strattera vs concerta | ADHD Information
My son is 10 years old. He was diagnosed with ADHD inattentive type. I am constantly trying to get him to focus on his homework. The doctor recommended Strattera and Concerta. Can anyone tell me the pros and cons of this drug. Does your child take one of these medicines. If so how are they doing? I am scared to try these medications but I am running out of ideas as to how I can help him. The school district I live in will not help me because I go to a catholic school. Special education teacher will not be provided so I am on my own with this matter.
Can anyone help me!
i can tell you first handed that strattera is better. I am 13 and i just got diagnosed with ADHD in Octuber and they started me on Concerta. After i was on it for a while i started having really bad mood swings and not being able to sleep at night. I didn't sleep for five days straight and that is when my doctor and counseler started getting worried. So they decided to put me on Straterra. For the first three weeks i felt nauses in the mornings but then it really started to take action. My grades went from straight E's to B's and C's.Just a little from a kid who went through it.
Please read my post on Concerta.My boy just turned 12 a couple of days ago,so he is close in age to your son.If I knew what I know now about Concerta,I personally would not have waited this long to try it.As you are well aware raising a child with this condition is so Stressful on the entire family! When your child succeeds-so does everyone around him.Good luck.Feel free to ask any questions,be happy to answer. My son will be 12 in March. He was on Concerta for about 2 years. I loved it. The only problem he had was after a year, he started having stomach problems, so we lowered the dose and after a year same thing. We just put him on Strattera and it seems to be OK so far. The only thing with Strattera, you have to give it 3 to 4 weeks and the side effects ususally go away.My son was on Concerta about 2 years ago. The medicine worked great in the morning, but by the afternoon his body was metabolizing it too quickly and the medicine was basically wearing off, no matter what the dosage.
We then switched to Adderall XR and are SO pleased with the results. As with all the different meds he was on he had some quirks the first week or two......biting nails and becoming overally emotional about certain things.
Good Luck and God Bless.
I am 19 years old and have tried everything from ritalin t concerta which worked for a while but i had stomach pain. strattera makes me zombied out and SUPER focus on work and if i stop moving i get bored and agitated and i need to get back ti doing things. it weird but i don't like the side effects. Usually i take in in the morning 40mg strattera and it starts working and uaually i'm at work. after 15 min i start organizing my things i am workin on at the time and i don't move till it;s time to leave or even stop to talk toanyone. i kinda block out everything and stay focused on work till it starts wearin off. anyone think adderall would wrok well? can Anyone tell me the adderall is compared to strattera as far as side effects. i don't wanna be zombied out.
I HAVE A 10 YEAR OLD DAUGHTER THAT TAKES STRATTERA. SHE HAS HAD NO SIDE AFFECTS. IT IS A WONDER DRUG FOR HER. Just a word of praise to firsthandkid you seem to be a very intelligent kid. much success to you
My 14 yr old son has been on concerta for over a year (we live in the uk) we have been up to 54mgs last year but he wasnt eating and his personality was completely flat (we are usually living with Jim carey 24/7!) Our latest combination has been to get 45 mgs (from 18 plus 27) - he is still not focusing well at school, is very 'silly' and irritating and not achieving his full (quite high ability) educational potential. We are torn between having a 'zombi-fied' completely compliant child who achieves high results at school but who hardly eats and is not our son and someone who is often in trouble for minor misdemeanors at school, says he is bored but eats, sleeps (well with melatonin) and is fairly popular. I guess my question is - has anyone come accross this discrepency before between the relatively similar doses of 54mgs and 45 mgs and how have they managed this, do different makes of the same dose have different effects and if anyone has tried anything with Concerta which makes a difference
with many thanks in anticipation of lots of replies
jan
my son was on ritilin and was doing great but it only lasted while he was at school and when he got home he was wild so the doctor put him on cencerta it didn't do a thing it was like he was on no meds at all and he lost weight where on ritilin he gained 6 pounds. We just started him on straterra and although I see a difference the teacher says he's coming along but not as good as he was on ritilin.
I like the straterra because it is not habbit forming and my doctor says we can always increase the doses he is only on 25 mg but his teacher thinks he should be on ritilin do you think I should listen to the teacher or should I do what is best for him and give the straterra a chance.
