kids want to gain better weight, and taking a drug holiday can help with appetite.

Talk to your child’s doctor if you plan on not giving your child the medicine daily to be sure that is the right choice for your child.

Remembering the medicine

It’s difficult to get into the habit of giving medicine to a child every day.  Tomorrow’s post will be about how to remember medicines

My favorite tip is to put the pills in a weekly pill sorter at the beginning of each week. This allows you to see if you’re running low before you run out and allows you to see if it was given today or not. These medicines should not be kept where kids who are too young to understand the responsibility of taking the medicine have access.

Controlled substances

Controlled substances, such as stimulants, cannot be called in or faxed to a pharmacy. Many physicians now have the ability to e-prescribe these.

Controlled substance prescriptions cannot have refills, but a prescriber can write for either three 30 day prescriptions or one 90 day prescription when they feel a patient is stable on a dose.

Stimulants are not controlled substances because of increased risks and side effects. Some of the more significant side effects of ADHD medicines are seen in non-stimulant medicines. 

They are controlled substances because they have a street value. Teens often buy them from other teens as study drugs. This can be very dangerous since it isn’t supervised by a physician and the dose might not be safe for the purchaser. It is of course illegal to sell these medicines.

The DEA does monitor these prescriptions more closely than others. If the prescription is over 90 days old, many pharmacists cannot fill it (this will vary by state), so do not attempt to hold prescriptions to use at a later time.


Acids and Stimulants

It has been recommended that you shouldn’t take ascorbic acid or vitamin C (such as with a glass of orange juice) an hour before and after you take medication.

The theory is that ADHD stimulants are strongly alkaline and cannot be absorbed into the bloodstream if these organic acids are present at the same time.

High doses of vitamin C (1000 mg) in pill or juice form, can also accelerate the excretion of amphetamine in the urine and act like an “off” switch on the med.

In reality  have never seen this to be an issue.

If anyone has noticed a difference in onset of action or effectiveness of their medicine if they take it with ascorbic acid or vitamin C, please post your comment below.

When Mom and Dad disagree

It is not uncommon that one parent wants to start a medication for their child, but the other parent does not.

It’s important to agree on a plan, whatever the plan is.

Have a time frame for each step of the plan before a scheduled re-evaluation.

If the plan isn’t working, then change directions.

Be cautious of how you talk about this with your child. If kids know it is a disagreement, they might fear the medicine or think that needing it makes them inferior or bad.

Do not talk about the diagnosis as if it’s something the child can control. They can’t.

Don’t make the child feel guilty for having this disorder. It isn’t fair to the child and it only makes the situation worse.

Having the medicine when you need it

Refills 

There is nothing more frustrating for a parent and child than to realize that there’s a big test tomorrow and you have no medicine left and you’re out of refills.

Technically none of the stimulant medicines can have refills, but a prescription covering 90 days at a time can be given. This can be done with a 90 day prescription or three 30 day prescriptions.

The technicality of this is sometimes difficult. You cannot call your pharmacy to request a refill. You must ask to have the next prescription filled if your physician provided 3 prescriptions for 3 months.

Be sure to know the procedure for refills at your doctor’s office.

Travel

It’s very important to plan ahead prior to travel if your travel involves the timeframe of needing new medication.

You must plan ahead so that if a refill will be needed during the trip you will either be able to fill a prescription you have on vacation or you will need to fill the prescription in advance.

Most people can get a prescription 7 days prior to the 30 day supply running out but not sooner, so you might need to fill a couple prescriptions a few days earlier in the month each to have enough on hand to make it through your vacation. It takes planning!

Sometimes you can work with your physician and pharmacist to get medicines early prior to travel. Talk to your pharmacist to see if they can help arrange this.

If you are out of town and you realize you forgot your child’s non-stimulant, call your doctor to see if they can e-prescribe it. Many of the non-stimulants are not safe to suddenly stop, so they are likely to send in a prescription. Insurance is not likely to pay for these extra pills if it was recently filled.

International travel will require that you find the laws in the other country to find out if you can bring controlled substances into the country. If you will need additional medicine while you are in that country, you will need to find a way to get the medicine.

 

Mail order

Some insurance companies will allow mail order 90 day prescriptions.

There are insurance companies that not only allow, but require them on daily medicines.

Others do not allow it.

In general I advise against a 90 day prescription if the dose is not established or if there are any concerns that it might not be the perfect dose. If there is any concern that it might need to be changed, a 30 day prescription is a better option.

