adderall and tolerance:
a subject i've been working on for a little while now.
1st of all; amphetamine binds to dopamine neurons in the brain. there is a chemical reaction as a result in which those nerves receive an increased influx of calcium ions (Ca++) which bind to them, which somehow "balances out" the effects of dealing with a synthetic drug. the nerves on one level percieve the drug as foreign, so it attempts to build a defense against its binding to them. it does this by "calling" calcium ions to the many docking sites along the nerve, which makes it more difficult for the drug to bind with the nerves after awhile. So, one of the most effective strategies (but most expensive) is using a Calcium Ion antagonist - the one i know of is Namenda (memantine); used for alzeimer's patients. but it'll cut the tolerance down by 40-50%.
A much cheaper method is Green Tea. The ingredient in it is L-Theanine, an amino acid which is also a calcium antagonist, but not as powerful as Namenda. I'd reccomend 2-3 cups or so of strong green tea first thing in the morning (the caffeine will also increase absorption of the drug), and then periodically throughout the day. take the med an hour or so after the first 2 cups of tea.
L-Tyrosine is another amino acid supplement that will help. it is the precursor to dopamine - the chemical that adderall works with. when you take amphetamine, your brain is buring through those resources faster than normal. when your dopamine levels are low, it's like trying to turn on a car with no gas. L-tyrosine Must be taken on an empty stomach or with water only. wait 45 mins or so.
And the other thing to do that is probably the most important is: EAT LOTS!! esp. complex carbs. and protein and/or protein shakes- esp. first thing in the morning before meds. a full carb./protein breakfast will make adderall last about 40% longer in the day without nearly as many ups and downs happening. and it is important to eat a full lunch and dinner, snacking between them if u can. fiber, fruits and veges should be eaten after breakfast, cause they're easier to digest during the time the med has taken effect and you've lost your appetite somewhat.
Also, weekend med breaks are one of the most effective ways to lower tolerance. it works better than all the other methods, but i rarely use it cause on those days i feel like i've wasted them, being unmotivated and all. 1x a wk is better than nothing though.
Last thing. sleep 8 hours or more. there is no substitute. your brain can't replenish its diminished store of amino acids and neurotransmitters wholly without this. some ppl (incl. me sometimes) take an SSRI before bed. it deepens sleep as well as rebalance the dopamine-serotonin equilibrium. the next morning you feel the effects of the meds much more prominently.
hope i could help
[QUOTE=molecularshaman]the one i know of is Namenda (memantine); used for alzeimer's patients. but it'll cut the tolerance down by 40-50%[/QUOTE]This is my first time creating a post. Thank you "molecularshaman" for your information. I've just started adderall xr 30mg this week, and am very concerned about building a tolerance. I've been spending the past week reading all the forums on adhd meds. I focus wonderfully on 30mg and my pdoc told me that I might build a tolerance which she'd then have to switch my meds maybe to dexedrine or metadate. I was first given Concerta 36mg. It made me very sleepy the first day and the positive effects soon wore off. I have a very high tolerance to medicines, (very high). I appreciate all the responses and want to say "thanks" to all those who take the time to post your experiences and knowledge for the rest of us laymen.
Thank you both for your responses. It is very helpful to learn through other's experiences.
KDLMaj- A lot of that last post made sense to me. We are not planning on increasing her meds at this point (even though it seems like it would help) because I feel like it would be temporary and that in another 6 months we'd have to increase again. I don't know why an increase helps I just know that each time we have increased her dosage in the past it has been great yet temporary. I do think hyperactivity/ impulsivity are harder to control and add another component to meds but there are many on this board who have only inattentive add whose stimulants seem to lose effectiveness too. I tryed backing her meds down last summer and boy you could really tell 20mg of XR just wasn't doing it for her at all. I have often wondered if there isn't something in the way the XR releases that causes some sort of "tolerance" to build?? I think it releases the 2nd dose about 4 hours after the initial dose which I was thinking might be too soon for some causing the med levels to be higher than needed in the middle of the day causing the brain to need a higher level of med to achieve the same results. I don't know if that makes any sense at all but I have questioned that. So all that being said we will probably try adding to her stimulant. She has tryed concerta, daytrana and focalin XR but none were very effective. I had never heard of adding a different stimulant to her adderall. Her psychiatrist said never mix types of stimulants. We are considering guanfacine because it is so good at controling hyperactivity/impulsivity and might allow us to cut back on the adderall.
One thing that has really bothered me throughout her treatment is that after being on the adderall for about 6-7 months, her unmedicated behavior is way worse than it ever was before she started meds. Her hyperactivity/impulsivity is so bad when she is umedicated, it is like they are magnified 20x what they used to be. It causes her to need meds all the time. I originally thought that if we took her off in the summer after a week or two she would be back to normal but that has not been the case. After 4 weeks off meds, she still had magnified ADHD symptoms. I have read on this board that it takes some kids 6 weeks to return to normal when unmedicated. That is so hard to deal with. Anyway I thought it was worth mentioning because I feel like it may be tied in to all this.
