Teen Driving and ADHD: How to Tell If Your Teenager is Ready to Learn to Drive

Teens with ADHD are at higher risk for driving accidents, so, how do you know when your teen is ready to learn to drive?  And how can you help them stay safe?

What is the problem, exactly?
People with ADHD may have trouble with attention and impulsivity beyond what is expected in the teen years.  Attention deficits cause a person's mind to wander off of the road and the driving task.  Impulsivity can result in speeding and other dangerous risk taking in a vehicle.  Also, people with ADHD tend to overestimate their driving abilities.

How can you tell when your teen is ready to learn?
Your teen may be ready if he or she...

• consistently shows good judgment
• is able to listen to constructive criticism and make change
• understands that rules are for safety, not for control
• responsible/mature enough to not push to have their license until he or she is a safe driver
• remembers to take prescribed medication for ADHD regularly
• is able to ignore his or her cell phone when the situation demands it, or willing to leave it behind or silence it while driving.

You should not let your teen drive if he or she...

• has issues with substance abuse, including alcohol.
• has uncontrolled symptoms of oppositional defiant disorder or antisocial personality disorder.
• is unwilling to take medication or doesn't remember to take medication on a regular basis.
• consistently has poor judgment.
• is unwilling or unable to abide by safety rules, including those regarding cellphone usage

Resist the urge to put your teen with ADHD on a timeline for driving.  A teen who is not ready to drive will possibly be disappointed about being "behind" peers, but waiting a few months or even a few years is unlikely to cause long term problems.

What can help?
Does extra training help?
Yes, as with any skill, extra training can help.  Prior to driving, teens may benefit from narrating their parents' driving--talking through what their parent is doing and seeing to get an idea of what driving involves.  Teens with ADHD probably should have formal driving instruction.  Parents should be prepared to put in extra practice time (and possibly an extra passenger side brake (cheaper than repairs and medical bills after an accident)) before and after licensing.  A formalized driving practice program such as the Teen Driving Plan, may help parents to understand how to help their teen understand the key skills they need to master, and when they are ready to move toward licensing.   Some patients may benefit from driving rehabilitation, which helps people with neurological problems such as strokes, to safely drive with neurological deficits.  A physician usually refers patients to this type of a program.

Does medication help?
A recent review concluded that stimulants improve driving performance in teens with ADHD, but that the effect tended to diminish over the course of the day.  Studies involving atomoxetine have mixed results, so it is not possible to conclude whether it helps driving or not.  Teens and younger adults showed the greatest improvements with stimulants.

While many adults with ADHD do not necessarily need medication to drive safely, people who are learning to drive should strongly consider at least temporarily increasing their focus with medication.   This is because driving is a complex task involving many distractions that has potentially lethal consequences if not done right the first time.

Does taking away the cell phone help?
Extensive research demonstrates that texting and driving can be lethal in people regardless of their ADHD status.  However, teens with ADHD in  at least one study have been shown to spend more time looking at their phones while driving than teens without ADHD, even in a hands free situation.  It's a great idea for anyone who is driving to pull over to talk or text on their phone.  However, for people with ADHD, it's probably an even better idea to minimize distractions.

That being said, taking away a teen's phone during the learning phase is probably a measure a parent should approach in a diplomatic fashion.  You might discuss it as a matter of fact kind of measure, like this:  "So, after you put on your safety belt, you'll want to make sure your phone is off, so you can focus on driving, especially while you are learning."  and later, "Now that you can pull on and off the road safely, we can talk about what you want to do about your cell phone."

 Does having a driving contract help?
Having a driving contract will help you communicate with your teen the types of behaviors which are responsible and which will help keep them safe.  It spells out consequences so that there should not be any arguments about what is fair.   There are sample contracts out online from a number of different organizations, but a good contract will stipulate that driving is a privilege not a right, and that the parent has the right to confiscate keys or have a license revoked if needed.  It should also cover expectations and consequences for issues such as traffic violations, use of cell phones, adjusting/use of music, passengers, and allowed destinations.  It should make clear that passing the driver's test is not the end of your supervision and that part of the learning process will be ongoing discussions of driving experiences with the parent or guardian.  Many teen crashes occur even several years after the teen gets their license, so its important to continue to supervise their driving and emphasize critical safety skills such as not speeding when in a hurry or upset, scanning carefully at intersections, especially when turning left, etc.

That being said, many teens with ADHD do not remember the terms of a contract and may find going over everything at once to be boring and therefore difficult to attend to fully.   A contract by itself will not guarantee compliance with safety rules.   As you are teaching them to drive it is important to continually return to safety rules so that they are more likely to remember your expectations.  It is also important to be a good example and model of how to handle different situations, such as what to do when you get a call on your cell phone.  

Teens with ADHD do have some elevated risks when driving, but with a plan and practice, many go on to be safe and successful drivers.

Obtaining ADHD Medication When Traveling Overseas

Suppose you would like to travel overseas, either for work or for pleasure, but you have to take your ADHD medication with you.  Is that even possible?  This article deals with what you can bring with you, what you have to leave behind, and what you can get a prescription for abroad.

Tourism
Most countries will allow a limited supply of medications from a foreign country provided that the medication you are bringing is (1) limited in quantity (limits may be country, drug, or length of stay  specific) (2) for yourself and not someone else , and (3) on your person.  You have to be very careful about this.  If you bring the wrong meds, or the wrong quantities, or break some other rule, you could be imprisoned for drug smuggling, which can have severe penalties.  I recommend checking with the embassy of the country concerned to be sure before you bring your medication outside of the country.

Additionally, TSA has its own rules about traveling domestically with medication which you should also be aware of. These rules change depending on existing threats and so its best to check the TSA website for up to date information.  Individual states also have rules you need to comply with.

Long term stays
It can be very tricky to get ADHD medication if you do something like stay overseas for more than 3 months for work, for example. The best possible scenario is that you see a doctor overseas and get your prescription there.  However, not all medications available in the United States are available overseas.  Although many countries may have Ritalin, most do not have the wide range of different dosages or delivery systems (such as Concerta) that are available in the United States.  Also the criteria for diagnosis may be different, so that there is no guarantee you will meet diagnostic criteria overseas.

If you have a child who requires ADHD medication for school, it is possible that the school overseas may be more accomodating than your school in the US (the opposite is also true), so that your child will not need medication.  Typically this would be with younger children who mostly have trouble sitting still, and who do not need medication on the weekend.  Most older children who need medication will find the expectations for sitting still will probably be the same.

What you should NOT do is have your medication shipped from the United States.  This would be considered drug smuggling and could get you in a heap of legal trouble.

You must consider the possibility of needing to return to the US to see your doctor and obtain your prescription, carrying only a limited amount of medication back with you every so often.  This could become an issue for your employer, your budget, and/or your doctor, so before committing to a lengthy overseas stay, be sure to know all the relevant regulations.

Supplements

Not all medications and supplements retain their designations as prescription medications and/or supplements overseas.  All stimulants are likely to be regulated as prescription only if they are allowed at all in most countries.  However, supplements like CBD or fish oil which are regulated as over the counter supplements may require a physician's prescription or even be illegal to possess in other countries.  Do your research carefully before travel.

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!

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.

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.