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Does DS need a meds adjustment? How to tell


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My 8th grader, aged 13.5, has ADHD-inattentive.  He is on 30 mg daily of Methylphenidate (Ritalin)

I have noticed when he is doing his math, he is often staring off, or picking at his fingers, etc.  He does the same when he is reading. I have tried to call him on it, but I am wondering if this means that the medication is not working like it should. 

We haven't had a counselor/psychiatrist in years because our insurance doesn't cover the one we saw initially, so our pediatrician prescribes the meds.  

Any thoughts on this? 

ETA: the only issue we have had with methylphenidate is that it surpresses his appetite so he doesn't eat very much until the med wears off at night. I don't give him meds on the weekends and he eats all day long.  😃

Edited by cintinative
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Time release or single dose? What time is this occurring relative to the dosing? 

There's usually a range on meds where you're sorta close and you strategies or like fully there or even a fuzz too much. So yes he may have grown and need a higher dose. He could also try using some strategies. You can look at 360 Thinking and also Interoception.

Any other indications of anxiety?

Edited by PeterPan
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38 minutes ago, PeterPan said:

Time release or single dose? What time is this occurring relative to the dosing? 

There's usually a range on meds where you're sorta close and you strategies or like fully there or even a fuzz too much. So yes he may have grown and need a higher dose. He could also try using some strategies. You can look at 360 Thinking and also Interoception.

Any other indications of anxiety?

Thank you!

Usually math is within maybe an hour to two hours of taking the med. It's a single dose, but it is marked as "ER" which I assume means extended release.  

It hadn't occurred to me before, but this is probably also why he can't really remember a book he read three months ago. 

I am not seeing anxiety except as it relates to the inattentiveness. The lack of ability to focus causes stress and anxiety, kwim?  

Can you point me to where to look for 360 thinking and interoception? I am going to google, but if that's not a good way to find info, let me know.  😃

 

 

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hmm, i looked up interoception and it reminds me of something my counselor said to try for my anxiety. Sitting in a space, name five things that I see, four things that I hear, three things that I feel, two things that I smell, one thing that I taste. 

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40 minutes ago, cintinative said:

hmm, i looked up interoception and it reminds me of something my counselor said to try for my anxiety. Sitting in a space, name five things that I see, four things that I hear, three things that I feel, two things that I smell, one thing that I taste. 

Yes, they were trying to get you to practice mindfulness. It's evidence based to bump EF, help anxiety, etc. yes. So it's a component but interoception is the larger piece of self awareness. We want to be aware all the time, not just when we turn it on, so that we can realize what we're feeling and self advocate. 

https://www.kelly-mahler.com/what-is-interoception/

 

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54 minutes ago, cintinative said:

"ER"

Yes

55 minutes ago, cintinative said:

Usually math is within maybe an hour to two hours of taking the med.

Can he feel when it kicks in? People take different amounts of time, so he almost could be doing it a little too soon, depending on how quickly he processes. 

56 minutes ago, cintinative said:

360 thinking

https://www.efpractice.com

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My kids are on ER methylphenidate, but it comes in increments of 9 mg, so I don’t know how you have 30 mg and ER. 

That’s a fairly low dose. My kids take more than that and one of them takes a short acting dose of regular methylphenidate in the afternoon. My younger kid is 13 and takes considerably more.

They eat more in the evening. One of mine sometimes skips meds on weekends because he wants to feel hungrier. Neither have had weight issues due specifically to meds yet. (Both are slim and have always been—one has a genetic condition that is associated with being unusually thin.)
 

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29 minutes ago, kbutton said:

My kids are on ER methylphenidate, but it comes in increments of 9 mg, so I don’t know how you have 30 mg and ER. 
 

Maybe because it is methylphenidate HCl ER?  I didn't realize there were two kinds of methylphenidate.

https://www.rxlist.com/metadate-er-drug.htm

 

It looks like yours is Concerta and ours is Ritalin?

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Edited by cintinative
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3 hours ago, cintinative said:

It looks like yours is Concerta and ours is Ritalin?

Yes. I didn't realize that Ritalin came in ER.

We love Concerta. We get it at Meijer because we have to do the generic, and they are the only place that will guarantee that they give us the same release mechanism. There is a generic that is not the same release, and lots of people have trouble with it.

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7 minutes ago, kbutton said:

Yes. I didn't realize that Ritalin came in ER.

We love Concerta. We get it at Meijer because we have to do the generic, and they are the only place that will guarantee that they give us the same release mechanism. There is a generic that is not the same release, and lots of people have trouble with it.

It might be possible that we could switch. It's the same drug, so I am not sure exactly what the differences are.  Is it very expensive? The one I have costs us about $70/mo with Good Rx or over $150 with insurance.  I don't mean to make it about money, but if it was more expensive, that might be prohibitive for us right now because of other medical bills.

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DS takes Concerta, and it has had a huge variety in costs. At Target, we were paying over $150. We didn't realize, but it would have been cheaper to get it elsewhere; when we moved, we switched to getting it at our grocery store and then at Costco for between $70-90. It was cheaper at Costco for awhile with Good RX, then became cheaper at our grocery store; then it became cheaper to use our insurance, instead of Good RX. Sigh.