If you will need to do a mail order, be sure you schedule your appointment to get the prescription early enough to account for the lost time mailing.

Looking for more?

Many parents benefit from support groups to learn from others who have gone through or are currently going through similar situations, fears, failures, and successes. Find one in your area that might help you go through the process with others who share your concerns. If you know of a support group that deserves mention, please share!

ADHD

CHADD is the nationwide support group that offers a lot online and has many local chapters, such as ADHDKC. I am a volunteer board member of ADHDKC and have been impressed with the impact they have made in our community in the short time they have existed (established in 2012). I encourage parents to attend their free informational meetings. The speakers have all been fantastic and there are many more great topics coming up!

Anxiety

Many parents are surprised to learn how much anxiety can affect behavior and learning. To look for local support groups, check out the tool on Psychology Today.

Autism

The Autism Society has an extensive list of resources.

Dyslexia 

Dyslexia Help is designed to help dyslexics, parents, and professionals find the resources they need, from scholarly articles and reviewed books to online forums and support groups.

Learning Disabilities 

Learning Disabilities Association of America offers support groups as well as information to help understand learning disabilities, negotiating the special education process, and helping your child and yourself.

Tourette’s Syndrome and Tic Disorders 

Tourette’s Syndrome Association is a great resource for people with tic disorders.

General Support Group List 

For a list of many support groups in Kansas: Support Groups in Kansas .

School information

Choosing schools for kids with ADHD and learning differences isn’t always possible, but look to the linked articles on ways to decide what might work best for your child. When choosing colleges, look specifically for programs they offer for students who learn differently and plan ahead to get your teen ready for this challenge.

Midwest ADHD Conference – April 2018

Check out the Midwest ADHD Conference coming to the KC area in April, 2018. I’m involved in the planning stages and it will be a FANTASTIC conference for parents, adults with ADHD, and educators/teachers.

Midwest ADHD Conference
The Midwest ADHD Conference will be held in April 2018, in Overland Park, Kansas.


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ADHD Medications: Starting out and titrating

I have spent many days covering a lot about learning and behavioral problems. Topics covered include why and how to get these issues diagnosed, who is involved in the diagnostic process, and treatment options with diet, supplements, and alternative treatments. Yesterday I covered what prescription medications are typically used and side effects they may cause. Today I’ll discuss common ways to choose a medicine, how to titrate it to a proper dose, and when to change to something else.

Tomorrow will discuss final thoughts on how to remember medicines, if it’s okay to take days off, and what to do if parents disagree about the treatment plan.

Getting Started


starting ADHD medicinesThe first step in treating ADHD is getting a proper diagnosis. This should be done with input from parents and teachers since symptoms should be present in at least two settings. ADHD symptoms overlap with many other conditions, and if the diagnosis is not correct, medications are more likely to cause side effects without benefit.

Do not jump into medication until the symptoms have been fully evaluated and a proper diagnosis is made according to DSM criteria.

Stimulant medicines

Stimulant medicines are considered first line treatment for ADHD in kids over 5 years of age.

There are short acting and long acting formulations available for each type of stimulant. There are advantages and disadvantages to each.

Short acting medications tend to last about 4 hours, so can be given at breakfast, lunch, and after school, allowing for hunger to return as each wears off to help kids maintain weight. Short acting stimulants are often used later in the day after a long acting stimulant wears off for teens who need longer coverage.

Long acting medicines tend to last between 6 and 12 hours, depending on the medicine and the person’s metabolism. The benefit is that people don’t need a mid-day dosing, which for school kids means avoiding a daily trip to the school nurse. This can be socially unacceptable for older children. It is also easier to remember once/day medication versus multiple times/day dosing. The downside is that some children don’t eat well midday with long acting medicines.

Which stimulant medicine to choose?

Methylphenidate vs Amphetamine

While some children respond better to methylphenidates, others to amphetamines, some do equally well on either, and some cannot tolerate either.

It is not possible to predict which children will do best on any type, but if there is a family history of someone responding well (or not) to a medicine, that should be taken into consideration of which to start first.

Swallowing Pills

Another thing to consider is whether or not a child can swallow a pill.

Some of the medicines must be swallowed whole.

If you aren’t sure if your child can swallow a pill, have them try swallowing a tic tac. Use a cup with a straw, since the throat is narrowed when you tilt your head back to drink from an open cup.

Another option is to put it in a spoonful of yogurt or applesauce and have your child swallow without chewing.

If your child cannot swallow a tic tac, you can choose a medicine that doesn’t need to be swallowed.

