Evening "Med Crash" Struggles

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    • #61815

      I’m new to this whole ADHD, thing. When I went through the process to adopt my daughter, they taught me about Fetal Alcohol Syndrome, Reactive Attachment Disorder and Post Traumatic Stress Disorder. They didn’t say a darn thing about ADHD (which is odd because it usually accompanies FASD). As it turns out, my daughter has all of the above. We are working really hard and have come a LONG way with her other diagnosis, but the ADHD has been kicking our butts. She is not hyperactive but struggles more with the impulse control and is very defiant. Because of her attachment issues, her behaviour is always directed at me. She will lick me, paw at me, pull my hair, poke and prod me, talk back constantly, ignores my requests… etc.

      She has been on Concerta for a while now and it is night and day. She is a kid I actually want to be around and in fact, quite enjoy! She is also doing much better at school, both academically and behaviourally. But, in the morning before it kicks in and the evening as it is wearing off, her behaviour goes back to really awful and she also struggles to fall asleep. I love my daughter to pieces, she is the light of my life, but lately I am finding myself burnt out, spiteful, resentful and unable to control my own frustrations, yelling at her all of the time, doing neither of us any good.

      I have an appointment with her Paediatrician in a couple of weeks and wanted to ask about a drug that is round the clock. I did some googling and read that non-stimulants like Straterra and Wellbutrin are 24 hours and can be taken in combination with the Concerta.

      Does anyone have any experience with these drugs and did they help the end of day “med crash”? I could deal with the difficulty falling asleep if the attitude was better. I just want to have my awesome kid 24 hours a day because this mama is tired of the morning and evening battles. Any and all suggestions welcome!

    • #61820

      I was having the same issues when my son took meds. My son was also on Concerta and it helped somewhat. I did notice he became more aggressive when the drug was wearing off so we spoke to his psychiatrist about it. He prescribed Guanfacine, just 2mg, to be taken as soon as he got home from school. Kept him focused a little longer for homework and kept him from having that med crash. Unfortunately, my son pretty soon afterwards refused to take medications so I can’t tell you long-term how well it worked. Now we’re battling trying to get him to take meds again as his home behavior is awful when he doesn’t get his way. My suggestion is you talk to a child psychiatrist as they’re the experts in psych meds. Our pediatrician wasn’t an expert and just prescribed a bunch of meds hoping one would work. Best of luck!

    • #61824
      Penny Williams

      Intuniv (guanfacine) is frequently prescribed with stimulants for this reason and to ease behavior a bit when stimulants aren’t in the system.

      Intuniv: Answers to Your ADHD Medication Questions

      There is a “major” interaction warning between Wellbutrin and stimulants, so you have to use extreme caution there. I know some doctors prescribe them together, but I’d leave that as a last resort, personally.

      There’s a moderate interaction warning between Concerta and Strattera. There have been some parents on this forum whose kids have taken this combination successfully.

      Here’s more on how to lessen rebound:

      When Meds Go Bad: After-School Rebound Strategies

      ADDitude Community Moderator, Author & Mentor on Parenting ADHD, Mom to teen w/ ADHD, LDs, and autism

    • #61878

      Hi! My son is 6, dx at 4 with ADHD and ODD (oppositional defiant). We used guanfacine starting at age four and still do, along with a stimulant. My son is defiant and oppositional, as well as hyperactive and impulsive but has no symptoms of inattention. We have been quite happy with guanfacine; it helps a lot as a “bridger” for when stimulant wears off after school. It also helps with emotional regulation. I saw a youtube video of Dr.Russell A. Barkley talking about guanfacine and how it helps with emotions etc, so that might be worth looking into. We dose our guanfacine in an unusual way, just solely based on trial and error of what worked best and we have been at 1/4 of a pill in the morning with the stimulant and then the remaining 3/4 at 4:30pm, using that dosage schedule for over a year now. I find that it helps my son to sleep at night (without it the stimulant keeps him up, even though he takes it only once early in the morning). His behavior is far from perfect with just guanfacine in the evening, but he is not bouncing off the walls, completely out of control like he would be without it. I have to rely on a lot of behavior modification in the evenings to get us through. I hope that helps. Best wishes, thinking of you.

      • #61901

        All of the comments about Guanfacine almost have me sold, but if it isn’t enough to manage the behaviour in the evenings then it won’t work for us. My daughter isn’t “hyper” (or at least not enough that it’s a problem), for her it is the impulsiveness which leads to the defiance and mouthing off. It is extreme in the evening and that is when her PTSD kicks in (she’s scared to go to bed) so I must have the ADHD completely under control so we can tackle the other stuff.
        I will definitely ask her paediatrician about it, though, because it sounds like it could be an option!

