Taking the A Train, Part I

Two months since my last post, whaaaat?

Summer time is always busy, but geez. Being Cancer Dad will sap your time.  At the moment, I’m staying in the hospital with my son (we’re on day 5 now) so I’ve got to write or risk climbing the walls.

On the AD(H)D front, I went to see an ADHD specialist about six weeks ago.  He’s a physician who specializes in ADHD treatment.  I had a recommendation from a friend about a year ago to see this guy, but, ahem, ADHD.

I went to see him on a Thursday morning his office is in East Grand Rapids, a tony part of town (there’s a yacht club, for Pete’s sake!).   EGR is about an hour from my house, and I had taught a class the night before in Grand Rapids and decided to stay over with my brother who lives downtown GR.  I did not sleep well, unfortunately, and was quite tired that morning.

I found my way to the Sundance Grill for breakfast, had some fabulous breakfast tacos, but felt weird dining alone at a place with table service. I kept eavesdropping on all the business meetings going on all around me.  The best conversation was at the next table; a business man from Ecuador was being entertained by a local guy.  At first, I thought the local guy was being kind of rude, all he had to go on was stereotypes.   You like soccer down there, right?  But it turned out Mr. Ecuadorian returned those stereotypes right back. You all play baseball up here, yes? Mr. Grand Rapids said he actually didn’t like baseball all that much.

I got to Gaslight Village early, found the doctor’s office, then hit the Starbucks down the street to wait. My nerves were getting the better of me.  As I said, EGR is a tony part of town, and I was surrounded by very successful looking people in sailing, tennis, or yoga outfits, with the occasional hipster thrown in for seasoning.  I’m more at home in the university crowd with a bit of earthiness thrown in by going to my local Biggby’s in a college town, where someone wearing Carhartts might have just arrived from a construction site or an art history class (or both).  In all honesty, the pending appointment probably kicked up my hyperawareness a notch; my first meeting with a psychologist many years ago I started to question the choice of magazines and muzak in the waiting room.

I forced myself to wait long enough not to arrive too early, and then walked into the door of the doctor’s second-floor office at five minutes before my appointment.  The office was empty, not even a receptionist.  Knowing that this doctor himself has ADHD, I wondered if he forgot my appointment.

Instead, he appeared at the door and said “You’re early!  Remarkable!”  I guess not too many of us ADHDer’s show up on time.

I took a seat and he got ready for me.  I went in a few minutes later and we started the consultation.  I had very thorough testing before, so he didn’t see the need to re-test me, and instead we talked about why I had come.

I talked about being on Ritalin and that it was sort-of working sometimes.  I got about two hours of benefit from each 10mg pill and then felt terrible when it wore off.  I had filled out extensive paperwork ahead of time with medical history and self-reporting of symptoms and we went over that. (Another sign that they were used to dealing with ADHDer’s: the staff would not schedule an appointment for me until after I had filled out and returned the paperwork.)  I also talked about my son having cancer and my needing to have more executive function so as to be more reliable and available to support him and my family.

We talked about my issues, such as not being able to get things done on time, not being able to stop doing things that I get involved in, my unreliable performance, etc.  I also talked about how I couldn’t understand why Concerta didn’t work for me.  On straight Ritalin, about 40mg a day seemed right (four 10mg pills) but the constant roller coaster was exhausting.  I felt constantly fatigued and downright hopeless most of the time.  On Concerta, I never got the full feeling of benefit even though I was taking 54mg (Concerta is Ritalin with a time-release mechanism).  And I had been working with my GP who basically let me decide what to try (“sounds like the wrong person is driving that bus,” he said).

The doctor had the simple answer to this confusing problem: “Some people respond more to the slope than the level.”  Ritalin has a sharp up and down level in the bloodstream.  The dose of Concerta I took had had a higher overall level, but a relatively weak up slope.

Oh.

We talked through various other things and then he said I had sat long enough for my blood pressure to calm down.  My blood pressure always measures as borderline, but I was just the high end of normal, even though I had been nervous.  “Perfectly normal for a stressed-out dad.” At my GP’s office, they take my BP as soon as I get there, so I always measured higher than when I measured at home.  He also took my weight and height and, demonstrating his ADHD, forgot what my weight was in the time it took to walk over to his computer to record it.

He went through a lot of PowerPoint slides on his computer, showing me the different slopes of different drugs and talking about brain scan studies.  He was careful to say that the brain scan stuff is easy to oversimplify and overdetermine, but (putting it simply and deterministic) my brain is inefficient because it tries to use emotional motivation for almost everything instead of more logical motivation when it is appropriate. (And that everyone is always a mix of emotional and logical motivation.)