Some come in liquid or chewable formulations. Some capsules can be opened and sprinkled onto food, such as applesauce or yogurt. There is a patch (placed on the skin) available for the methylphenidate group.

Genetic testing

I’ve met many parents who request “the lab to say which medicine will work best.”

There is no lab that does this.

Many companies promote that their genetic test can predict which medicine will be best tolerated, but in truth they do not predict which will work best to maximize treatment and minimize side effects.

There are pharmacogenetic tests that will help to identify if a person has an issue with metabolism that would require a higher or lower than typical dose, but it does not tell which medicine will work best. It also doesn’t verify the diagnosis, so if the diagnosis is incorrect, no medicine is the right one.

Pharmacogenetic testing for ADHD (and other conditions) is still relatively new. It has the potential to significantly change the medication treatment process, a term called Personalized Medicine. Personalized medicine needs to be further validated and its precision improved before it becomes mainstream.

Insurance

I would love to say that cost shouldn’t matter, that we pick the medicine based purely on medical benefit, but cost does matter. Insurance often dictates which medicine we choose. 

Before you go to the doctor to discuss starting medicine look at the formulary from your insurance company. All other things being equal, if one medicine is not covered at all (or is very expensive) and another is covered at a lower tier, it is recommended to try the least expensive option first.

Of course, if the least expensive medicine fails, then a more expensive one might be the right choice. 

Not knowing which will work best in any individual, choosing the least expensive makes sense. Sometimes all approved medications for ADHD are expensive. If that’s the case, see Affording Medications for tips on finding the best price.

Generics historically have been the least expensive, but that isn’t always the case. You must know your insurance formulary to know the cost.

The ADHD Medication Guide is a great resource to look for generics (marked with a “G”), which must be swallowed whole or can be opened or chewed (see the key on page 2).

Age indications

The age indications listed on page 2 of the ADHD Medication Guide are those that have FDA approval at the ages listed, but there are many times that physicians use medicines outside the age range listed.

Some do not even have an age indication listed. These ages are due to testing results, and can be limited because one age group might not have been tested for a specific medicine.

Note that the 17 year and adult medicines are different. Is there really a difference between a 17 and an 18 year old? Not likely.

start low and titrate to best effect

In general it is recommended to pick one of the stimulant medicines and start low and titrate to best effect without significant side effects.

Feedback on how the child is able to focus and stay on task, and reports of other behavioral issues that were symptoms in the first place should be received from teachers and parents, as well as the child if he is able.

There are many things to consider that affect focus and behavior that are not due to the medicine: sleep, hunger, pain, illness, etc. It takes at least a few days to identify if the medicine is working or not or if other issues are contributing to the focus and behaviors.

The younger the child is the longer I usually advise staying on a dose so a parent has a chance to hear from the teacher how things are going. I usually don’t increase faster than once/week in younger kids.

I rely more on the student’s report in middle and high school, since those students can be more insightful and they have so many teachers throughout the day that most teachers are not as helpful. Older students who are in tune with their problems and how they are responding to the medicine might be able to increase every few days, as long as there are no confounding factors that could influence symptoms, such as change in sleep pattern, big test or other stressor, or illness.

Finding the right dose

It is recommended to start with one of the two main classes of stimulants with a low dose, and slowly increase to find the best dose.

Continue to increase until either symptoms are well controlled without significant side effects or side effects won’t allow another increase.

If that stimulant doesn’t work well or has side effects that are not tolerated, then change to the other class of stimulant.

If that one does not work, you can try a different medicine from the class of stimulant that worked best.

If the third medicine doesn’t work, then a non-stimulant can be tried.

I recommend re-evaluating the original diagnosis if the third medicine doesn’t work, since ADHD might not be the cause of the issues and finding the right cause can lead to a better treatment.

Titrating the medicine goes something like this:
  • If symptoms are well controlled and there are no significant side effects, the medicine should be continued at the current dose.
  • If symptoms are not well controlled and there are no side effects that prohibit increasing, the dose should be increased as tolerated.
  • If symptoms are not well controlled (i.e. room for improvement) but there are side effects that prohibit increasing the medicine, consider a longer period of watching on this dose versus changing to a new medicine.

 

Before your visit:

Before you meet with your physician to discuss a new ADHD diagnosis or a possible change in treatment plan, be sure to get the following information and have it available at the visit or the visit will not be as productive as you desire:

  • Insurance formulary
  • Standardized testing from teachers, parents, and other significant adults
  • Verify if your child can swallow a tic tac or pill
  • Any contributing family history (family member responses to medications, family history of heart issues, etc)
Tomorrow there will be more on fine tuning ADHD medications.

