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Sunday, June 30, 2019

Getting Your ADHD Child to Clean Their Room

Cleaning your room is a hated chore in our house.  As I suspect it is in many houses.  However, children with ADHD struggle more with cleaning their rooms than other children because they often have difficulty with focusing on tedious unexciting activities.  So how can you get your child to clean their room and stay on task until the room is actually clean?  And what can you do when your child doesn't actually clean their room?

1)  Choose your battles.  A messy room is really not as big of a deal as failing in reading or even not brushing your teeth.  This is one of those tasks where it is ok to let your child fail and it is ok to turn a blind eye if it isn't perfect.
That being said, there are good things about learning to clean your room.  Safety and hygiene come to mind.  Being able to find things when you need them is also a top priority, especially if you have ADHD.  So there are certain parts about cleaning a room that are less negotiable than others.  In our house, we don't allow food outside of eating areas ever and if the room is dangerously cluttered it must be cleaned.  Also, if you lose something you need, you clean until you find it.

2) Define cleaning.  Cleaning your room can mean shoving everything into the closet and shutting the door.  And that may be good enough if your goal is to vacuum the carpet so no one dies from dust allergies.  However, if you need to find something, cleaning means putting everything back in it's place, finding a place for it if doesn't have one, or deciding to toss it if all of that is too much trouble.  In any case, if you are not clear on the goal, you shouldn't be surprised if you ADHD child cannot read your mind.

3)  Less stuff means less to clean.    You can use toy rotation or exchange schemes to limit the number of toys that are accessible at any given time.  Also, encourage your child to bless other children with toys they no longer use or no longer want to care for.

4)  Have a routine.  If cleaning up is part of the daily or weekly routine, it will be less of a battle.   Your child will know to expect it and eventually will plan on having to do it, so it won't seem like an interruption.

5) Make it less unpleasant.  Play music.  Join in the fun.   Have races against each other or a timer.  Have a reward (different from a bribe--a reward being agreed to before the task is accepted and a bribe being offered once the task is refused). 

6)  Break it down into smaller chunks.  This is something that works for a lot of unpleasant tasks.  You can either break it down in time increments  (clean for 15 minutes as hard as you can and then take a 5 minute break, repeat) or into parts of the task (first pick up the dirty clothes, then pick up the Legos, then toss out extra papers, etc.) or into parts of the room (divide the room into sectors, cover the rest up with blankets, and then clean one sector at a time.

Keeping things neat and orderly probably won't be your child unless they just get in the zone and hyperfocus when they clean (and some people are like that!).  But teaching them that cleaning up their room isn't an impossible task is a worthy goal and probably will help them stay safe and healthy.  So, happy cleaning!

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.

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.

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.

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.