Your experiences and knowledge are helpful to me esp since your most severe symptoms are hyperactivity & impulsivity like my daughter. You mentioned that you've had success with adding a nonstimulant to your stimulant, can you tell me what that is?
Thanks so much for reading such long-winded posts and sharing experiences, knowledge and opinions!
Are the behavioral problems worse at school than at home (or vice versa)? Does she report enjoying school as much as she used to? Or is she showing increased signs of stress?
Third grade is actually an odd turning point in school for most kids. Those with moderate (or even severe, depending on their intellectual strengths) reading disabilities, or comprehension disabilities related to CAPD often don't begin to struggle until third grade. Children who suffer from dysgraphia also find that the sudden increase in written work and the switch to cursive makes academic life much more difficult, increasing anxiety which does a serious number on impulsivity and hyperactivity (compounding them horribly at times). Finally, third grade is often the point where in-class breaks between subjects (and other more "social" activities like show and tell and such) suddenly begin to vanish. For hyperactive children, this can turn a once interesting classroom existence into agony (as was the case for me in third grade!).
Third grade is also the time when many districts begin tracking students into gifted programs. If your child happens to be ADHD and gifted, then they would be spending most of their time around gifted children for the first time in a while. While gifted ADHD students tend to be more mature than average peers, they do have a tendency to lag behind the emotional maturity of gifted non-ADHD students. And their tendency to be unpredictable in their emotional maturity from one moment to the next generally doesn't fare well with other gifted students. This is a time, in general, when interpersonal relationships begin to become a bit more complex for kids. Unfortunately for the ADHD child, especially those with noticable hyperactivity and impulsivity, this is often when they start to struggle with peer relationships.
It may very well be that none of these things are the case. Her life may not include more academic and/or personal stress, and her metabolism may not be changing at all. Like I said earlier, go with what works! But there are so many reasons why a child may be experiencing increased problems with ADHD, it's always good to explore every option before increasing meds! Remember, increasing meds will eventually create the very tolerance you're hoping to deal with.
Good luck!
Both of my children take adderall XR and I do think my oldest who has been taking it for 4 years has developed a tolerance to the meds. She started taking adderall XR at 10 mg which worked beautifully for her at first but after 6 months or so we started seeing all the old ADHD behaviors again so we bumped her to 15 mg and again it was great. This cycle took place over the next couple of years where we slowly increased her meds by 5 mg when her ADHD behaviors reappeared and each time the increase really helped. She now takes adderall XR 30mg. She has been at this dose for a while but it is a struggle. The adderall just isn't as effective as it used to be. She has never taken more than what was prescribed for her by her psychiatrist. I feel like she could really benefit just by increasing her to 35mg but her pychiatrist doesn't want to up her and I really don't want to either. The only thing that really seems to make a difference is a medication break which she obviously can't take during the school year. SHe did try Daytrana for 9 weeks this school year. We didn't love the Daytrana but when she returned to the adderall the effectiveness had been restored somewhat.
We will be taking her off the stimulants this summer which is very hard to do. SHe may try guanfacine over the summer. I think the issue of tolerance is tricky and seems to be a touchy subject. I think it must be different for each person. I have witnessed my dd's meds becoming less effective the longer she is on them.
Also, the newest research is showing that stimulants actually do slow growth for some. Our psychiatrist said they especially worry about kids who take it year round 7 days a week. My daughter has only had 4 weeks per summer off in the last 3 1/2 years. When she started adderall she was off the charts height and weight. She is now in the 65% for both. Hopefully 2 1/2 months off this summer will help.
Let me just start with the disclaimer that whatever works...do it. So if medication breaks and such really make a difference, then use them.
But I'm curious..how old is your oldest child? Several things came to mind when I read your post. First, children experience dramatic metabolism changes over the years. Particularly around puberty, many children see an abrupt shift in one direction or the other. It appears as though stimulant medication dosage isn't dependent on BMI or severity of symptoms but actually on individual metabolism for stimulants. If your child experienced an increase in metabolism (either simply from the innevitable changes young bodies go through or from an increase in sports-related or other physical activity), their dosage requirements are certainly going to change. I know when my mother stopped going to the gym regularly, she found that her ritalin dosage was suddenly not enough. I had to point out to her that she was probably breaking it down more slowly now, and that it was probably staying in her system longer but hitting her brain at a slower rate. She was also losing the effects of exercise (which, in addition to helping to deal with hyperactivity also increases general dopamine levels in the brain), which would make more ritalin necessary to keep her previous levels.
