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Saturday, September 22, 2018

Book Review: 1000 Best Tips for ADHD

1000 Best Tips for ADHD, by Susan Ashley, PhD, a psychologist specializing in behavioral disorders in children, is a practical book that has helpful tips for improving various aspects of life for parents of kids with ADHD.

The book has an introduction on how to use the book, followed by a list of tips categorized by the issue at hand.  The introduction is crucial to using the book, otherwise, the book is a reference style manual meant to help parents with specific common problems faced by children with ADHD.  The book avoids being trite and it acknowledges the hard work that sometimes comes with implementing behavioral strategies, so in a sense, while this is a book of tips, it is not a book of hacks.  Some of the suggestions given are easier to implement than others, and some of them will not work for a given child's situation.

The book has many strengths.  It is very practical and is not a long treatise on a certain approach or philosophy.  The main philosophy in this book seems to be, "Do what works."  Many parents with ADHD willl appreciate that fact that this book is reference style, so you don't have to read the whole book to understand or get to the part that you want, which is a fix for your child's problems.   The book offers a wide variety of tips in a wide variety of areas such as medication, behavioral issues, school, diet, and social issues.

There are several downsides to this book.   I was looking for a book about managing behavioral issues specific to older children and teens with ADHD, things like hygiene, organizational skills, and driving.   Those issues are not specifically addressed in this book.   I  would love to see the author write a similar book about teens with ADHD.  Another omission was that the book only talked about children having difficulty in brick and mortar school situations and did not address how to alter home schooling to help a child with ADHD.  It does refer the reader to a website and there are some tips on homework and specific subjects which could be helpful, however. 

Overall, though, the book offers many useful behavioral strategies you can try to help your child with ADHD.  While it is not the only book you will ever need, and not really a "complete reference for parenting a child with ADHD" as it is advertised to be, it certainly is a solid starter book for parents new to dealing with ADHD in a younger child.



Friday, August 10, 2018

Cleaning Up for Adults with ADHD

If you have ADHD, it's likely that you fall into one of two categories of housecleaners.  Either you clean sort of obsessively, to the point of it sort of taking over things that are more important, or you are the classic "messy".  I don't want to pretend to have all the solutions for you, but I do have some household tested tips that might help you.

A place for every thing.  Everything might not be in it's place all the time, but if you make it a rule that everything must have a home before you acquire it, or it gets tossed, it can help limit the stuff you need to keep track of.  Also, if you do create places for your things, it makes it easier to put them away when the time comes.  For example, if you place labels on boxes for say "winter accessories", "summer accessories", "winter shoes", "summer shoes" then your coat closet will be easier to clean up and it will be easier to find the things you want when the season arrives.  I personally recommend clear plastic boxes so that you do not have to bother labeling.  However, cardboard is infinitely cheaper if you have boxes laying around and a sharpie is sometimes fun to use.

Make your cleaning supplies easy to get.  It's hard enough to get motivated to clean without having to search for your cleaning supplies.  Keep what you need for the kitchen in the kitchen, for the laundry in the laundry room or in the clothes basket.  If you have more than one bathroom, consider either a caddy for your stuff or just have duplicate supplies for each bathroom.

Get rid of excess stuff.  The more stuff you have, the more stuff you have to clean and put away.  Everyone has their own ideas for simplifying possessions.  My own rule is that if I haven't used it for more than 2 or 3 years, then it probably needs to be put back into circulation to make someone else happy.  If it makes you feel bad to give stuff away, donate it to charity and take a tax deduction.

Do a little every day.  If you hate cleaning, doing a little every day can actually help you.  When you let cleaning get out of hand, you start to have this huge mountain of stuff that you just never want to address.  When you clean a little every day, things can't accumulate as badly.   But the key is to make it a task that has a definite end.  For example, set a timer for 5 minutes.  Clean a single room as hard as you can without stopping until your timer goes off.  When it goes off, you can stop.  Or, challenge yourself to throw out 5 things every day for a month.  Or even, pick up and put away 5 things in your room every night before you go to bed.  Don't forget to reward yourself for doing your part!

