Concerta and morning irritability?

[lovemy2]

DS8 (72lbs if that matters) was diagnosed by a psychiatric in Jan with ODD and borderline ADHD. He has been on 2mg on Intuniv given at bedtime which has been nothing short of a miracle after two years of therapy and school struggles. Once school began this year the emails from his teacher began. He is getting irritable with other children and is not focused. Took him to the pediatrician and she started him on Concerta just to get him through the day. 18mg at first and we saw nothing. Upped to 27. His teacher says his focus is better but he is really irritable and aggressive the first few hours of school and then is great the second half of the day. I give it at 7am because any later and he cannot fall asleep. pediatrician is now saying she wants him referred by psychiatric again which will be weeks waiting for another appointment. She will not up the Inuniv either and will not consider another stimulant until after psychiatric. To make the situation worse we are moving soon to an area with even less available care so I need him stable ASAP. We currently live in a small area and she is the only pediatrician that our insurance will pay for. The psychiatric here cannot get him in until after we move so I'm stuck trying to convince this pediatrician to try something else.

I plan on meeting with her again but I'm wondering if it is normal for the Concerta to cause irritability for only a few hours? He is great for me in the morning and is fine in the evening. It is just the hours from about 9:30 until noon-ish.
I'm so stressed out I cannot sleep and I need him stable before our family moves. I'm going to ask for a neuro-psychiatric evaluation when we move and am willing to travel for it.

 

[InsaneCdn]

Hi, and welcome.

I'm not familiar with Intuniv, but very familiar with Concerta (and ritalin).
To me, it would be very unusual for Concerta to create the behaviour pattern you describe - doesn't mean it isn't possible, but I haven't experienced that, nor seen it in other families I know. Far more often, there is an irritability called "rebound effect" that kicks in when the Concerta starts to wear off - and you aren't seeing that, it seems.

I'm just a parent, but... could there be some sort of reaction between the Intuniv and the Concerta?

 

[lovemy2]

Assuming it is not Concerta related, could there be any other explanation for difficulty the first few hours of school? Teacher said that he gets irritated with classmates and has meltdowns. Something switches and by the afternoons she said that he can tell her when someone is upsetting him and even if he gets a behavior card at the end of the day, he can talk about it without getting upset. It's all very strange but I need a game plan with this doctor.

No concerts at home this weekend and minor meltdowns but nothing major. Even got him to clean his room with minimal complaining (that's huge).

 

[InsaneCdn]

What is the reason for not using Concerta on the weekend? I'd have thought - especially initially while you're figuring out what works - that it would give YOU a 24-hour picture that you don't get when difficult child is in school?

 

[lovemy2]

I gave it the last two weekends but did not this weekend. I wanted to see if he was irritable without the concerta. Dr is convinced the morning irritability is ODD and not medication related. I cannot eliminate the ODD but I can the medications. Assuming I cannot get in to see her until later in the week, I'm considering not giving concerta at all until we see her again. He did fine last year without concerta but I know things change.

 

[InsaneCdn]

Was the morning irritability there before starting Concerta? If not... then somehow, either Concerta is giving an atypical reaction, or there is an interaction between the two medications.

 

[BusynMember]

My son was aggressive and mean on all stimulants. I am thinking that maybe the dose is too high so that your son is crabby in the morning and better in the afternoon when it wears down a little. I'm not a fan of ODD (the diagnosis...many of us are not) and I also know that doctors don't like to blame the medications or reduce them even when it warrants trying that out. I have no idea why they don't, but I've been on medications most of my life and they tended to ADD medications when I would complain about a symptom, not consider that perhaps the medication itself was the problem. I think it's a good idea to try him off the medications on the weekend to see for yourself. Often I had to swtich doctors because a doctor would not believe a medication was actually harming me. The doctor would usually blame something else and up the dose but I knew better. I was almost always right. In your case, use your mom gut. Doctors aren't Gods. They are often wrong. We know our kids.

Intuiv, I believe, is long acting Concerta. (I can't spell it though).

 

[lovemy2]

I honestly cannot remember how he was before the medications. I've emailed his teacher to see if she does.

I know Intuniv is long acting Guanfacine. I wanted to avoid stimulants initially and he has had no side effects with the Intuniv.

 

[InsaneCdn]

For the record, Concerta is long-acting methylphenidate (of which Ritalin is the brand-name short-acting form).

 

[buddy]

I'm not sure I have this straight and admit I haven't read all of the thread. Did you say that the concerta was started because of similar behaviors but once on the concerta he got more irritable in the earlier hours?