What is more likely, I think, is that your daughter is simply getting older, which means higher academic demands, higher demands within interpersonal relationships, and more responsibility for self-monitoring and self-care. It's not unusual for parents to remark that it seems as though their child is becoming MORE ADD as they get older, as opposed to less (particularly for children whose symptoms are more related to inattention). And many students who were able to get by without stimulant medication in their younger years end up having to start in high school and college due to increased demands. Your daughter may simply be facing challenges that are rapidly outpacing her coping mechanisms and medication benefits. Unfortunately, medication only goes so far, particularly with moderate to severe ADHD. I'd highly suggest getting her a learning coach, ADD Coach, or a psychiatrist that does cognitive-behavioral therapy if you haven't already. Pay particular attention to her eating and sleeping habits. When children are younger, adults regulate food and sleep for them. As they get older, it's generally assumed they can do so adequately themselves. The ADHD child, particularly one that is on stimulant medication, may find that to be an incredibly difficult ordeal (as do most of the adults!) without actually realizing how it is affecting them. I always suggest high protein diets! And have her stock boost nutritional drinks (or something similar) in her backpack while at school so she can take it out and drink it, even if she's not that hungry. And have her do a sleep log for a week to see if she's getting enough sleep. (It should include when she went to bed, when she feels she actually fell asleep, what the quality of the sleep was like, and what time she got up) Often someone with ADHD is surprised to find out that they are horribly sleep deprived, and that makes ADHD symptoms MUCH worse.
And you are right to point out that some recent research has suggested that the growth effects of stimulant medications may not be quite as short-lived as we thought. Though signs point to the ultimate problem being one of nutrition, and not the stimulants themselves. The reason why medication breaks were thought to help is that children would start eating regularly again, and that would allow the body to grow as it would have normally. I've always personally thought that if parents would just put some more work into getting their kids enough nutrients, there'd be no problem. Sometimes parents are just too exhausted from dealing with their ADHD children to get into a battle over eating. Sometimes they're just ADHD themselves and have a hard time monitoring what their child is actually eating (or have too much faith in their child's ability to self-monitor!). But if more parents would simply stock nutrition drinks in their homes and once-a-day vitamin supplements for their kids, I think we'd have far fewer irritable ADHD kids and far fewer medication breaks!
Oh, forgot to add...have you tried using a medication combination for your daughter? Stimulant + Nonstimulant? It seems to work wonders for people (myself included)
My dd only just turned 9 and is in 3rd grade. I don't think the demands on her have changed much in the past couple of years nor has she had any major growth changes. She has the very hyper/impulsive type of ADHD and is not really that inattentive. Her grades are good. It's more behavior related. She eats and sleeps GREAT on the adderall. The adderall effected her appetite when she first started for about 6 months but that completely leveled off and ever since she has been eating very well. She has always slept great while taking adderall (Sleep was HORRIBLE on Daytrana). I don't think nutrition or lack of sleep are really contributing to her ADHD behaviors. The adderall just does not give her the calm, self-control it used to. As an adult who lives and observes her daily it has been very easy to see the medicine lose effectiveness the longer she is on it. ANd the med break definitely helped. I wish we didn't have to give her a break in the summer. It is tough but I can't come up with an alternative. We are contemplating using guanfacine over the summer and maybe combining it with the stimulant next school year. We will see what her psychiatrist wants to do................
Thanks for your suggestions!
Hrm, I'm going to step in with a dissenting opinion here.
There are two major ways to build tolerance to stimulant medication. The first has to do with the amount of time it spends in your system. While moleculeshaman is correct in pointing out that your body has a mechanism to deal with changes in its delicate chemistry (several, in fact), your body does not automatically do so in every instance. One of the primary things your body is looking for is the amount of time chemical balances are altered. Because stimulant medication is broken down so rapidly, your body will not normally build a tolerance to it at the dosages prescribed. It simply isn't affecting your body's chemistry long enough for long-term defenses to kick in (i.e. your metabolism is an effective enough strategy). If you were to take stimulant medication several times a day, 24 hours a day, then your body would kick in additional mechanisms to compensate for the fact that the substance has become permanent in your system. However, even the 8 hours of break time while you are sleeping is more than enough time for your body's chemistry to reset.
Of course, this brings me to the second way that your body determines it is time to build long-term tolerance: dosage amount. The stimulants we're prescribed are very powerful, but they are prescribed in incredibly small doses (think about the last time you took two extra strength tylenol for a headache...imagine taking 1000mg of adderall!) and go through your digestive tract (so figure about 40% of it is lost by the time it even hits your system). These things are the buffers that prevent a radical change in brain chemistry (read: a high) when we take the medication. Taking the medication in dosages higher than FDA Approved amounts has the potential to create long-term tolerance to these medications. Likewise, taking the medications via injection or snorting (which bypasses both the medication loss from the digestive tract and the slower tmax time that comes with entering the brain and blood system though such a roundabout process) can have the same effect. Make no mistake, taking a 20mg pill of adderall through your mouth versus through your nose are two VERY different things. If you are taking 60 mg or less of adderall (I'm not sure exactly what the ritalin dosage is), then you should not be building any tolerance to the medication.
There is, at this time, absolutely no conclusive evidence supporting a tolerance building effect from taking stimulant medications orally at theraputic and FDA approved doses. Read this twice so you remember it!
Medication breaks have very much become a common practice among those who use and prescribe stimulant medications. However, the entire notion of the medication break came about when they realized that small children were experiencing growth retardation when put on full-time stimulant medication. So doctors began suggesting medication breaks to give them a chance to catch up. (It turns out all is well- these kids end up catching up eventually anyway) Unfortunately, people sort of forgot why the practice was begun, and now it's become a popular practice to suggest medication breaks to prevent tolerance building. Well folks, I'm sorry to say that there is absolutely no need to take medication breaks to prevent building tolerance. All it does is tend to increase side-effects again when the medication is started up after a holiday (even if that holiday is merely a weekend).