I say you know a lot better what's best for your child than the teacher does. My experience has shown that the teacher is far less interested in the welfare of the child than they are about what's ultimately easiest for THEM to get through the day. Besides, her time with him is over in 3 months but your son has to continue on with ADD. My experience with my daughter has also shown me that kids who don't respond well to stimulants (Ritalin, Concerta) will respond better to the non-stimulant Strattera. I guess the important thing is, have you asked your son which one he feels better on?
I would not be to antagonistic towards our teachers for wanting to help us, our children, their classmates, and themselves. I like teaching in Sunday School for one hour per week. I think it is very difficult to manage a class of 30+ students for 30+ hours a week. The pay is not what keeps teachers devoted to educating our youth. Also they have an advantage of seeing our child in realtion to 30+ of their piers.
I think one of the most distructive aspects of ADD/HD is the high probability that we develope a sence of low self esteem. Negative feed back we get from everyone affected by our impulsivity, lack or concern for consequences, irratability, moodyness, inattention gradually wears us down. Many people with ADD/HD feel depressed and escape into fantacy or hyperfocus on things that interest us requardless of the surrounding situation. (The teacher is trying to teach a curriculum that they are held accountable for.)
I am an older (56) ADD parent with three ADD children. I learned about ADD 12 years ago, while getting my son (now 23 working as a plumber) some help for lithargy, depression, anger, and fighting in school. I have 22 year old daughter in her third year of college (just formally diagnosed with ADD) who is getting a 3.9 GPA with help on Ritalin and Wellbutrin. She is so greatful for the help, and constantly thanks us for being such good and concerned parents. (This makes all the struggle, prayers, counseling worth the effort.) My 15 yr old daughter will take her ritalin 20SR if we ask her every day. She is still embarrased about needing the help.
I and my children have gradually overcome the stigma, embarrased feeling about being "mental" or "crazy" and accepted the fact that we are different. We stopped caring so much about what other people think and start doing what is most benefical for us. Now, with the help of medication, we can tap into our full potential and become productive happy people.
I have espressed by personal experiences with trying the "non-stimulating, non addicting, Strattera. I feel angry that I accepted the lie that it is non-stimulating and wasted a month and a half trying various strengths with out getting 2/3 the benefit of ritalin. The negative side effects are 10x worse that anything I have ever experienced on ritalin.
I think those who buy into the addicting fear of stimulant medication do not fully understand the fact that people who have ADD/HD have brains with different chemical proplems. I am calmed by ritalin. My anxiety level decreases, I have patience, and I am more considerate of other people's feelings.
THIS IS THE NUB OF IT ALL.
MY EXPERIENCE: I think I am anxious and fear that someone is going to observe me "spacing out" or hyperfocusing on a very interesting tangent. Or worse yet, not observing my tangent or giving credence to anything I usually say. Then I come back into the discusssion with some idea I have extrapolated while on my personal quest, full of excitement at the idea I have to offer. I CANNOT WAIT to share the idea and blurt it out!!
THEIR EXPERIENCE: Everyone has been politely waiting to take their turn to contribute their single itteration of an idea to the topic at hand. They are shocked with the inappropriate level of enthusiasm, and confused with the strangeness of my comment. (I have gone through 3 or 4 levels of exprapolation while they are waiting patiently to contribute one idea.)
They are angry that I have jumped the line, interupted the flow of the conversation, and may be caused them to forget their thought. If they are able to "catch up" and follow the line of thought I have contributed, they may also feel angry that I am showing them up or even angry at me for being so enthusiastic and excited about my idea and not giving them their due respect for their ideas.
The negative and angry comments, torpedo my enthusiasm, and shock me. Why could'nt they appreciate my great idea? Almost everone seems to feel that I have done something rude and innapropriate. WHAT IS WRONG WITH YOU?
I wonder - what is wrong with me? I leave feeling unappreciated, and slip into a depressed and withdrawn space to lick my wounds, and find some sollice in a non-people related activity.