Key into hyperfocus.  If you like cleaning, its possible to key into you hyperfocus and just clean until it's done.  The main thing is to get started, which is probably the hardest part.  The key to getting going is to break this seemingly overwhelming task down into a smaller goal at first.  Instead of cleaning the kitchen, maybe focus on dumping all the expired and gross stuff out of the fridge.  Once you have that task done, you'll be on a roll--or--if not, at least your fridge is clean.

Happy cleaning!  And happy enjoying your cleaned space!

Jornay PM for ADHD

Although Jornay PM (Ironshore Pharmaceuticals) (methylphenidate) is marketed as the first bedtime medication for ADHD, it is in fact, not quite all that.  Guanfacine (Intuniv,    ) and clonidine are often given at bedtime and treat symptoms during the day as well.  Jornay isn't even the first stimulant that can be given at bedtime.  Mydayis is actually the first and has been on the market for several months.  However, Jornay PM is the first stimulant that can be given to children at bedtime (unfortunately Mydayis caused a high rate of insomnia and appetite suppression in children and so is unlikely to ever be available for kids).  And anyone who knows what it's like to struggle with ADHD in the morning can tell you, the potential to have a medication work first thing in the morning could be a game changer.

Disadvantages
Cost.  Like any new medication  Jornay PM is likely to be expensive while it is under patent.  It is yet to be seen what type of assistance, if any, Ironshore Pharmaceuticals, will offer to patients.  Also, during the first year after approval, insurance companies are unlikely to cover any new medication unless it is truely unique, which it is not.
Nothing new.  This drug does not really offer anything new in terms of avoiding potential risks.   It is still causes issues with appetite, sleep, anxiety, emotionality, and other symptoms commonly associated with stimulants in some patients.  In addition, preliminary studies showed up to a 33-41% chance of insomnia in 6 weeks of treatment.  Similar studies done with Concerta showed up to a 12% chance of insomnia.  Since the studies were not done as direct comparisons, it's difficult to know how the risk for insomnia truly compares, but 33% seems high.
Takes longer for it to get out of your system.   If side effects are likely, the big advantage of stimulants is that they are out of your system quickly.  This would not be out of your system very quickly, although likely if your child has severe side effects, such as hallucinations, it would not be more than 24 hours (as compared to 12 with Concerta).
Drug levels likely to take a long time to stabilize.  Clinical studies have not actually addressed this issue, but we often see that long acting drugs often manifest side effects later in the game--6 to 8 weeks later.  We would not expect things to be different with this drug.
Difficult to deal with missing doses.  If you miss a dose, you'll definitely have to wait until the next day.  It would be possible to take a short acting medication to cover the gap, but obviously your morning would still suffer.

Advantages
Works in the morning.  The main advantage of Journay PM is that it allows patients to have the benefit of their stimulant from the time when they wake up, onward through the day.  No waiting for your med to kick in before you can really function.  No more difficult mornings.
Different.  As with any new formulation, a different time release can produce advantages for some patients.  The let down off of Jornay PM may minimize symptoms of rebound, for example. 

Should your child use Jornay PM?
Jornay does not really have an advantage over traditional long acting meds like Concerta except for the hour that it takes a traditional medication to get started.  If mornings are manageable with behavioral strategies, this medication probably would not be worth the cost or the potential for side effects lasting through the night.  However, if your child is truly unmanageable in the mornings before meds and the extra hour of medication effect is worth it to you, then this medication could be helpful.

Should adults with ADHD use Jornay PM?
Adults who really struggle with mornings to the point of being late for work, and who have no one at home to make sure they get out of the house in a timely fashion may find Jornay PM to be helpful.  Jornay PM, unlike Mydayis, is a member of the methylphenidate family and so may be more appealing to patients who find methylphenidate more effective than Adderall.

References:
Jornay PM [package insert]. Ironshore Pharmaceuticals.,  Grand Cayman; Aug 2018.  http://www.ironshorepharma.com/labeling.pdf.  Accessed 8/10/2018.