ADHD is a full-time disorder, unfortunately. There is no evidence that people benefit from medication breaks, and there is growing evidence that it is detrimental over the long-term (how many people can afford 2 truly unproductive days a week?) when applied with regularity. Older children and adults are far more likely to feel the consequences of medication breaks than younger children.
As far as the food issue goes...be careful with what you do with that information. High Portein diets are commonly believed to be beneficial to people with ADHD (particularly since people with ADHD have notoriously bad eating habits- either overeating as self-medication or under-eating due to low attention span and motivation, high distractability, and a poor ability to self-monitor). But high fat meals eaten right before or right after medication is taken tend to reduce the overall effectiveness of the amphetamine-based ADHD treatments (the ritalin family, including ritalin LA and Concerta, are not much affected by morning diet). In the instance of the new drug Vyvanese, it seems largely to slow down the time it takes to reach peak plasma levels of the drug, but in the case of Adderall SR and XR, it does seem to reduce the amount of the drug ultimately absorbed. Those who eat with regularity through the day are far less likely to suffer rebound effects and the peaks and valleys, but this is largely due to the fact that those who aren't eating properly (due to appetite supression and general ADHD behaviors) are feeling the effects of malnutrition, which is often falsely attributed to the ADHD drugs (and will very much compound any side-effects they may be feeling as the drugs kick in and wear off). Taking long-acting versions of stimulant medications tend to reduce these problems as well.
So don't worry about taking calcium antagonists, and don't worry about medication breaks. Worry about ensuring that you are taking a high enough dose that isn't higher than FDA approved, make sure you are giving yourself needed nutrition, and don't load up on fats right around medication time!
Good luck!
I forgot to add that many people falsely believe they are building a tolerance because they tend to correlate the onset of initial side-effects (racing heart, shaking hands, etc.) with the onset of the beneficial effects of stimulant medications. After a few months, that "rush" may no longer occur, and people are left thinking the medication has ceased to be as beneficial. The irony is that this is the point where the medication has become MORE beneficial- you've gotten rid of some of those nagging side-effects!
Also, when people first begin treatment, they are comparing their VERY ADHD selves to how they feel on the medication. As the months go by, they adjust to a new baseline (medicated ADHD), and the onset of the medication doesn't have the same stark contrast that it once had (since the night before you were medicated, the next morning doesn't feel significantly different when you take your meds again. As opposed to the night before feeling chaotic and restless with a striking calm when you take your meds the next morning).
And when people are first medicated, they are often feeling a huge surge of motivation and focus due to the excitement and relief they feel. As the months go on and your new medicated ADHD becomes normalized, the initial excitement fades, and with it can often come an increase in distractability, decrease in motivation, etc. Remember, stimulant medication treats ADHD, it doesn't cure it. When that realization sets in, people often lose the benefits of that initial excitement which occur when medication is begun but aren't actually directly related to it. If you don't build long-term skills when you start taking your medication, you won't be able to maintain that state for long-term gains.
Don't fall into this trap! Remember, we are notoriously bad at self-monitoring. Often the person with ADHD will complain that their medication isn't helping them, and all the while the people in their life will be noticing dramatic changes and effects. Misreading a lack of side-effects as a lack of benefits is what often leads people into tolerance-building dosage increases. They'll continue to request higher doses (causing a return of side-effects which are interpreted as a return in beneficial effects) until they truly have reached a level of medication that creates tolerance (and quite possibly addiction)! And don't boil everything down to your medication. It is a part of the treatment, there needs to be more to it. And beginning medication comes at a time when you are likely feeling more motivated and focused for a variety of reasons which are unrelated and often temporary.
KDL,
Thank you for your comments. I wanted to answer but you did it very effectively and truthfully. I hope everyone takes the time to read your posts.
I too have often wondered about the Tmax levels of XR versus SR. I've seen studies that compared the point when Tmax is reached, but I've never seen anything that actually compared the levels of medication in your system at those points. It'd be interesting to see. The different chemicals in adderall have half lives of 10-11 hours depending on the specific chemical, so when the 4 hour burst is released, a big chunk of the first burst would still be in your system. The things I have read (note: NOT published by Shire) have all stated that half the drug is released immediately and half is released later, but I have a strong suspicion that this is not actually the case, and that most of the drug is released immediately with another quarter or so released afterwards (much as concerta works). But who knows?