Can anyone relate to this experience? Does this help any non-ADDer relate to the ADD experience? This is such a great idea!! Does anyone have any positive feedback to help me reestablish my self esteem? No? I was just hoping- -
This forum is a theraputic place for me I would like to develop another forum on the aspect of ADD/HD and self esteme. Any one else interested?
wmp
TO OLDMAN 56
First of all, I can't speak from experience because I'm not ADD -- but my daughter (who is adopted) is and so is my husband. My husband was only diagnosed in adulthood and has had some measure of success using Dexadrine, but he's also very aware of his ADD and has always struggled to overcome its obstacles as best he could. Because the whole dynamic of it is so foreign to me, I had a real hard time dealing with my daughter until I really started studying the subject. My daughter was 4-1/2 when we adopted her (from Russia, so we had some real language and bonding problems to begin with) and she was diagnosed when she was in the first grade. For years I just kept wondering (to myself and, often, out loud to her) why don't you get it? you're just not even trying! I've had to read every book I can find on parenting an ADD child because I have to keep reminding myself that it's not her fault and she's really got some serious obstacles to overcome. Her self esteem is also pretty low most of the time because, of course, she has such a hard time keeping friends around and teachers are always hounding her to "live up to her potential" even though they KNOW she's ADD (why don't they make teachers learn more about this subject for god's sake???).
I guess the reason I'm writing this is because it's so interesting to me to hear from someone your age. So often I wonder what my daughter will be like in adulthood and if these problems will somehow just go away for her. Apparently the best we can do is just keep being aware of its existence and working on it all the time. What you said about Strattera, though, I want to reiterate what I keep saying (my daughter started on it a year ago after trying all the stimulants) -- the manufacturer makes it very clear that if stimulants are working for you, you should not switch to Strattera. It isn't for everyone, but it has been know to help those for whom stimulants don't work. When it first came out I think people were so excited that there was some new drug to try -- that maybe it would be the magic bullet -- but the manufacturer makes it very clear that it's not a magic bullet and is not for everyone. So I do defend it as an ADD med, particularly since it's been helpful for my daughter.
As for you and your self esteem issues -- first of all, I think your kids are very lucky to have a parent who can truly understand what they're going through. Have you tried contacting your local chapter of CHADD (http://www.chadd.org/)? They're probably the best known of the ADD organizations and I'm sure they have groups, etc. you can attend. I would think talking to other adults who know exactly what you're experiencing would be very helpful. I hope so.
Thanks again for giving me a little look into the possible future for my daughter.
To skg122596 I want to thank you for the encouragement in making my own choices and not the teachers. I am married to a teacher who teaches high school he knows the way teachers feel with 30 plus kids a day I also work in the school system as a teachers aid so as for you oldman 56 although I value your opinion it is your opinion and yours alone and their are people on my side in this.
Thank you again skg122596 you are a person who understands the pain we all go thought to make the decision to put our children on stimulating meds.
I have asked this once already. My daughter was diagnosed with ADHD in a mild/medium version. we had her on ritalin at school and home 7 days a week no breaks or we couldn't cope (nor anyone else) and tried concerta...not sure if it is a fluke but after 3 days it is like a MIRACLE 
and seem very happy. she is eating, sleeping and getting along better with everyone (cat and dog included) does this last for long or is it a "short term" thing. Anyone who has been here I could use some help. We are still learning about this and with all the couselling and support people we somedays feel OVERWHELMED.
thanks for anyones help
LiasM, It is interesting to me that you frame this issue from a competative point of view. I am not taking any side, although I am positively biased towards medication since it has been such a benefit for me and my family.
I am also biased toward helping anyone learn about the positive and negative aspects of ADD and various medications.
I do believe that ADD is something we are born with and inherit from our ancestors. I know from personal experience it is something that can easily be treated by stimulating medication.
Why try to create a more tramatic situation for anyone by denying someone a medication that works? Would you deny a diabetic insulin? Would you propose an alternate method of behavioral modification to deal with the the transfer of glucose across the cell membrain? If insulin was classified as a stimulant would you have the same bias against insulin?
ADD is similar to diabetis in that ADD brains are missing chemicals which allow our brains to processes information, easily access memory areas to check our past experiences and filter the spontainious flow of information from our sensory inputs.
The PET scans have substantiated the theorys that ADD brains process information differently. One finding I found very interesting was that when we try to concentrate, out frontal lobe activity decreases. I cannot recall if the same studys compared scans of the same brain on and off medication.
I am saddened by stories I have heard of some youth saving their medication and giving or selling it to someone else. I think these same young people are driven by a typical addolesent need to belong. They feel different, have been told they are special, unique, slow, etc. They are willing to give up something that is helping them to prove they are worthy to belong to the non-add group. Sadly it is the medication which will accually fill the chemical deficency in their brain and allow them to think and act like a non-add person.
