ADHD medication and avoiding tolerance

Not the social kind of tolerance, the medical/pharmaceutical kind.

One of the things we noticed about our son is that the dose of Vyvance he’s been on for about three years seems to wear off sooner: before it was good until after school (we used to call dinnertime the Arsenic Hour), and now we’re getting reports that he becomes his unmedicated self while at school in the afternoon. The temptation is to ask for an increased dosage, but tolerance is a known side effect for some people taking methilphenidate drugs. (There’s also an interesting thing that a doctor on some podcast mentioned, which is that changed life circumstances can affect how much you need. That doesn’t apply in this case, but I figured I’d mention it to lay the groundwork for pointless theorizing in some future post.)

Anyway. What my son’s pediatrician prescribed is alternating Concerta and Vyvance. The boy was on Concerta before, and for reasons related to anxiety, we switched to Vyvance, which has been good for several years.

As he explained it to me, a moderately-educated layman (I have a rusty B.Sc.Hons. in biology) is that the tolerance is in how well the liver processes the drug. Essentially, and I know I’m anthropomorphising here, the liver “knows” the stuff from familiarity and has become really good at eliminating it from the bloodstream.

So, just like switching up your exercise program when you plateau, what he’s doing is switching up medications. The liver isn’t as familiar with the form of the Concerta, it switches, and it “forgets” the shape of the Vyvance molecules. In our case, we’re alternating every two weeks. The pediatrician said he’s kept patients on this regime for as long as 11 years and has seen no increase in tolerance from either. (Given that he’s a pediatrician, he might only see a patient for 18 years, so 11 years is the longer end of testing regimes.)

I didn’t ask whether this has been tried only with Vyvance and Concerta, or whether it’s a general strategy for all of the slow-release methylphenidates. And I trust the man (I send my son to him, after all) but the most I can recommend is that, if you or someone in your household is experiencing tolerance problems, you should talk to your health care provider and see if it’s a strategy that would work for you.

Some basic ADHD strategies

With a recent diagnosis, now the majority of people in our house have ADHD, which drives the remaining person crazy. But. I need to write down the ADHD information for reference. Maybe this will be useful for others.

Dr. Ari Tuckman (More Attention, Less Deficit) suggests these six strategies as the ones that underlie the hundreds of strategies he’s run across. Sometimes you have to give the specific strategy because the underlying one here seems too diffuse to you, but with practice you can apply these. There are basically two strategies for each flavour of ADHD:

INATTENTION

1. Reduce distractions. So if you have the TV going, shut it off while you’re having a conversation. If you have a cool neato program running when you’re supposed to be doing something else, shut it off. You can always tape the show and watch it later, or play the game later. Your friends will probably be on FaceBook later, too.

2. Make what you’re supposed to be doing more attractive. Sometimes that’s as simple as new pens or Post-Its for the novelty. Novelty isn’t a bad word; just make sure that the novelty makes you want to do the thing you’re supposed to be doing, and isn’t itself a distraction. (This would apply to those ADHD sufferers who have to have something else going on, like the fellow who had to have a movie playing on his laptop while he wrote his thesis.) Know yourself!

HYPERACTIVITY

3. Find a way to fidget legitimately. This involves maybe having a fidget toy, or scheduling some time after school or work for some punishing exercise to try and get it out of your system for a while.

4. Avoid situations where you can’t fidget at all. If you have a choice (and sometimes you don’t), don’t go to the opera if you have to sit still for three hours. Don’t hang around with the friend who sits on the couch doing nothing if that’s all they do. (Everybody has bad days, so that might be what they do once in a while, but if you find they’re sitting still and you can’t more than half the time, well, maybe you should restrict your time with them and find people who want to do things.

School is tough, but usually they’re helpful about fidget toys if you just ask.

IMPULSIVENESS

5. Try not put yourself in situations where you know you’re impulsive. If you know you spend too much money at a store, try not to go there; if you know you spend too much time at a web site, try not to go there. When I went to the World Fantasy Con, for instance, I left my credit and debit cards in the car in the glove compartment, and took a certain amount of cash. I was trying to limit how much I could spend.

6. Limit the damage of an impulsive action. For instance, if you spend too much money at a store, don’t take your credit or debit card, and decide how much you can spend–and then take that much cash. If you spend too much time at a website, don’t use it as your reward for doing 45 minutes of good work, because you know yourself and you’ll spend more than ten minutes there. So instead, visit the website as your end-of-the-day, it’s-all-finished reward. You might still spend too much time there, but at least the other stuff got done.

So for instance, my son frequently loses track of time at the bike park: so maybe he sets it up so a parent will come at the predetermined time, so he can’t miss the deadline. Or he sets his iPod to buzz him at 5:00 so he comes home. (He keeps losing his watch; he loses the iPod less often.)

My daughter spends a lot of time on Tumblr. Maybe she puts a time lock on her computer so that she can only open certain programs at certain times, or that they are up for only a little while before the program complains. (Actually, there are add-ons like that for Chrome and FireFox; there might be something for other browsers, too.) Sure, she can beat them (it’s her computer) but that takes time, and that gives her the chance to figure, "Should I be doing this?" Maybe she rewards herself for piano practice by playing some song that’s she’s really good at, so she gets that reward of "Yeah, I am good at this," because when you’re learning a new piece, you spend a lot of time making mistakes.

Making something into a habit is about reducing distractions. You don’t have to think about it, it just happens: I go into the bathroom in the morning and take my medicine just before I brush my teeth. If I don’t brush my teeth in the morning (which sometimes happens on a weekend) I usually forget to take my medicine until later, because the two usually go together for me. Often I don’t remember doing something that’s a habit (but that’s a different issue).

Hello world!

I got a WordPress account by accident; I was trying to consolidate my various subscriptions to other WordPress blogs, and I ended up giving myself an account.

Since I normally blog about writing and roleplaying (my hobbies) over on DreamWidth as doc_lemming, there didn’t seem any point to this blog, and then I posted a summary of ADHD strategies yesterday. Now, it’s not like anybody has responded to that post, but having a place focused on my family’s various altered abilities seems like an appropriate idea. So.

This will be a place to post things that are specifically about (in alphabetical order):

  • ADHD
  • Binocular vision problems
  • Club feet
  • Colour vision deficiencies (not, strictly speaking, colour blindness)
  • Epilepsy
  • Fibromyalgia
  • GAD (General Anxiety Disorder)
  • Learning disabilities
  • Near-sightedness
  • Schwannoma (better known as an acoustic neuroma)

Most of the time I’ll be talking about ADHD, because that’s the one that affects us the most and the one I’m currently looking into. And, for the most part, I’ll be hiding the identity of my wife and kids: not in a serious way–if you try hard, you can figure them out, but really, I don’t want them showing up with a copy of a blog post in three years and their names highlighted. They get the choice to reveal any problems that they have. For the purposes of this blog, I have Wife, Boy, and Girl, occasionally varied by the alternative names Spouse, Son, and Daughter.

So: next, the ADHD strategies I talked about.