        Thank you all for your replies!

    • #61886


      I’m an adult, and felt the same thing when I was studying and working long days.. the Concerta would taper off mid-shift in the evening and then I couldn’t get a handle on busy bar orders. Strattera isn’t commonly prescribed in Australia, so we came up with the idea of adding 10mg immediate release Ritalin around 6pm, so I would remain medicated long enough to finish work and get home. Worked a charm! Also, because I’d had a full and productive day I was usually able to slide into bed happy without churning thoughts. And it saves introducing a new drug with potential side effects. Good luck with you and your sweet girl!

      • #61902

        Thank you, I’m definitely going to ask the doctor about a quick release dosage and see what she thinks.
        We’re in Canada so I’m not sure which drugs are common here but probably the same as the US
        I’m curious to know if Straterra is enough on it’s own, in which case maybe she can come off of the Concerta instead of taking both.

    • #61903

      My son’s symptoms are largely affected by his emotional state. Especially the defiance/impulsivity. Example: my son gets upset because my daughter has a cousin her same age and we go to the cousin’s house for family functions. My daughter has a playmate over there, and he doesn’t, so his impulsivity seems to be heightened, and he is prone to behavior that is out of his norm. He got in trouble the last time we were there for impulsively hitting someone and also for bugging the dog, things he doesn’t normally do but he was acting that way because his emotions were running high. A lot of ADHD people are like that (Dr. Barkley has also written about emotions + symptoms). A lot of times there’s a lot of “stuff” going on and they just don’t know how to express or process it appropriately so they act out, and every kid is different in how that manifests. If your daughter is triggered by bedtime, then I think it sounds a lot like what we experience with my son when he’s upset; I think your daughter’s emotions are probably heightening her symptoms and making it sort of unbearable for both of you. Meds might be able to help a little to sort of calm that down, but I think it might be more of a therapy thing too, considering it’s trauma/PTSD related and ADHD etc. It sounds like you’ve already had/are doing therapy for your daughter so maybe bring it up with her therapist or talk to another professional about other options to address this particular issue.

      • #61907

        Huh… that’s definitely food for thought. It’s hard with multiple diagnosis because they overlap and sometimes I can’t tell which behaviour is caused by which diagnosis. I can say that her emotions are definitely playing a part in worsening her ADHD symptoms so I’m hoping that meds will help deal with the ADHD response so that I can deal with the PTSD. Because when she’s on an ADHD “high”, nothing positive comes out of it. We can’t get to helping her manage her emotions because she’s so wound up.
        We have a new bedtime routine we’re trying this week and it’s going okay, but it would be going much better if she wasn’t arguing and mouthing me off 24/7!
        Thanks again for your input, I appreciate it!

    • #62068

      Our 12 yr old son was diagnosed 5 yrs ago with ADHD & has been on varying dosages of Adderall. Adderall has a kick in time of about 45-60 minutes. I used to give him his meds as soon he woke up, recently tho, I’ve been giving him his meds a 1/2 before I actually need him to get up so the kick in time is less. But this works because I can give it to him then he goes back to sleep for that 1/2 hour. This might be a good option for you guys in the morning. I was reading your responses to the commenters. I used to give our son a quick release of Adderall for afternoons he had sports practices. It was not good. The come down from as AWFUL! So just be sure to you investigate the side effects of the quick release. Insomnia/sleep issues are common for people with ADHD. You might want to try either Melatonin which is a natural, non- addictive sleep aid. Our Pysch also prescribed Tenex. Good luck!

    • #62069

      Our daughter is 7.5 and taking 18 mg Concerta at 7:30 am. At 7:30 pm we give her .01 mg of Clonidine and 5 mg of Melatonin to go to sleep by 8:00 pm. She has been on the Clonidine and Melatonin since she was 5.5 and we just started the Concerta 4 months ago. So far it’s working well but her doctor did say that we might consider an afternoon “bridge” dose of Ritalin after school if we find her symptoms are not controlled. We’re going to wait and see.