I personally take strattera (50mg: about half the adult dose) with 30mg of adderall XR 1-2x a day. I've found that it's a great combination for my symptoms. Guanfacine is a drug I have very little experience with, but with Shire's impending release of Guanfacine XR, it seems like a good choice with Adderall XR- though guanfacine does less for attention than other ADHD drugs. (Though Strattera has an even longer duration- slightly over a day) Clonidine is another option. It's particularly useful for children who suffer from insomnia related to the stimulant medications (Though I believe you mentioned that your daughter, like myself, has found her sleep much benefited by stimulants). And, honestly, tricyclic antidepressants are also an option (desipramine has about a 68% response rate...almost as high as stimulants). I wouldn't really go that route until you've tried the other drugs mentioned above, however! And also remember that when taking these medications, the time of day you choose is very important. Guanfacine and clonidine can both cause drowsiness, so you may find that you need to administer them at night (at least at first). Strattera usually does the opposite and causes some of the stimulant side-effects (as a side note, the first day I take strattera I always end up lying around in a daze, and then after that it tends to make me a bit fidgety for the first hour or so after it hits my system), although it can cause drowsiness too. And you may have to take half in the AM and half in the PM for any of these drugs. Much like the stimulants, they'll require some fine-tuning to give them a suitable chance. If you go with strattera, by the way, remember that it'll take a few days before the effects kick in (usually 3-5 days for it to start working and around 2-3 weeks for it to hit full effect for that dosage...and you will likely have to increase dosage a few times before you hit the mark. Be patient! Despite what the label says, however, four weeks is almost never necessary for the dose to kick in; though it may be necessary to give you enough time to really evaluate her progress).
Stimulants CAN be mixed. Your doctor was giving you a good general warning, of course, which is not to add more fuel to a blazing fire. Odds are your daughter can't have much, if any, caffeine while on her medication because it overstimulates parts of her brain (making side effects worse). People who don't respond very well to ritalin-based or amphetamine-based stimulants are sometimes given smaller doses of each. The mechanisms of action are different for the drugs, though the overall effect is the same, and the combination can be even greater than either alone (the ritalin-based products bind to dopamine receptors to block re-uptake; amphetamine products also bind to dopamine receptors, and also norepinephrine to a lesser extent than dopamine but a greater extent than ritalin, but its biggest benefits are in the way it induces your brain to release more dopamine and norepinephrine into the system). This isn't used often, and it was a lot more common back before we had the nice array of non-stimulant therapies, but it's always an option. Your daughter would basically cut her adderall XR in half and take an appropriate dose of ritalin (likely concerta, ritalin LA, or focalin XR) in combination. The side effect profile should be about the same (depending on her tolerance to ritalin-based products), but some people respond very, very well to the mix. Run it by your doctor. It may be worth trying a VERY low dose of focalin (2.5mg or so maybe) with a lower dose of adderall. If your daughter's primary problem is that she has the gene that doubles the number of dopamine receptors in the ADHD-impaired region of the brain, then this will cause more receptors to be blocked, allowing the excess dopamine and norepinephrine released by adderall to stay in her brain even longer (producing more effect). Like everything else, it's all individual. I do suspect, however, that your doctor is going to suggest non-stimulant treatments before combined stimulant treatments. People have responded very well to that combination as well; probably more than those who responded better to combination stimulant therapy.
It's interesting that you bring up ADHD-I in the medication discussion. 70-80% of patients in trials have responded positively (usually measured by at least moderate improvement) to stimulant medications in the short-term. That leaves 20-30% of patients who don't respond well at all. And, don't be fooled, the VAST majority of people tolerate stimulant medication just fine. The ones who claim the side-effects outweigh the benefits (who aren't on completely improper dosing) are often the ones who aren't getting much in the way of benefits. A significant chunk of the people who discontinue stimulant medication due to a low response are diagnosed ADHD-I. For those who don't know the history, ADHD-I; ADHD-H; and ADHD-C didn't show up until DSM-IV. In DSM-III it was simply Attention Deficit Disorder with and without hyperactivity. ADD WO was never a particularly large group of people, but when DSMi-IV came out with ADHD-I, the numbers suddenly began to swell. At this point, in any given random sample of children diagnosed with ADHD, ADHD-I is likely to be the largest group.
This opinion may not make me very popular, but I'll give my two cents! One of the primary problems with ADHD as a diagnostic category comes from the source of the diagnostic procedures: the DSM. Since the disorder orginated in psychology (as opposed to, say, neurology), it is characterized by behavioral symptoms and not physiological symptoms. Ever shown an ADHD checklist to someone without the disorder? They'll say "That's everyone!!". Of course, unless the symptoms are producing clinically significant problems in at least two areas of life, then it's not really ADHD. But it gets the point across. The symptoms listed in the DSM for ADHD, particularly those related to inattention, can be symptoms of a broad set of neurological conditions. With ADHD increasingly diagnosed based entirely on checklists by doctors and psychiatrists with no significant background in neurologically based learning and cognitive disabilities aside from ADHD, this becomes a significant problem. Particularly when it comes to children, distractability and inattention are measured in very limited contexts. Since the classroom instruction is primarily oral, any child with an auditory processing disorder (or even a mechanical problem with the ears) will be easily viewed as inattentive. Add to that the fact that Central Auditory Processing Disorder tends to produce hypersensitivity to motion in peripheral vision (as a way to compensate for poorer auditory processing), and you've got a disorder characterized primarily by auditory and visual distractability! It would take quite the diagnostician to realize that the problem was poor auditory processing coupled with high visual sensitivity was to blame and not the area of the brain that processes and filters incoming stimuli. A child with visuospatial processing deficits will likewise appear to be highly distractable in a classroom setting (afterall, why would they spend their time looking at the teacher when they learn little, if anything, from visual input? And when it comes to activities that involve visual components- anything from playing with blocks to reading- the child is almost certainly going to show little or not interest in the activities. Add to that the strong possibility that this child's desk and backpack are eternally disorganized and messy (due to an inability to make use of "space" that they cannot adequately process) along with a tendency to forget where they've put things (since their brain isn't properly processing space and physical locations, it isn't going to be able to produce an accurate memory of the location of the lost item), and you've got one heck of a case of disorganization and inattention! Dyslexia, often characterized by slow processing speed but average working memory, will also produce severe symptoms of inattention in many children (there is a significant diagnostic overlap between dyslexia and ADHD; the jury is still out as to whether the disorders simply often co-exist, or if dyslexics simply exhibit enough of the symptoms of inattention that ADHD-I is being slapped on as well). Historically, the majority of studies on ADHD (unrelated to medication) have specifically excluded ADHD-I and ADD W/O subtypes specifically because they show such different clinical profiles than ADD W and ADHD-C.