Eventually - hopefully they will learn to accept they need some help, and put a high value on the benefits of using medications that fill the gap and make it easy to study, work, socialize, belong. I am so grateful for my medication I would not give it to anyone. I regularly discuss the benefit I have recieved and encourage others who exhibit ADD like behavior to seek advise from a physician who understands and treats people with ADD.
I fear that the lack of understanding and empathy of parents in denial will retard the progression of other people like me. Our children will act out our feelings about ADD. If we are loving, honest about the problems we had at their age, and discuss the problems associated with ADD, the solutions, and benefits, then I believe they will come to accept they have a problem and be willing to accept the solution. My 22 yr old daughter and I have become much closer, as I have given her the counseling and courage to discuss these issues with her primary care doc.
Fortunately she found a female doctor who does not presume to know everything and refered her to a psychiatrist who specializes in adult ADD. He ran her through a battery of tests, a self behavioral survey, and conducted two face to face interviews. He placed her in the upper 90th percential of all the people he had tested. She had been working 10 times as hard non-adders to work 20hrs a week and attend JC. She was able to pull off a 3.25 GPA but at great personal stress and feeings of being inferior. I was not pushing her. She wanted to prove to everyone that she was equal. Now that she has medication, she is enjoying her upper division classes, has a social life, and is optomistic about graduating.
We are much closer now that we have talked and share the experience of having to deal with ADD. We have a closeness now that we used to have when I held her in my lap and read stories to her.
Parents, if you do not have ADD be very careful about the messages you are sending your ADD children. Your lack of understanding may be interpreted as lack of love, your incredulous looks a some manifistation of ADD behavior may be interpreted as criticism and contribute to low self esteem. After all - if we do not love and accept our children and their deficiencies, how will they grow up to love and accept themselves?
wmp
To...all, I guess
Oldman56, so much of what you say is so true. Everything I've read indicates that ADD is inherited -- they don't know what causes it, but they do know you are far more likely to get it if one of your birthparents has it. They suspect it may be linked to drug or alcohol abuse by the birthparent (which would make sense, since my adopted daughter's birthparents were both alcoholics), but again, they don't know. All they know is that it's a chemical imbalance that really does exist and people who have it aren't acting "that way" on purpose!
Also, it's funny you should compare ADDers taking meds to denying a diabetic insulin -- I've been using that same analogy since my daughter was first put on meds. Needless to say, well meaning family members kept asking if that was really necessary ("can't you just take sugar out of her diet or something??"). My response was -- yes, it's necessary. She has a chemical imbalance. And it's not caused by too much sugar in her diet!
I also fully agree that meds alone are not the answer! The best thing we can do for our children (or spouses, even, if they have it) is to arm ourselves with education on the subject. I read everything I can on ADD because I really just want to understand my daughter so I can help her. We started a behavior modification chart about 6 weeks ago where she earns points for fulfilling certain daily functions (everything from washing up in the morning to cleaning up after herself after a meal to doing homework and turning it in -- things that non-ADDers do automatically but ADD kids often forget to do unless reminded on a daily basis). She collects the points and turns them in for treats that she's picked out (everything from a special dessert to movie night to a lobster dinner!) The more points she turns in, the bigger the reward. I also started taking kids books out of the library on ADD/ADHD (she's ADHD) for her to read and understand that she's not alone. She sees a child psychiatrist who specializes in ADD, but I don't find it very helpful so I'm thinking about getting her into a specialized playgroup for ADD kids that helps them learn how to socialize. It's nice because all the kids in the group start in the same place -- being ADD.
I never realized being the parent of an ADD child is almost a full time job in itself (even more than just plain parenting alone!) but my daughter is so sweet and happy and full of life and potential that I feel it's really my obligation to help her any way I can, even though it would be easier to just keep yelling at her to do better. I suggest to all parents who are not ADD to just keep reading, reading, reading. The libraries have great books on the subject ("Drive to Distraction" is sort of the bible of ADD).
Sorry this is so long, but I guess we're all pretty passionate on the subject.