    • #62089

      We do the “homework dose” of Ritalin 5mg (Concerta in the morning, 36mg) at about 4pm … we actually also do the guanfacine/intuniv in the evening… we arrived her by trial and error and sometimes it feels weird to have so many different meds but it actually works for us which is a sanity saver…. that said, it has been a rough month or so and it may be time for. Achange up… however I wouldn’t recommend switching completely to a non-stimulant (like strattera) if a stimulant is working for a good part of the day. Consider adding or even adjusting the dose of the stimulant… good luck – it is hard for sure!!

    • #62092

      Do your homework very carefully on Strattera. Doctors who are skittish around stimulants seem to really like to push this one, but I’m not impressed by the efficacy data, and it can come with a side of mood instability. I’ve encountered a handful of people who take it and swear by it–but only a handful.

      Wellbutrin is the non-stimulant that I have observed and experienced to be the most effective. That’s anecdata, not actual data–but for what it’s worth, I’m hearing it repeated by a lot of the folks I encounter with ADHD, *as well as* a lot of the clinical professionals I collaborate with. It’s solid anecdata, as such things go, lol! Helps a lot of people, myself included, with focus, motivation, intentionality, impulse regulation–and I encounter almost no one who experiences significant side effects. Across the board, it seems to play nicer with ADHD than SSRIs or SNRIs.

      The other one you might ask about is Adzenys. It’s a reformulatiom of Adderall, but it’s meant to last 12 hours, instead of the 8ish that you get with Adderall XR. My med provider offered it as an option, when I asked about an immediate-release evening dose, and it’s been *great*. I don’t have to remember an extra pill; I’m definitely getting a solid 12 hours from it–and I’m seeing additional benefit from not falling off the stimulant cliff in late afternoon/early evening. It feels much gentler; I can tell when my ability to concentrate starts to taper off, but it’s not the sudden drop into chaos that I was getting, before. I had no idea how irritable that made me, until it stopped–sounds like it might be a help to your daughter, as well!

    • #62094

      We live in Canada. We too adopted and ended up with alphabet soup. ADHD, ODD, RAD, FASD, and more…

      Our 9 year old son has the same effects, crashing after his Concerta wears off and falling and staying asleep.

      We started with Intuniv, it was OK. No major side effects, but we knew he could be better at school if we could help him further. Increasing the dosage didn’t do much.

      We switched to Vyvanse. That was so horrible. He didn’t sleep for a week, way too stimulated and more impulsive. We didn’t sleep either!

      We changed to Concerta and have had one dosage increase. It has helped enormously with attention, impulsivity and he has been able to learn at school. A lot of that also has to do with the quality of teaching, small class sizes, and support from administration.

      Mornings can be a bit rough, but if we get up early enough, keep a strict sequence of activities and don’t rush things, it seems to work out. Plus, if he gets things done early there is iPad time as a reward. Some people like to give medication to their child an hour or so before they get up, in order for the medication to start when they get up. Our problem is then it wears off too early.

      The draw back has been his appetite. He would skip lunch if it was up to him. We ensure that new teachers know this and they watch him. We also pack a nutritional supplement like Ensure for those days that he just can’t eat, he still gets calories. We find it important to ensure that he does get food in as his Concerta wears off around 2-3 pm. He is voraciously hungry at night. He can have supper, and then snack until bedtime which again happens more likely when he doesn’t get food at lunch.

      For his aggression we give him Risperidone three times a day, one when he gets up, one at lunch at school, and one when he gets home.

      For sleep, he used to be a kid that would take forever to get settled for sleep, sleep three hours and then be up. A few things have happened over time. One, we knew he had a small head (microcephaly), but after getting a lung function test done, we found out he had asthma. Getting him on puffers has helped. He showed no symptoms and the doctor ordered the test on a hunch. He is also on a nasal spray Omnaris at night. As he’s gotten older he is able to tell us more, but when he was younger, we never wanted to sleep with him as he kicks, lashes out with his arms and sits up and flops over into a new position. About an hour before bedtime, we give him Gabapentin, this is to help him sleep longer and supposedly to help with the restlessness. It seems to be working. We also give him Clonidine. This is new, he used to be on a high dose of Trazadone, but it looks like he will be diagnosed with a genetic disorder that lists Trazadone as risky. Then 10 minutes before sleep, we give him Melatonin.

      I know this seems like a lot of medicine. We feel the same, but we do have a boy who gets rest at night now. So do we! He can get 10 hours straight now. More rest means happier boy!

      The best advise is to see a psychiatrist. I know the wait time is long, but it is worth it. We also have a sleep doctor for him too.