That's not to say that people who have an ADHD-I diagnosis are somehow less impaired or less in need of help. It is interesting, however, that they tend to respond much more poorly to standard ADHD medication (though they tend to do just as well with behavioral and academic interventions) and show different clinical impairments than ADHD-C, which used to be the bulk of diagnoses. The ADD W/O and ADHD-I subtypes have been the source of endless debate for these reasons. My opinion is that people with ADHD-I (and many people with ADHD-C of course) are generally misdiagnosed. Or, rather, they're not diagnosed specifically enough. Most LDs are characterized, in addition to their primary symptoms, by non-sequential thinking and short-term memory impairments. Hence symptoms often thought to be primarily ADHD symptoms, like chronic disorganization and memory issues, are actually symptoms of a broad range of neurological problems. And, as I pointed out in my last post, stimulant medications really only demonstrate the "paradox" effect when it comes to hyperactivity: they continue to provide benefits for inattention and motivation as dose increases, and anyone who takes them will receive these benefits (much as anyone who has a cup of coffee will feel more focused). Being ADHD or not doesn't affect that part of the medication's benefits (hence why it's so popular on college campuses).
So many people whose primary problems are processing deficits still benefit from the medication in the short-term. In the long-term, however, that boost to motivation often fails to overcome the difficulties attributed with specific processing deficits: you can be as motivated as you want, but it's not going to change the fact that your brain still cannot process certain sounds and refuses to filter peripheral movement. Well, probably not anyway. Remember that the brain builds compensatory neural networks when a connection isn't working properly. (So the blind often develop keep hearing, those with broken reward and motivation systems develop self-stimulant hyperactivity, etc) Stimulant medications may help activate these compensatory networks (which are usually less efficient than what your brain would have produced without a processing deficit), but no amount of stimulation in those areas will change the fact that they're less than ideal wiring (hence why ADHD brains on stimulant medication are more normalized but don't resemble the brain activity of normal controls). And if the stimulants don't affect your particular compensatory areas of the brain much, or at all, then they're not going to do much for you aside from boosting motivation...which, again, will likely dwindle in the face of neurological barriers.
It's my personal belief that if stimulant medication works for your clinical symptoms, you should take it. It's as simple as that. But I do feel that most, if not all, ADHD-I individuals are being cheated out of proper therapy. More work needs to be done to determine where the exact impairment is and how to overcome it. Much like ADHD-C, someone with a processing deficit who is on stimulant medication is going to find a combination of medication (with a motivation boost and perhaps increased activity in compensatory neural networks) AND academic interventions aimed at their particular processing deficit to be the most effective treatment. Too often, however, they get a pocket full of ritalin that they hardly take after the first month or two and continue to fall behind.
The length and quality of this post reminds me why I should always take my adderall BEFORE activities like this! (That and it took me almost two hours to write it because I kept wandering away)
[QUOTE=molecularshaman]adderall and tolerance:
a subject i've been working on for a little while now.
1st of all; amphetamine binds to dopamine neurons in the brain. there is a chemical reaction as a result in which those nerves receive an increased influx of calcium ions (Ca++) which bind to them, which somehow "balances out" the effects of dealing with a synthetic drug. the nerves on one level percieve the drug as foreign, so it attempts to build a defense against its binding to them. it does this by "calling" calcium ions to the many docking sites along the nerve, which makes it more difficult for the drug to bind with the nerves after awhile. So, one of the most effective strategies (but most expensive) is using a Calcium Ion antagonist - the one i know of is Namenda (memantine); used for alzeimer's patients. but it'll cut the tolerance down by 40-50%.[/QUOTE]
Great info. Do you know if the same is true for medications other than amphetamines, e.g. will Namenda reduce tolerance to Ambien? I'm taking Ambien for chronic insomnia and am worried about long-term tolerance.
Phew!! interesting though!