Looking for more?

Many parents benefit from support groups to learn from others who have gone through or are currently going through similar situations, fears, failures, and successes. Find one in your area that might help you go through the process with others who share your concerns. If you know of a support group that deserves mention, please share!

ADHD

CHADD is the nationwide support group that offers a lot online and has many local chapters, such as ADHDKC. I am a volunteer board member of ADHDKC and have been impressed with the impact they have made in our community in the short time they have existed (established in 2012). I encourage parents to attend their free informational meetings. The speakers have all been fantastic and there are many more great topics coming up!

Anxiety

Many parents are surprised to learn how much anxiety can affect behavior and learning. To look for local support groups, check out the tool on Psychology Today.

Autism

The Autism Society has an extensive list of resources.

Dyslexia 

Dyslexia Help is designed to help dyslexics, parents, and professionals find the resources they need, from scholarly articles and reviewed books to online forums and support groups.

Learning Disabilities 

Learning Disabilities Association of America offers support groups as well as information to help understand learning disabilities, negotiating the special education process, and helping your child and yourself.

Tourette’s Syndrome and Tic Disorders 

Tourette’s Syndrome Association is a great resource for people with tic disorders.

General Support Group List 

For a list of many support groups in Kansas: Support Groups in Kansas .

School information

Choosing schools for kids with ADHD and learning differences isn’t always possible, but look to the linked articles on ways to decide what might work best for your child. When choosing colleges, look specifically for programs they offer for students who learn differently and plan ahead to get your teen ready for this challenge.

Midwest ADHD Conference – April 2018

Check out the Midwest ADHD Conference coming to the KC area in April, 2018. I’m involved in the planning stages and it will be a FANTASTIC conference for parents, adults with ADHD, and educators/teachers.

Midwest ADHD Conference
The Midwest ADHD Conference will be held in April 2018, in Overland Park, Kansas.


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ADHD Medications: Types and side effects

I have spent several days on the diagnosis of learning and behavioral problems and non-medical, dietary and supplemental treatments that can be used for these issues. Today I will focus on the types of prescription medications used primarily for ADHD as well as their side effects. Tomorrow will cover how to get started on a medication for ADHD.

Approved vs not approved medicines

There are many treatments out there that are not approved for the purpose they are used. This sounds scary, but if done properly might be a good consideration.

Physicians sometimes use treatments that have not been approved for the purpose or an age group because they know from general experience that it works or they are at a loss from approved treatments failing and they need to try something else.

One example is using a shorter acting form of guanfacine (Tenex) that has not been approved to treat ADHD, but it has some advantages over the longer acting form (Intuniv) that is approved for ADHD. The short acting form can be broken, allowing slower titration of dose changes. The long acting form cannot be broken.

Another common example is the use of albuterol, a medicine that helps breathing with conditions that cause wheezing. It is not approved for use under 2 years of age, but it is commonly used for younger children with difficulty breathing — and it helps them breathe, which might keep them out of the hospital and off of supplemental oxygen.

I do not think that all non-approved medicines are good or bad. It is a very individual decision of what medicines to use. Discuss with your doctor if a treatment is approved or if they are using something that is not. Although this is relatively common among people who treat children because many drugs have not been tested in children and have been “grandfathered” into use through experiences that show benefit, be sure the provider is not picking something that has no basis or supporting evidence, especially if he or she profits from the treatment.

Be very wary of anyone who promises a cure – if one really existed everyone would use it.

Medications approved to treat ADHD


When a medication is needed to control symptoms of ADHD, the first line medications are the stimulants unless there are contraindications. Non-stimulant medications are not found to be as effective as stimulants in the majority of children, but they do have a place in the treatment plan for some children. They are sometimes used in addition to stimulants for optimal results.

For information on these medicines, see A Guide to ADHD Medications. It reviews how stimulants act on dopamine and norepinephrine and various time release patterns of different medicines.

ADHD medication guide
ADHD Medication Guide

I love the ADHD Medication Guide (different from the similarly named post above) because it lists the medicines approved to treat ADHD in a colorful chart that groups the medicines in an easy-to-read format.