Hi all, Someone wrote earlier that ADD is genetically-caused. But there is a HUGE problem with that statement: How does one's genetic code actually bring about a disorder like ADD? Does it send out a memo, telling all the cells to line up in an ADD formation? NO! One's genetic code uses two systems for making illness or wellness happen: one is through the use of electrical impulses. The other is using the body's natural chemicals. These chemicals are 100% natural, AKA "bio-chemicals." Usually, when an illness takes place, it's because the body simply does not have enough of the right bio-chemicals to make everything work right. For example, there are literally millions of cases of ADHD that are caused by a lack of Omega-3 fats in the brain. Other symptoms that typically coincide with this deficiency are: asthma, dry skin, dyslexia or dyspraxia (or apraxia), visual acuity problems, etc. The child needs these fats, NOT drugs! B. Jacqueline Stordy wrote about this problem in "The LCP Solution." In my family, my son's so-called "ADHD" was caused by a lack of B-6. He hasn't been on ADHD drugs for 8 years and is doing very well. Anyway, the point of this posting is just to say that when doctors tell you "ADD is caused by genetics," they're showing their ignorance of the truth. AMA and APA doctors don't even study the biochemical causes of disease, so how can they say it's not true? Doctors are trained to prescribe drugs, period. Drugs only control the symptoms of the disorder and rarely cure anyone. As for "CHADD" supposedly being a good source of info on ADD, keep in mind that it is really a marketing tool for the company that manufactures Ritalin: Novartis. Our entire "healthcare" system needs revamping but that will never happen - there's too much money to be made from drugs. Linda To skg122596 et al. I appreciate the feedback. With respect to the issue of inherited trates and links to alchohol or drug abuse. I propose the following.
Add/hd is and has been a biochemical problem for a long time. We are becoming aware of its prevelance through education and mass media. I think drug and alcohol abuse are symptoms of the root problem not the source of the problem.
People who come from generations of genetically concentrated ADD trates may live in culture of poverty or are underemployed in temp jobs and do not have access to good healthcare. They never meet a physician who understands and treats add may result to easily available drugs and alcohol.
Thom Harman (I think it was Thom) suggests that a very high percentage of the prison population is affected by ADD/HD - high risk behavior, lack of concern for consequences, irritablity, anger, and frustration. These people are dropped through the cracks in an education system that is not properly educated about ADD behaviors, lacks the funding to properly deal with the large numbers of young people with "behavioral problems". Young uneducated truants are living on the streets where they are easy prey for local "phamicological entraprenures" who are grown up unemployed ADD/HD children
ADD/Hd people need something to quiet the constant unchecked stimulas that our sences feed our brains. Since stimulants and other controled substances are not legally available to them, they buy under-the-counter meds without instructions on how to use them properly. They end up abusing them as an escape mechanism from the frustration and depression that results from being intellegent, underutilized beings with out hope of legitimately getting some thing better.
They do not trust their parents or the educational system, the government that has not understood or heard their initial crys for help.
I am so grateful I found help. I say daily "There but for the grace of God - go I."
This is why I am so parochial in my tyrades on this forum. I wonder how much more productive our entire nation could be if all the people affected by ADD/Hd, (non-adders and adders) could get the treatment they need from infancy. How can we measure the waste of talent, and the drain on our society for not addressing this issue head on.
We need more compassion and understanding and less judgment of and limitation of effective medical and behavioral treatment.
wmp
concerta 54 worked for awhile for me but the effect seemed to have worn off. is this possible? will changing medications help? i'm 21 and inattentive ADD, day dream all day and wander into space.
TO JAN FROM THE UK:
Did your son come from 36 to 54? Or 36 to 45 to 54? Because if the 36 wasn't working well enough, and he went up to 54 (which was too much) and then came down to 45 (which is too little), I would say that he needs to be introduced more slowly to the higher doses. What I mean is that he might actually be better off at the 54 in the end, but the body has to get used to the dose for a few weeks (even 6 weeks, to be sure) before it will be ready to adequately adapt to a higher dose.
If, however, he went from 45 to 54 (and he had been at 45 long enough to adjust to the dosage before you went up), you could try adding on 2.5 or 5mg of an immediate release methylphenidate. That will keep him in the same therapeutic class that he is already in (ie. methylphenidate), and it will increase his dose, but not as high as 54.
Also, to answer your question about the pills, if I understand you right, your asking if three 18mg pills is equally efficacious as a 54mg pill? Yes, it is. Any dosing combination works as well as any other to get you to an end point mg.