Then DH's employer changed insurance plan options, and suddenly we have a prescription co-pay of $10!!!

The pricing has been crazy. The delayed release mechanism mentioned by kbutton is a problem for many who use Concerta (you can google this), but we've found that our DS does fine with any generic version, so it depends on the individual.

There are so many options. It's worth discussing with your pediatrician. Our pediatricians have been really good about thinking through things with us and being willing to adjust dosages or try new things. DS was on Ritalin first, then Focalin for years, then we switched to Concerta, because DS didn't like how Focalin made him feel (though he couldn't explain what he didn't like); he's fine with Concerta.

You could probably check with your pharmacy (and other pharmacies around you, since they can vary so much) to see what Concerta or Focalin would cost, compared to the Ritalin.

What you are paying for Ritalin seems high. When DS was on Ritalin, we used a generic, and it was relatively cheap (less than $15?). I suspect that you are on the name-brand in order to get the extended release version. If you are homeschooling, one option would be to try the generic for Ritalin, which would be much cheaper and lasts about 4 hours. Then take a second dose for the afternoon. The benefit, other than the cost, is that you may be able to time it for appetite to be there at lunchtime. We did that when we were homeschooling and only switched to ER when DS started to go to school.

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4 hours ago, cintinative said:

It might be possible that we could switch. It's the same drug, so I am not sure exactly what the differences are.  Is it very expensive? The one I have costs us about $70/mo with Good Rx or over $150 with insurance.  I don't mean to make it about money, but if it was more expensive, that might be prohibitive for us right now because of other medical bills.

You’d have to see what your insurance pays. We have an HSA, so things are always expensive early in the year.

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13 hours ago, kand said:

Is he still able to get his work done in a not totally unreasonable amount of time? I wouldn’t be expecting to eliminate all spaciness with medication, so it would only be concerning to me if he was struggling. That behavior would be normal in all my kids, though only one needs meds for adhd. I can stare off into space during things I’m supposed to be doing as well, and I definitely don’t have adhd. OTOH, my now-medicated kid was taking hours to do something that should have taken 45minutes. That’s an issue. 

I know what you mean. That is one reason I am not sure. After all, he is 13, and how much of this is the spaciness that they seem to have at that age? My oldest who is neurotypical, struggled at age 13.  

He is definitely pokey, and it seems worse that last year, but again, how much does the puberty brain fog play into that?  

Would talking to a counselor be helpful?  I talked to my son the other day about some of PeterPan's questions. He said he doesn't feel it when the medication kicks in.  That said, we both notice if the medication was forgotten because of his behaviors and focus.  He said he doesn't feel less able to concentrate now than before when it seemed like maybe the meds were working better (That said, one of the reasons he went on medication is that he would complain to me that he couldn't focus). 

Have you all had success with the interval sort of timers that buzz or something after certain time intervals? Maybe that would be a good first step? 

Edited by cintinative
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I haven't tried the interval timers. Trying out different tools can be really useful, because different things work for different people.

What I really want to say, though, is --- talk about this with the pediatrician. It is completely normal for ADHD medication dosages to need adjusting over time, and if it has been years, it's worth discussing an adjustment as one of the first steps. Sometimes increasing the dosage one step higher can make a big difference. Sometimes a different medication works better.

My DS also does not notice the effect that medication has for him, though others do notice. I worry that this will be an issue for my son, once he turns 18 and legally can make his own medication decisions. In addition to perhaps finding a way to help his medication work better, having your son listen in and participate as you discuss modifying his meds with the doctor is a great learning experience, for the time when he will need to do this on his own.

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8 hours ago, cintinative said:

He said he doesn't feel it when the medication kicks in. 

https://www.kelly-mahler.com/what-is-interoception/

You can do the curriculum with him yourself. And I guess you could say the dose is so low it's doing nothing, but then why is he on it? If you know it's making a difference and he's not self aware enough to notice, then that's a piece to work on. 

Self monitoring requires self awareness. You work on the self awareness piece so he can use the self regulation and EF strategies. They all assume that self awareness piece is present.

Some kids can get there just by being taught to body scan and some kids are going to need the full blown curriculum.

Edited by PeterPan
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17 minutes ago, PeterPan said:

https://www.kelly-mahler.com/what-is-interoception/

You can do the curriculum with him yourself. And I guess you could say the dose is so low it's doing nothing, but then why is he on it? If you know it's making a difference and he's not self aware enough to notice, then that's a piece to work on. 

Self monitoring requires self awareness. You work on the self awareness piece so he can use the self regulation and EF strategies. They all assume that self awareness piece is present.

Some kids can get there just by being taught to body scan and some kids are going to need the full blown curriculum.

Isn't there a difference between noticing when it kicks in and noticing when he hasn't had it? Because he can do the latter, and tell me we have forgotten his medication. He just isn't sure that he knows at what time after taking it he can tell the medicine has started to work.  

I see how both are self-awareness. It seems like the first (knowing when it kicks in) is a more nuanced thing?

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