Thanks for all those insights. I really don't want to increase her meds again nor does her dr. Thats why we are trying to figure out what other course of action to take. I know there are many reasons an ADHDer can struggle but then why has a small dose increase always worked great when her symptoms become worse? Also when she has had a dose increase it works great for a while and then gradually the ADHD symptoms begin to show up again getting worse and worse. The small dose increases have beeen very gradual from K through 3rd grade. Her very conservative, highly respected child psychiatrist said her brain is bascially "used to" the adderall and that the adderall is probably only about 70% effective at this time.
Her hyper/impulsive behaviors are very consistent no matter where she is although they do get worse later in the day as her meds wear off. She goes to a great private school where she has been since pre-K. They are very ADD friendly. She definitely has NO learning problems although I doubt she is gifted. They just tested her class for reading fluency and comprehension and she tested above 100% for 4th grade (she is in 3rd) nationally. SHe is one of the least anxious children/person that I know and LOVES school. Her hyper/impulsive behaviors are just very inappropriate and hard to be around. Just within this school year, she started the year on 30mg which she had been on for quite sometime already but was having trouble fairly quickly even focusing. Not only was the teacher observing it, her grades weren't great and she said she just felt so fidgety and was always looking for something in her desk instead of paying attention to the teacher so we switched her daytrana rather increase her adderall. The Daytrana was definitely better than the adderall had been when she switched but not nearly as good as the adderall had been when working to its fullest. The daytrana caused horrible skin reaction & MAJOR sleep issues so after 9 weeks on daytrana we switched her back to adderall XR 30mg again. Her dr thought it might be "fresh" again. This was right after CHristmas. It was GREAT at first. January and Feb. were great and then the ADHD behaviors started cropping up again but it was still better than back in the fall. Hse has gradually gone down hill. We are now in May back to where we were in October. This is all in one school year with very a consistent environment and a very ADHD friendly teacher. Her teacher doesn't make her write cursive since her print is so much better and recently put little pieces of astro turf on the sides of her desk for her to "fiddle" with because her fidgetyness had gotten so bad!
Sorry for the long respopnse and thanks for your insights. We truly believe that we have witnessed our DD develop a tolerance to the stimulants. Hopefully summer break from them will help!
First of all, KDMLaj, let me say that your posts are very informative yet easy for anyone to read and understand. Thank you for your insight. You are extremely well informed and well spoken.Thanks both of you for your perspectives! I'm learning a ton myself. To the mother of the 9 year-old daughter, I'm just playing devil's advocate here. Please don't read my responses as saying that you are absolutely wrong in how you and your doctor are dealing with your child's medication. You all know far better than a stranger what your daughter needs!
To chasemom...it's not just getting children to drink those shakes, it's getting adults to do it too! I know I struggled with that. It's easy to start drinking them because they're new and exciting, but after that wore off I was left with some pretty foul tasting drinks. One solution, if you find yourself needing it, is to use Naked Juice. Unfortunately, it's not particularly cost-effective (they usually go for around .50-.00 a bottle, but if you can find them sold in cases it's a bit cheaper). They have protein-enhanced juice that tastes like pineapple, and it may be easier for a child to take (note: it's about 40g of protein, so it may be a bit too chalky for them. Try mixing half of one with some apple or pineapple juice). Otherwise, I've found their "Superfood" juices (which come in a variety of flavors) to be excellent supplements. They're all made with pure juice, so they're very tasty. They are also all based in apple juice, and apples have more in them to wake up the body than a cup of coffee. So it's a great way to get your child started out fresh, and since it's pure juice and hence digested VERY quickly when taken on its own, it's a great pick-me-up for your kids during lunch or later in the afternoon when the meds start to wear off. If you can find a Whole Foods, Trader Joe's, or any similar store in your area it may be worth looking into. Even with an appetite stimulant, as you said, it can be virtually impossible to get your child to eat a balanced meal. Tossing one or two of these into their diet a day will likely have significant benefits. I definitely felt my concentration and focus increase when I was drinking these regularly. Just make sure they don't drink them right before or right after they take their adderall- the fruit juice interferes with absorption. (I used to set my alarm an hour early in the mornings to take my meds. Then I'd go back to sleep, and I'd end up grabbing one on my way to work, leaving plenty of time for the medication to be absorbed)
As far as the question..why does a small increase in adderall dosage always seem to be effective. That's a great one. I think ultimately we just don't know for certain. Due to the high response rates of ritalin and the belief that ADHD was a childhood illness, no one really bothered to study stimulants until fairly recently. So we're still working our way through exactly how they work, where they work, and why they work (though we've got pretty good ideas for most of those questions at this point). One thing that's worth noting again is that in the 15 years or so of heavy research into stimulant medication, we have found absolutely no evidence supporting the belief that people develop a tolerance to these medications when they are prescribed in approved doses. (Though, to be quite fair, most of that research was on short-acting stimulants. However, none of the studies on the extended release mixes have demonstrated any tolerance building in periods as long as two years at the same dosage)
The truth of the matter is that small increases in dosage will almost always turn out to be more effective than lower doses for certain ADHD symptoms. The reason being that these stimulants, while powerful, are given in such tiny doses that it's difficult to increase dosage to the point where euphoria kicks in- which would defeat the purpose of those benefits). The reason why we're told to administer them in the smallest effective dose is because higher doses will continue to be beneficial to a child's focus and motivation far beyond what is really necessary. (and because we haven't studied the stimulants beyond FDA approved levels- for children that's 30mg a day of adderall XR). Now, of course, side-effect profiles increase as well. Too much of a dose increase at once can create a range of symptoms, from overly anxious and active children to the so-called "zombie" effect, until the child's body has adjusted to the new dosage. This actually may account for why small increases in dose are actually more effective in the short-term. For overly hyperactive people, the "zombie" effect can feel quite theraputic. It is read instead as "calm" (which, to be fair, it is). Those of us who get the "zombie" effect with dosage increases (And I've certainly had them with increases as low as 2.5mg) can attest that it feels wonderful: it's a relief from how we normally feel. But, as your body adjusts to the new dosage, the "zombie" effect fades.