Mydayis [package insert]. Shire, LLC., Lexington, MA; June 2017. https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/022063s000lbl.pdf.  Accessed November 19, 2017

Concerta [package insert]. Jannsen Pharmaceuticals, Inc.,  Titusville, NJ; Dec 2013.   https://www.janssenmd.com/pdf/concerta/concerta_pi.pdf.  Accessed 8/10/2018.

Thursday, July 26, 2018

Online Pharmacies and ADHD Medication

Buying ADHD medication online might seem like a great way to save money and certainly is convenient.  However, there are many online pharmacies which promise cheap, easy medication, which deliver more trouble than they are worth.  How can you tell the difference?

Warning signs
There are certain warning signs that a pharmacy is illegitimate or running a scam.  

First of all, most ADHD medications are scheduled medications worldwide.  So it's safe to say that it is impossible to buy ADHD medication legally without a doctor's prescription.  Pharmacies which do this may say that they will have their company doctor write the prescription for you, but if the doctor doesn't see you and doesn't interview you and doesn't really know your case well--it's likely that you're dealing with a criminal enterprise.  Stay away.

Another product of ADHD medication generally being scheduled is that it is very hard to legally ship it across international boundaries.  Generally the only way is if you buy the medication legally (with a doctor's prescription) in your country, and you are bringing a limited supply with you in your bags when you are traveling abroad.  If you live in the US, it's not legal for a private citizen (or resident) to legally buy ADHD meds "from Canada" to ship back to the United States.  

Safe online pharmacies
Generally, if an online pharmacy has a brick and mortar pharmacy that is legal, the online pharmacy will be legal as well.  Retail chains such as Rite Aid, CVS, and Walgreens have safe online pharmacy services.

However, not all online pharmacies have a brick and mortar component.  Some internet pharmacies contract with insurance companies and basically keep their prices down by specializing selling bulk quantities of medications to consumers and not carrying certain other medications (those that are needed for a short time) that a brick and mortar pharmacy would.  Examples of legitimate pharmacies in this category are Merck Medco and ExpressScripts.  Usually your insurance company will only contract with one of these companies and they will tell you which one you must use.

 The Verified Internet Pharmacy Practice Site certification is a program run by the National Association of Boards of Pharmacy, which basically accredits pharmacies throughout the United States.  You should always choose a pharmacy which has been accredited, regardless of whether it is online or brick and mortar, as this demonstrates that the pharmacy is aware of best practices in the field.







Friday, February 2, 2018

Quillivant and Quillichew Shortage: Update September 2018

Pfizer recently posted nationwide shortages of Quillivant and Quillichew on the FDA website due to manufacturing problems.  The Quillichew shortage has been resolved.  Pfizer published an updated doctor letter in March 2018 but the Quillivant shortage is ongoing with an updated resolution date of "unknown at this time".  This situation has not changed since July, our last update.

Quillivant is available in pharmacies, however, there continue to be some manufacturing problems.  The Quillivant that is available may not dissolve properly and has the potential to be less effective than properly manufactured Quillivant.

These medications are popular among younger patients due to their ease of administration.  Quillivant additionally is one of the most easy ADHD medications to titrate due to its being available as a liquid and so it is not easily replaced.

For those patients who are using Quillivant  because of being unable to swallow pills, there are a number of other long acting medications which could be used.  Focalin XR (capsules can be sprinkled on food, and drug (dexamethylphenidate, same class as methylphenidate) is available as a generic) Quillichew (chewable tablet, also methylphendiate) and Cotempla-XR-ODT (orally dissolving tablet, also methylphenidate) are the most similar to Quillivant.

For those patients who are on Quillivant due to difficulty coming to a correct dosage of methylphenidate, the issue becomes more difficult.  Focalin XR can be titrated, but not very exactly.  It's smallest pill size is 5mg and could potentially be split it to half that amount by opening the capsule and dividing up the beads.  Any more division would probably make the dosing fairly imprecise.  Quillichew 20mg and 30mg are scored for easier division and titration.  Cotempla-XR is not made to be divided.    These patients may find that staying with Quillivant, despite the manufacturing issues, may be the only workable alternative.

Patients switching medications should consult their doctor about appropriate dosing.  In addition, they should plan on frequent follow up just as when they were first starting their first medication.