      I don’t know where you live in Canada, but in Alberta, there is FSCD, Family supports for Children with Disabilities, there is funding that you can apply for to pay for respite, over night care and other things.

      Not like you need more things to do in your crazy life, but I find Jeff Noble an excellent resource for FASD. http://fasdforever.com/ Ross Greene is an excellent resource for behavior. His philosophy is that all kids want to do good, but don’t have the skills. So instead of punishing them, help them. http://www.livesinthebalance.org/parents-families

      Hope this helps!

    • #62120

      Hi. I feel your pain! Two years ago I could have written your paragraph about being “burnt out, spiteful, resentful and unable to control my own frustrations.”

      My 11 y.o. son has ADHD (mixed, but mostly inattentive), anxiety, and a tendency toward depression — so not quite the same cocktail your daughter has. We found Concerta worked well during the day, but once he got used to it, his symptoms were worse than ever before when it wore off (or if we forgot to give it to him on the weekend). We also found ourselves yelling far too much and his self esteem took a huge hit, as we were always angry when the “real” him came out.

      We switched to Strattera. It was a ROUGH transition for him emotionally (perhaps because it took place over the Canadian winter, when he has a tendency toward seasonal depression) but has worked out fantastically for him. He has now been on Strattera only (plus a bunch of supplements) for 18 months. It doesn’t help as much with focus as the Concerta did when it was working, but everything is much more even throughout the day. It took 6-8 weeks to see the full benefit, and weeks 1-4 were really, really difficult. So I encourage anyone who is trying it to stick it out. In hindsight, we should have continued the Concerta or a morning dose of Ritalin during the transition.

      Strattera definitely does not work for everyone. I was so impressed with it for him that I tried it for myself and had absolutely no benefit. But then stimulants have no benefit for me either, unfortunately.

      He has started middle school and if we find him struggling, I’ll consider a small dose of a stimulant for during the school day.

      Even without a stimulant, he struggles to fall asleep. We give him magnesium, L-theanine, and melatonin before bed. I recently learned that 300 mcg (roughly 1/3 of a mg) of melatonin is the ideal dosage, and now order it online since I’ve never seen less than 3 mg doses in stores.

      Overall, it’s hard to know just how much of his current success is due to Strattera, and how much to Neurofeedback, which he started around the same time. I am sure the Neurofeedback has been beneficial, because once he evened out on Strattera we could still see weekly improvements during periods of Neuro. It’s not cheap, and like medications, it doesn’t work for everyone, but I highly recommend looking into it. We are lucky to have excellent coverage, but if we were paying 100% out of pocket it would probably have cost us around $3,000 so far ($100 per session) and I think that would have been worth it (but of course $3,000 means very different things to different families — if that $3,000 would have otherwise been spent on a family vacation, I’d say neuro could be well worth trying, but if it would have been spent on food then neuro is an expensive and risky experiment.)

      Have you looked into EMDR? https://emdrcanada.org/emdr-defined/ It sounds kind of wacky, but I’ve been doing it with a psychologist who is not at all wacky and have seen remarkable results for myself in terms of core beliefs about myself that I just couldn’t shake. It is supposed to be effective with PTSD and RAD. http://reactiveattachmentdisorderlife.blogspot.ca/2008/12/emdr-and-rad.html

      Best of luck! I hope you’ll update this thread after you’ve seen your doctor and tried something new.

    • #62129

      I have a daughter, 8 years old, going to be 9 soon, in 3rd grade. Her impulsiveness was OUT OF CONTROL. We did therapy for 2 years, started on Concerta. This helped a lot in school, but we experianced the same… terrible evenings and rebound behavior. It was heartbreaking, because when we could get her calmed down (we offered sleepy-time tea, calm bedrooms, lavender diffuser, Church Music, all of it), she’d cry and be very sorrowful that she hurt others, that she was crazy, and she’d tell us that she remembered her coping skills we learned in therapy, but just “couldn’t do it”. She’d cry that she wanted to be “like other kids”.

      We took this to our doctor, who added Clonidine 0.1 mg; 1/2 tab in the AM, full tab at night. I was very skeptical because the reviews for this med are kind of heavy (as they are with all psych meds and children), but we tried it for 30 days. WHAT A DIFFERENCE! The first day or two was kind of weird; she reported she felt “drugged” and “tired”, but after that (which she got lots of TLC!), she came home from a full day at school and said, “Mom! I can think clearly and I have time to make the right choices!” Now, we see her using her coping skills on the regular. The clonidine does knock her out at night within an hour of taking it, and she *needs* a full night’s sleep to wake feeling rested.