Categories of Medicines used for ADHD:

Stimulants
  • Methylphenidates (Aptensio©. Ritalin©, Focalin©, Concerta©, Daytrana©, Metadate©, Quillivant©)
  • Amphetamines (Adderall©, Vyvanse©, dexedrine)
Non-stimulants
  • Atomoxetine (Strattera©)
  • Guanfacine (Intuniv©)
  • Clonidine (Kapvay©)
  • Others are used off-label (no FDA approval for the purpose of ADHD treatment): Tenex, Catapres patch, antidepressants, and antipsychotics

Side Effects

Parents usually worry about medication side effects. This is a very legitimate concern, but must be balanced with the risks of not treating. Overall the medicines listed above are very well tolerated.

If a child has side effects to one stimulant, they can usually do well on a different class (methylphenidate vs amphetamine). When neither type is tolerated, a trial of a non-stimulant is indicated. If this isn’t tolerated, reconsider the ADHD diagnosis.

I often hear concerns that parents don’t want their kids changing their personalities or becoming “zombies”. If the right medicine is used at the appropriate dose, this is usually not a problem.

Finding that right medicine and right dose might take some trial and error. Work with your prescriber to get to the right one for your child.

Most commonly observed side effects of stimulants:

Decreased appetite

Appetite is often low in the middle of the day and more normal by supper time if kids take a long acting stimulant.

Good nutrition is a priority. Encourage kids to eat the healthy “main course” first and leave the dessert out of the lunchbox. They should have healthy snacks (think of mini-meals) after school when they get hungry.

Short acting meds improve mid day appetite since they wear off around lunch time. The downside is the child needs to take a dose around lunch time at school.

Kids are often very hungry in the evenings when medicines wear off, so encourage healthy foods at that time.

I have seen some kids who have a really hard time off medicine sitting down to eat. These kids actually gain weight better on medicine because they can finish the meal.

Some kids can improve their appetite with an appetite stimulant. I often use cyproheptadine if weight drops too much in a child. It works best if it is not used every day. I will have kids skip their cyproheptadine at least a couple days each week.

Insomnia

Trouble sleeping is common with ADHD — with or without medicines.

If it is due to the stimulant medicine still being active, trouble sleeping may be relieved by taking it earlier in the day.

If the child’s brain is too active in the evenings because the medicine wears off, learning relaxation exercises can help. Check out the Winding Down section of Sleep Tips for more details.

Increased irritability

Moodiness is especially common as the medication wears off in the afternoon or evening and in younger children.

It makes sense if you consider that all day they are able to focus and think before acting and speaking, but then suddenly their brain can’t focus and they act impulsively.

Typically kids learn to adjust to the medicine wearing off as they mature.

Sometimes just giving kids 30 minutes to themselves and offering a healthy snack can help.

Cognitive behavioral therapy can help.

Anxiety

Anxiety does occur with ADHD and might be under-appreciated before the ADHD symptoms are treated.

Symptoms of anxiety are often missed. They can include avoidance, irritability, moodiness, somatic complaints (headache, stomach ache), and more. HeySigmund has a great list of subtle anxiety symptoms.

When kids can focus better, they might focus more on things that bother them, increasing anxiety and making it more apparent.

It is also possible that anxiety is misdiagnosed as ADHD, which is one reason for stimulant medication failure.

If you notice signs of anxiety, talk to your child’s doctor and/or therapist.

Mild stomach aches or headaches

Stomach aches and headaches are occasionally noted with stimulant medications. It is my experience that they are most common with a new medication or a change in dose.

Because these have many causes, it can be hard to determine if they are really from the medicine or another cause.

If they persist with the medicine, changing to another medication might help.

Tics

Tics are related to treated and untreated ADHD.

People with ADHD are more likely to have tics than the general population.

It was once thought that tics were caused by the stimulant medicines, but it is now thought that they happen independent of the medicine, and medicines might even help treat the tics.

Growth

Weight gain can be difficult for some kids on stimulant medications due to the appetite suppression on the medicine.

Studies have shown a decreased final adult height of about 1-2 cm (1/2 – 1 inch). For most people this small height difference is not significant compared to the benefits in self esteem, academics and behavior children gain on stimulants.

 

Rare side effects of stimulants

Hallucinations

I have only seen two children who could not tolerate stimulants due to hallucinations, but it is very scary for the family when it happens.

Unless there is a significant family history of them, I don’t know a way to predict which child is at risk.

These are a contraindication for continuing that medication, but another type of stimulant or medication can be considered.

Heart issues

Cardiac (heart) problems are overall a rare complication of stimulants and often times are not a contraindication to continuing the stimulant medicine.