Sunday, December 10, 2017

What is Using a Bedwetting Alarm Actually Like? Practical Tips and Pointers

 Enuresis is very common and can be especially difficult to conquer in a child who has ADHD.   Bedwetting alarms are a behavioral way of treating enuresis that has relatively high success rates and few side effects compared to medications and surgery.   We've recently started using a bedwetting alarm with one of our children so we thought we'd share some tips with you.

 When should you start?  Like many other things potty related, you should only start using a bedwetting alarm when your child is ready.  Bedwetting can be very tiring for a parent, but you need to have your child's buy-in or this technique will not work.  Getting up in the middle of the night is not fun for you or the child.  You need to have everyone be motivated for this or someone will quit before they are done.

Generally speaking, I would recommend waiting until your child is at least 6 or 7 before trying a bedwetting alarm, and I would also wait until your child talks to you about wanting to get out of diapers at night.  Prior to 5, most children do not need to go through this involved of a procedure to get dry at night.

The beginning stages of alarm use will be easiest if they take place at home and when your bedtime schedule and routine can be fairly normal.  However, once your child is fairly secure with alarm use,  it should be fine to go on vacation or stay up a little later than normal, provided the bed is protected in case of an accident.

 What type of alarm should you get?  There are many different types of moisture sensor alarms.   Some are pads that go under the child, and some clip to the underwear.  Pads are difficult because you have to make sure your child stays on the pad, which many ADHD kids will not, due to lots of in bed movements.  Pads also require a lot more liquid to come out which means bigger cleanups for the adult.  You should look for a secure clip, a fairly loud alarm (because the adult has to hear it, get up and get the child out of bed), and a wire that is long enough to extend from the underwear to the child's shoulder area, with a secure clip for the alarm to go on the pajamas.  If the alarm is not loud enough to wake you, you may need to use a baby type monitor in your child's room.
Some alarms have a variable feature, which could be handy if you or your child do not wake up to alarms after the first few nights of hearing them.  I can't say how likely this is, however.  I tend to wake up to an alarm more readily if it is the same one over and over again because it is a conditioned response.

 What else do you need to have to get started?
The alarm works best with tighter fitting underwear (i.e. briefs, not boxers).  Your child will have accidents, so a waterproof mattress cover is a must.  You can also try a waterproof pad, however, if it does not secure to the mattress it may slip off during the night.  Leftover waterproof pads from the crib could also be used if you still have them.

If your child sleeps with a sibling, the alarm probably will be loud enough to wake up everyone in the room.  If the sibling isn't good at getting back to sleep on their own, you may want to move one child to a different room.  It's not possible to predict how long the alarm will actually go off at night.  Some children only need it to go off for less than a week, but some will have alarms over several weeks time.

 How much parental involvement does it take?
At least one adult must get up when the alarm goes off to make sure the child does what he is supposed to do.  You should not count on your child doing this for herself.  Many children either do not wake up when the alarm goes off (until they are trained by force of habit to do so) or turn off the alarm and go back to sleep.  Even if your child does wake up fully, he may still have difficulty with taking the alarm off, going to the bathroom, and then reattaching it, or she may be unable to change her bed linens.  You should pick a time in your family's life where it will be ok if you miss a little sleep.

The first week or so, you may find it is better to sleep in the room with your child to make sure you learn to hear the alarm and can get to your child quickly.  After the first week, you can try sleeping in your own bed with the doors open or using a baby monitor to magnify the sound of the alarm in your room.

How do you know it isn't going to work?
If no adult is able to get up with the child despite using a loud alarm and a monitor, then this probably won't work.

Otherwise, it's a good idea to give it several months (up to 6) for your child to learn to hear the alarm and respond.  Most children will not have alarms every night for 6 months, so try not to envision the procedure that way! A more accurate way to think of it is this: typically if your child is making progress, having generally fewer and fewer alarms, it may take 6 months to be sure they are completely dry at night.

When should you stop?
A new habit takes at least 4 weeks to form, so you should continue use of the alarm for at least 4 weeks after the last accident, minor or major.  If there is an accident, you should restart your 4 week count.