At this point, I'm going to veer off into my own personal experience with adderall XR and dosage changes for a second. Like your daughter, impulsivity and hyperactivity are among my worst symptoms, so it may be analogous. I increased my dosage of adderall from 10mg slowly up to 20mg, eventually switching to Adderall XR in the middle of that (I was taking 30mg XR and adding 5mg every four hours). The reason why I kept increasing my dosage was because every increase in dose initially gave me a small dose of the "zombie" effect, which I interpreted as the medication working. Then, of course, that would wear off, and I'd end up even more hyperactive than before because I had more of the stimulant in my body and was quite prone to side-effects with stimulant medication. I would read that as needing more of the stimulant to get back to "calm". Fast forward a few months, and I'm on a dosage that is actually making many of my symptoms much worse than they were before- particularly my lack of internal calm and impulsivity. At the same time, my ability to focus was continuing to improve, so I felt that the increases were more beneficial than they actually were. I finally backtracked and went back down to 15mg at a time, and I realized that it was doing more for my hyperactivity than the 20mg was.
What's key in that is just how easy it is to confuse stimulant side-effects and ADHD behaviors. Particularly for children, who are prescribed stimulants at a higher amount/kg than adults are. Even when children receive the same amount of stimulant/kg of body weight as adults, their systems still show 30% more exposure to the stimulant (likely due to their increase metabolism), and females tend to show more exposure than males on average to boot! That is why children tend to be more sensitive to dosage increases than adults.
Stimulants work on a push-pull system when you're suffering from hyperactivity. Since the hyperactivity is your brain compensating for lower levels of activity in one area with increased activity in another, you get what appears to be the so-called paradoxical effect. The stimulant medication we're taking is increasing activity in a number of regions of the brain, including the area responsible for motor activity. But since they also increase activity in the area of the brain that is being compensated for, the net result is a reduction in symptoms of hyperactivity. However, too much of that same stimulant can increase activity in the motor activity area (and other areas) beyond the amount of activity being reduced for stimulating the ADHD-impaired areas of the brain. This is when you know you're taking too much: the side-effects are outweighing the benefits. Ironically, at the same time the increase in activity in the ADHD-impaired area dealing with focus and motivation can continue to produce benefits in those areas even while the hyperactivity/impulsivity symptoms are getting worse.
Since adderall XR in particular takes a while to reach Tmax levels (between 5.5-7.5 hours on average), the first few hours on the medication may actually be just fine, and the last hours (say around lunch or post-lunch classes) may be worse when the levels of the drug have increased. Of course, you can also have the exact opposite result when the first few hours aren't enough, and the last few hours are where the person needs to be (this tends to be more often the case, especially in adults). As your body begins to adjust to the medication levels, you see a reduction in side-effects of the stimulants. Depending on what the side-effects were (for some it's a bit of the zombie-like calm; for others it's an increase in heart rate and such), that can change how one begins to judge the effects of the medication levels in their body. Medication holidays followed by reintroducing medication into your system generally cause side-effects to become worse again for a shot period of time. If one of those side-effects is the "zombie-like" calm, then it's more of a side-benefit than a side-effect. But it will, unfortunately, fade.
The truth is that ADHD is on a continuum, and we all have different levels of brain activity in different regions. It may very well be the case for your daughter that her levels of hyperactivity and impulsivity are too high to be solved solely through stimulant medication (due to the push-pull effect I mentioned earlier), as was the case for me. In this case, mixing in a second stimulant, ritalin-based, instead of increasing the initial stimulant may be the answer. Or, as you've already suggested, mixing in a non-stimulant medication may be the answer. (I'm fairly certain you'll find that it is indeed the answer in this case) And, of course, it may be that simply increasing medication dosage is the answer. But generally when you've had to increase the dosage continually in a span of a year, it's a sign that the medication isn't working as well as it could. That's usually the point where a good doctor will begin suggesting switching to a different stimulant or combining the original stimulant with an additional medication.
But heck, no one really knows what is right until they've tried it. Unfortunately, as difficult as it is to get ADHD adults to self-read accurately, it's even more difficult for ADHD children. It makes this whole medication game more of an art than a science at this point.
Phew I'm long-winded