My son has taken ritalin and concerta for years. I have felt from the beginning it made him more crabby. But the benefits out weighed the negatives. Now in the last year as his aggression has increased at times again I (with permission ) reduced his dose at times to compare. He is much less oppositional and not as aggressive with about one third the dose less. Our psychiatrist was very clear (and his neurologist had even said this could happen as he gets older) that going down was always preferred if possible and that for children especially any individual can have responses like that. She is specifically trained in how bodies process drugs and did research at mayo Clinic. Nice for us because my son has an enzyme deficiency (two enzymes that are needed to metabolize some drugs are very low) and she worked on research for that. ( we.found her after his gen pediatrician found the problem ) So blood levels and therapeutic doses have to be very individualized for him. While learning about this I've read that there is such individuality in how we process medications that eventually dosing may be based on all of us having the enzyme tests to help guide medication selection and dosing. Anyway, I'm no expert but really get that each person is highly varied and thank God our doctor (mom to three with special needs ) never questions that it is likely medications....likes to test that theory first.

She and neuro have both told me to expect that as he gets older ...more importantly, as his frontal lobe develops more, he may need less and the stims for some can be more like they are for non adhd folks ......making them less helpful for what we sought treatment for. Not true for everyone .....but to watch for that.

****She also discussed how Concerta was developed to give a more even blood level compared to some other long acting forms of Ritalin. But, again it is individualized as well as not being a constant level. She describes it in general as 30-60-30....which I can't explain well but to say that if in your son's case the earlier hours are not yet at the level he needs maybe it is actually that he needs a small short acting dose till it fully kicks in. Just another idea compared to thinking the total dose is too high. I could be way off, its just a thought.

When we hit a point where we weren't sure of the most effective dose we went back to short acting to see what dose was best then converted that to the new concerta dose. Our doctor also said that.for some, other forms of long acting ritalin just work differently and are better for a given person. (We have considered patches because they work for us with the clonidine he is on) .

Anyway, bottom line yes for us it causes irritability but in your specific situation it could be interesting to see if it is dose related.
medication stuff hurts my brain sometimes, LOL.

 

[BusynMember]

I honestly cannot remember how he was before the medications. I've emailed his teacher to see if she does.

I know Intuniv is long acting Guanfacine. I wanted to avoid stimulants initially and he has had no side effects with the Intuniv.

Oh, that's right. My bad!

 

[TerryJ2]

My son is irritable after his Concerta wears off.
It's possible that his does is too high, since he's better in the afternoon.
Of that it's related to something else. Bright lights and too much noise first thing in the a.m.?
How is he with-you on weekends? Does he get to sleep later, have things go more slowly? Does that help?

 

[buddy]

But if the time it is better is not at the end of the dose but a few hours into it then (generally ) the blood level would be higher not lower at that point. So unless he metabolizes it ultra rapidly it shouldn't be wearing off but at the highest level during those hours. It's an interesting pattern.
Looking at the schedule and environment is a great idea. Some schools do more heavy academics before lunch too. What does he eat for breakfast, any protein? Does he have a morning energy snack he could bring?

 

[lovemy2]

Morning academics do involve math. He struggles with it but can do it, he just needs encouragement according to teacher. He even has trouble at carpet time though. Much of his irritability has to do with classmates trying to re-direct him and he lashes out at them. In the afternoon, however, he takes their re-direction just fine. Teacher did say that afternoons are better since he started Concerta. We started the Concerta to help him with focus at school.

 

[InsaneCdn]

What time does he take it in the morning?
Like buddy, I'm wondering if it takes too long for the therapeutic level to build up?
In that case, he may need a small Ritalin boost to help with the initial time period.

 

[Bluenose]

My difficult child was switched to Concerta (from Biphentin) 5 weeks ago. Last week I call the doctor because she had become very aggressive and irritable in the morning and evening. He said to take her off the Concerta and go back to the Biphentin. One week later and there is peace in the house again.

 

[lovemy2]

Thank you for all of the suggestions. I had been giving it at 7am but did not over the weekend and did not give it for school the past two days. Teacher says he has been having trouble but is less irritable. Tomorrow we see the Pediatrician to see if she will try something else or blame him and send us to Psychiatry.

 

[TiredSoul]

My difficult child takes 27 Mg concerta and 2 Mg Intuniv also but he takes them both at 7 am. Have you considered giving the Intuniv in the morning? Also could it have anything to do with something he eats for breakfast or being hungry and then feeling better after eating lunch?

 

[TiredSoul]

My difficult child was switched to Concerta (from Biphentin) 5 weeks ago. Last week I call the doctor because she had become very aggressive and irritable in the morning and evening. He said to take her off the Concerta and go back to the Biphentin. One week later and there is peace in the house again.

Bluenose - that is interesting since those are both methlyphenidate. I had to look it up because I have not heard of Biphentin. Here is something I read which may explain why it didn't work the same - maybe releasing less medicine at first and causing more rebound in afternoon/evening.

Biphentin is a methylphenidate drug too, but the mechanism of action is different, instead of being a ''pump'' pushing the drug during the day (OROS mechanism), is multilayers beads that melt gradually during the day . And Biphentin is 40% first layer and 60% second layer and Concerta 22% first dose and 78% second and third dose.

And this -

One final difference between Biphentin and Concerta is that Biphentin releases approximately 40% of its medicine in the early part of the day, whereas Concerta only releases 22%. This may mean that Biphentin may work better for ADD/ADHD in the morning, whereas Concerta may last a little longer into the day.