ADHD meds question

[egoldber]

Younger DD was diagnosed about a month ago with ADHD (hyperactive-impulsive). We started with the generic of Ritalin LA (long acting). The initial dose was 10 mg and the doctor said that if that wasn't enough, then move her up to 20 mg. (FYI she is 6.5 and weighs 40-45 pounds depending on the day.....)

The improvement is remarkable. We left her at 10 mg for 2 weeks, but the teacher then reported some struggles late in the day. We increased to 20 mg. Almost immediately, we started seeing an increase in symptoms again. Although she was getting good reports from school, at home it was as bad as it ever was (impulsive behaviors, hyperactivity, incessant talking, etc.)! So we went back to 10 mg. She's been on that for about a week. This is better for us at home, but school is again reporting issues in the afternoon.

And through all this, her sleep has really suffered. In the Lounge thread about ADHD and sleep I mentioned how she used to go to bed at 8:30/9 and sleep fine. Now it's like she can't wind down and she is routinely up until 10/10:30 and sometimes as late as 11/11:30.

She has to get up at 7 for school. DH says she gets up fine and she is still getting good reports from school (with the exception of issues in the afternoon).

Has anyone experiences a worsening of symptoms with an increased medication dose? In reading about side effects, this doesn't seem to be a common reaction.

I know a lot of people use melatonin. I wonder if that what we need to start doing?

Thoughts? Experiences?

[lalasmama]

My DD is on 20mg of Ritalin LA (generic). For what it's worth, her pill is d.o.n.e. and utterly worthless by about 3:45 or so. When we have evening plans, we will do 10mg in the morning, and 10mg in the early afternoon (12-1pm-ish). That usually affords some evening coverage. Early on, her doctor said its not uncommon to need a late afternoon dose of short-acting Ritalin as well. I think we will be starting that shortly; our family life is suffering greatly with her behavior in the afternoon.

[cuca_]

We have no experience with Ritalin, but I'm wondering if the behavior you saw when you switched to 20 was the rebound.

IME whenever we've changed a medication, the rebound is very marked. The ADHD behaviors intensify once the medication has worn off. This gets better after a short period. I can't remember if we had had the same experience with a change in dose.

I find that DD2, who takes focalin, can sometimes be difficult when she gets home. For her it is the combination of the meds wearing off, being hungry and tire. Eating right away always helps.

We do use boosters for after school activities and special events, but I tried to avoid them otherwise because they do affect their bedtime.

[egoldber]

Maybe it's the rebound? We saw some rebound when she started the med at 10 mg, but then it got better after about 3 days. We had her on 20 mg for a week and it did not get any better.

I am leery of a late afternoon dose because she is already having trouble sleeping. Even with 10 mg she is not getting to sleep until 10/10:30. It was worse with 20.

She goes to after care and has activities there. I guess that school or after care could give her an early afternoon dose. She leaves school at 3/3:10 and gets to after care around 3:30. We don't pick her up until around 5:30.

[cuca_]

When does she take it in the morning. Is it possible that it is wearing off before the end of school and that is the behavior they are seeing in the afternoon?

For us, the short acting pill is supposed to last about 4 hours. If there is a possibility that the meds are wearing off, I would talk to her doctor about maybe giving a booster in the early afternoon. If you do this, the effects should wear off by the early evening.

I know for my older DD the meds wear off earlier than they should. I imagine it has to do with the way she metabolizes it. She takes Vyvanse, which is supposed to last for about 12 hours, I think. In her case, the effects do not last that long.

[egoldber]

She takes it at about 7:15, right after breakfast.

I'm sure it's wearing off before school is over.

[o_mom]

It sounds like it could be rebound. From what I can find, increasing the dose of the Ritalin LA doesn't seem to increase the length of effectiveness by much, just the peak concentrations. To increase the duration, I think you would have to add another dose of short-acting or switch to something like Concerta which is even longer acting.

[egoldber]

It sounds like it could be rebound. From what I can find, increasing the dose of the Ritalin LA doesn't seem to increase the length of effectiveness by much, just the peak concentrations. To increase the duration, I think you would have to add another dose of short-acting or switch to something like Concerta which is even longer acting.

Yes, that's what the doctor said.

We're switching to Concerta. If that doesn't work then we will try using a short acting in combo with the long acting. And if that doesn't work we'll switch classes of drugs.

[SummerBaby]

When we first tried medicating my ADHD DD (i believe it was ritalin la) she also initially seemed to respond, but then the med seemed to quickly lose effectiveness in terms of helping the inattention. We also had issues with rebound in the afternoon- for a while I avoided doing anything with her between 4:00-7:00! It seems it just was not the right drug for her. We then went to Concerta, which really worked great for the attention issues- unfortunately it also made her extremely angry and irritable. She has been on Vyvanse for more than a year now and it works the best with few side effects. When she first went on the 20 mg she did have sleep issues and some rebound issues. After a while she adjusted and she rarely has problems sleeping, and I don't notice rebound. She seems to get about 11-12 hours from each dose. Sometimes I think it's not working anymore...and then I forget to give her the pill and all hell breaks loose. . It took us about 6 months of trial and error to find the right medication a d dosage for DD. But in the end it was worth it.

[zukeypur]

Have you thought about/looked into Intuniv? It helps to decrease the rebound and help sleep. It also seems to even out DD's impulsivity and decrease the severity of her mood swings related to coming off the Focalin. Also, we were having a hard time controlling the ADHD with little medication side effect. Several meds were effective in treating the ADHD but she was not eating, staying up all night, and having emotional outbursts that were not typical. We switched to Focalin XR and it has worked well for a little over a year. We do Focalin in the morning and Intuniv in the evening.