Hope that helps!
Beth
Hi,I'm a 19 year old college student with ADD-inattentive type. Right now I'm taking 54mg of concerta and it works really well for me. I had been on stratterra but I felt no change at all. I took it for about 2 months and nothing happened. I know medicine works differently with different people, but that one just did not help me.
Hope all is well!
I am 190lbs, 56 yrs, my doc asked me to move from 10mg and 20SR ritalin to "non-stimulating Strattera. I continued on ritalin and started 40mg of strattera for four days and then stepped up to 60mg. The first day on 40mg within 4 hours I had to take 3 times as long to drain my bladder. I felt "wired" tense, tight headed and shakey. When I stepped up to 60mg my family said I became irritable, and snapped at them. I felt tense and agitated. I discussed this with my doc and she suggested I drop the ritalin. I thought it would take 2 weeks for the strattera to work. That may be what the Lilly reps say to keep people taking it hoping that the nasty side effects will subside. I felt less aggitated off both ritalin, and strattera, but I felt fogged in and listless.
I gave the 60mg strattera one month trial, and I did notice my energy level picked up after about 10 days. I was able to focus about 70% of the time, but I still had impulsive tendancys. The side effects listed in the Strattera Poll I set up on the adult adhd forum are still a problem.
I have dropped back to 40mg of only strattera and feel about 60% as sharp as I was on ritalin. My family says they liked me better on ritalin and my wife encourages me to drop the strattera and go back to my 10 and 20 mg ritalin 2x a day. I have a couple of days to back off the 40mg strattera and then I am going ask my doc to give me the ritalin scrips again.
I appreciate the positive comments about concerta and AdderallXL. I may ask doc for a trial of each to see which works better for me.
wmp
I might suggest a search over all form headings for topic of Strattera to pick up on comments in the other adhd forums.
wmp
Teresa - I'm not an expert on meds but, as a mom who's been through the ADD routine, I know that it's quite possible that your son is unable to focus because his brain is missing something it needs. According to B. Jacqueline Stordy, in "The LCP Solution," most kids with ADD have a lack of essential fatty acids, also known as Omega-3 or Omega-6 fats. It's easy to supplement the diet with these capsules. Also, have his hair analyzed at a naturopathic doc's office: this analysis will tell you which, if any, minerals he's deficient in as well as if there are any toxic metals in his system, such as mercury, lead, or arsenic. He might also be reacting to a food. Allergies are well known to cause attention problems. One last, but really important thing: read about "pyroluria" at alternativementalhealth.com or restorativehealth.com or other sites. All four in my family have pyroluria and it causes everything from anxiety to ADD, bipolar and schizophrenia. Hope some of this info helps - Linda P.S. One more thing: drugs never cure ADD - they just control the symptoms of it. I decided that wasn't what I wanted for my son, so I found the natural causes & natural cures that I've written to you about. Getting him off the drugs was definitely a good thing. He's 22 now and doing great.
My daughter, 8 1/2, mid 2nd grade, has been on Concerta since the begining of first grade and did well on it. But now, it has stopped working. So we are starting Straterra. Don't know a thing about it. My doctor said you could safely using Strattera with another stimulant like Concerta without worry. He also said that if my daughter was his, he would start out with Strattera, so I feel ok about it. But with Concerta, Savannah had no problems, Sometimes when she crashed in the evenings she would cry or become irratable. I liked Concerta MUCH better than Adderall. Any info on Straterra would be helpfulMy daughter was diagnosed ADHD when she was 6. She'll be 12 this May. We tried just about every stimulant you can imagine -- ritalin, adderall, concerta and a host of others -- but nothing helped her. She has shown the most progress on Strattera, but not what you'd call remarkable. Strattera is great from a number of viewpoints -- it's not a stimulant, it's not a controlled substance so you can get refills. The problem (as I see it) is that it's dosed based on the child's weight. My daughter is a just a skinny little thing and Idon't think the dosage is strong enough for her. Anyway, it really has been better (for her) than the stimulants. The important thing to remember is that if your child is doing well on stimulants, DON'T change that! In other words, if it ain't broke, don't fix it. But concerta is nice only because it lasts the whole school day so children don't have the embarrassment of going to the nurse's office at lunch to get another dose (or, in our case in private school, never being reminded by the teacher to go get the afternoon dose).
Hope this helps.