There is a small increase in blood pressure and heart rate, both of which should be monitored regularly while on treatment and if the treatment is stopped.

A cardiologist should be considered to further evaluate a patient prior to starting a stimulant if there is any of the following:

  • Shortness of breath with exercise not due to a known non-cardiac cause, such as asthma
  • Poor exercise tolerance compared to children of the same age and conditioning
  • Excessively rapid heart rate, dizziness, or fainting with exercise
  • Family history of sudden cardiac death or unexplained death (such as SIDS)
  • Family or personal history of prolonged QT syndrome, heart arrythmias, cardiomyopathy, pulmonary hypertension, implantable defibrillator or pacemaker

side effects for the non-stimulants:

Atomoxetine

Atomoxetine can cause initial gastroesophageal complaints (abdominal pain, decreased appetite), especially if the dose is started too high or if it is increased too rapidly.

It can also cause tiredness and fatigue when it is first started or if the dose is increased too quickly.

It can increase the blood pressure and heart rate, both of which should be monitored regularly during treatment with atomoxetine.

There is an increased incidence in suicidal thoughts, though uncommon, so children should be monitored for mood issues on this medication.

A rare complication of atomoxetine is hepatitis (inflammation of the liver with yellow jaundice and abnormal liver function labs). The hepatitis resolves with stopping the atomoxetine.

Guanfacine and clonidine

Guanfacine and clonidine both cause fatigue and tiredness, especially when first starting the medication or with increases in dose.

Both of these medications can lower the blood pressure and heart rate, and these should be monitored closely while on guanfacine or clonidine, especially when first starting and increasing dose.

Handouts for medicines

I absolutely love the handouts that Dr. Nerissa Bauer has made for ADHD medications. Click on the image’s caption to go to her website’s page for that handout. The two stimulant classes are first, followed by the non-stimulants.

amphetamine adderall vyvanse
Amphetamines

Amphetamines (Adderall, Adderall XR, Vyvanse, amphetamine mixed salts, Dexidrine, Zenzedi)

 

 

 

ritalin concerta apetnsio metadate
Methylphenidate

Methylphenidate (ritalin, Aptensio XR, Concerta, Metadate CD or ER, Focalin, Daytrana)

 

 

 

strattera, atomoxetine
Atomoxetine

Atomoxetine (Strattera)

 

 

 

clonidine
Clonidine

Clonidine (Catapres, Kapvay)

 

 

 

guanfacine intuniv tenex
Guanfacine

Guanfacine (Intuniv, tenex)

 

 

 

Next up:

Tomorrow’s blog will be about how to choose a medicine to start and how to titrate it to find the best dose.

Looking for more?

Many parents benefit from support groups to learn from others who have gone through or are currently going through similar situations, fears, failures, and successes. Find one in your area that might help you go through the process with others who share your concerns. If you know of a support group that deserves mention, please share!

ADHD

CHADD is the nationwide support group that offers a lot online and has many local chapters, such as ADHDKC. I am a volunteer board member of ADHDKC and have been impressed with the impact they have made in our community in the short time they have existed (established in 2012). I encourage parents to attend their free informational meetings. The speakers have all been fantastic and there are many more great topics coming up!

Anxiety

Many parents are surprised to learn how much anxiety can affect behavior and learning. To look for local support groups, check out the tool on Psychology Today.

Autism

The Autism Society has an extensive list of resources.

Dyslexia 

Dyslexia Help is designed to help dyslexics, parents, and professionals find the resources they need, from scholarly articles and reviewed books to online forums and support groups.

Learning Disabilities 

Learning Disabilities Association of America offers support groups as well as information to help understand learning disabilities, negotiating the special education process, and helping your child and yourself.

Tourette’s Syndrome and Tic Disorders 

Tourette’s Syndrome Association is a great resource for people with tic disorders.

General Support Group List 

For a list of many support groups in Kansas: Support Groups in Kansas .

School information

Choosing schools for kids with ADHD and learning differences isn’t always possible, but look to the linked articles on ways to decide what might work best for your child. When choosing colleges, look specifically for programs they offer for students who learn differently and plan ahead to get your teen ready for this challenge.

Midwest ADHD Conference – April 2018

Check out the Midwest ADHD Conference coming to the KC area in April, 2018. I’m involved in the planning stages and it will be a FANTASTIC conference for parents, adults with ADHD, and educators/teachers.

Midwest ADHD Conference
The Midwest ADHD Conference will be held in April 2018, in Overland Park, Kansas.


Share Quest for Health