      GOOD LUCK!

    • #62144

      We are new to medication for our 9yo boy who has ADD and NVLD diagnoses. He went on Metadate 10mg in the morning back in August. We noticed the “hard crash” almost immediately; it was very out of character for him to be so emotional. We went back to the prescriber to trouble shoot and we got microdoses of ritalin short-acting- 2.5 mg to take at school at 1230P and optional second booster dose of 2.5 when he gets home at 400PM. It seems to be helping- the crash is less emotional and volatile, and he’s more reasonable.

      Sharing this in case it helps anyone to bring some ideas to their prescriber. Medicating is such a tough road- good luck everyone!


    • #62211

      Hey there!

      My daughter is a month shy of 9 years old. She was diagnosed when she was 5. She is *very* ADHD- and I have felt all those feelings. One time I stopped the car on the side of the road to get out and open her door and yell at her- so I knew she was paying attention. And then I cried all day because the guilt at having lost it that badly- in her face- broke my heart! I digress (she comes by the ADHD honestly…) For the last two years she has been on 72mg of concerta a day. Concerta takes about 2 hours to reach its potential- so I give it to her at 6am and let her sleep a little longer before I get her up to get ready for school at 8am.

      We, too, *had to* address the morning and evening times when the concerta was not in her system. We first added 1/2 of the 0.1mg Clonidine in the morning and a full tab at 7:30pm- so she could sleep. We soon added in another 1/2 tab of clonidine right when she gets home from school- especially now that she is a third grader with homework!! This has worked wonders (We still deal with 8 year old drama….normal 8 yr old stuff) As a second grader she was on the “all A” honor roll ALL YEAR. She has come a long way- the first week of Kindergarten she whacked the school counselor in the face.

      Adding something extra to a primary ADHD medication is not unusual- and definitely worth talking to her doctor about. Clonidine works well for us, I know nothing about guanfacine, but her doctor will have an opinion I’m sure. Sending best wishes from one Mom to another.

    • #62232

      I have 3 kids with ADHD and sensory processing disorder. We also struggle with the med rebound and morning craziness. One med that really helped was Daytrana. It’s a version of concerta administered by patch. The best part is you can apply it 1/2 hour before your child wakes up so the med is working before their feet hit the floor. It also works great if they sleep in on the weekend, because you can apply it any time. Just remove the patch 3 hours before bedtime. We found that the rebound effect was much less with the patch.

      For the ODD/backtalk, I highly recommend the website http://www.empoweringparents.com. they have real, usable, practical advice for handling difficult kids (I’ve got one). The most important thing I’ve learned about my ODD daughter is to walk away. ODD kids LOVE to argue. They don’t care if they win or lose, they just like the power struggle. So, the best thing to do is disengage and come back when she’s calmed down and ready to listen.

    • #62350

      Hi there! We have had the same issues, I think it is very common. It seemed like everyone else was getting the benefit of my Son being on his meds but his family at home. Mornings were awful and evenings worse. We tried the Daytrana patch and it has made a HUGE difference for us.

      He doesn’t seem to have the harsh “peak” like he did with all of the pills we tried (Focalin was the best and last). He also eases out of his meds in the evening really nicely without the crash. I put the patch on him as soon as he has showered in the morning and take it off when I give the night time meds. We do Melatonin and just added a little Clonidine for sleep and so far everything is really working great!

      I also made a chart for morning routine to take myself out of the morning craziness. He is 10 so I feel like he should be able to get himself completely ready for school at this age. He checks off each item he needs to do to get ready, AFTER he completes it. It is very detailed to help him. At the end of the week if he has completed each day successfully, he gets a special treat (ice cream, movie, etc.). I tell him Mom needs lots of coffee and time to wake up, so if he can do all of this on his own, I not only will be proud, but we won’t have the morning struggles. He is doing amazing and has really taken to it. Now I am out of the loop, he is proud of himself and he is learning the responsibility and routine of getting ready for school. Win-win.

      Good luck and hang in there!

    • #62498

      Sounds like her dose is too high. If it were right, she could sleep without difficulty and the crash shouldn’t be epic. Overmedicating does leave to a behavioral improvement over properly medicating just like a normal person could abuse a stimulant to clean the house really thoroughly. That doesn’t mean it’s a good long term strategy. The right dose gives her the chance to choose to control herself. It doesn’t give her a MOTIVATION to do any task set before her. Overmedication does.

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