That trend in my brain is both inefficient and exhausting.  It means I have to be “in the mood” for everything, even routine things that should not have an emotional investment, and that I spend my life trying to generate mood and feelings to motivate my work. I felt that was an apt description of what I feel going on in my head.  I told him that when I need to write, one trick I use is to Google Image search for writers, writing desks, writer’s studio, etc. Looking at those pictures gets me in the mood to do the work a lot of the time. He thought it was a great example of using creativity to work the problem.  One of the biggest problems I have is switching gears.

So I left with a prescription for Adderall XR and Wellbutrin. He had noted I was reporting depression symptoms and asked me to rate my depression on a scale of 1 to 10. My answer was 8.5, hence the Wellbutrin.  I was to start the Adderall first for four days, then start on a low dose of Wellbutrin.

I also had an appointment in a few weeks and a fat bill I had to pay up front.  This office does not bill insurance.  That’s something that made me put off getting my first appointment, until I read this in Jennifer Koretsky’s Odd One Out:

In the United States, most insurance companies reimburse health care providers so little that they are forced to see 4–5 patients an hour just to make a living. This is unfortunate. And it’s particularly dangerous when a healthcare provider who sees you for 10 minutes a visit is your psychiatrist, or other doctor prescribing your ADD medication! I always recommend that my clients see a psychiatrist for their ADD medication. And, due to the current state of the U.S. health insurance industry, it’s not uncommon for a psychiatrist to stop taking insurance once they have established a practice.

While this doctor is not a psychiatrist, the insurance bit seems to apply.  I have good insurance, so it will be paid for, but I have bad follow-through and may not get around to submitting my claims.

Next installment: All Aboard!

You must take the "A" Train ...

You must take the “A” Train … (Photo credit: keithcarver)

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18 thoughts on “Taking the A Train, Part I

  1. So what WAS the explanation about concerta?

    Always funny how unpredictable dose response is. I’m a 125lb girl and I need either 20mg ritalin or 72mg concerta!

    Also curious how Wellbutrin works for you!

  2. good job. the xr will probably do the trick. so you need a strategy to get the insurance filed.
    one possible approach would be to do it now.
    and since both the adderall and the wb can raise bp, you are right to be paying attention to it.
    best wishes
    doug

  3. Hey man. Clearly you have a lot on your plate, but it’s so important that you are continuing to take care of yourself and your ADHD. Stick with it. The condition itself is a bastard, and I understand how it distorts your life and makes it difficult to enjoy. Having had a sick child as well, it really makes an already impossible situation somehow much worse.

    I have a bad case myself, and meds don’t seem to help much.The best results I have achieved have been the result of daily visualization exercises and a shit ton of positive self-talk (Tony Robbins kind of stuff that I used to openly mock). For me, anxiety and negativity exacerbate my ADHD like gas on a fire. Taking the gas out of the equation (largely) has helped my state of mind immensely. So, don’t forget to take time to celebrate little and big successes, and how far you have come. Give yourself credit for your progress, and get excited about future improvements. I’m not sure if you are hearing it from anyone else, but believe this: you can do it.

  4. Wow, that whole bit about finding emotional stimuli to get work done sounds so familiar – with me and my kids. Maybe I am more ADHD than I originally thought.
    My daughter has been on Ritalin, Concerta and Adderall. I found all three had benefits and drawbacks. Hopefully you’ll find the right one that works best for you.
    Oh, and way to go on following through with the appointment. Especially as you going through so much right now. Pretty impressive in my books.

    • Don’t know the outcome yet; parts 2 and beyond to come. Right now it is hard to separate my usual ADHD stuff from the extra stress from my son’s cancer. Like we had an unexpected week-long hospital stay with him last week, which coincided with the end of the semester this week which is stressful anyway, and, and, and . . .

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  8. My 7-year-old son was recently diagnosed with ADHD, and my father is ADHD, and I have an anxiety disorder. My psychiatrist believes the anxiety disorder may have come from living a lifetime with untreated ADHD, and all of the anxiety that being forgetful, scatterbrained, restless and easily distracted can cause. I’ve developed more coping mechanisms to try to get through life with this brain than I can count that have led me to become extremely neurotic and worried about what I’m forgetting all of the time. I’m sure you understand exactly what I mean.

    After trying everything possible to avoid medication, we finally gave in and decided to medicate my son. He takes 10 mg of Adderall every morning, and we’ve seen behavioral improvement at home and school, and his self-esteem is rising my the minute. I decided that if my little boy can be brave enough to try medication, so can his mom, and discussed my symptoms with my psychiatrist, who prescribed a regimen of three 10 mg Adderall pills per day for me until we figure out what might work. We’re assuming because ADHD is genetic and runs in families, hopefully what’s working for the kiddo will help me too.

    I just wanted to thank you for writing about your experiences with ADHD and medication because I’m just embarking down that path for both my son and myself, and really appreciate your information and input. Please keep us updated about your progress if you have the time.

    My heart is also breaking for you as a parent that you are having to deal with childhood cancer and a sick child. I can’t even imagine how awful that must be, and I’m sending much positive energy your way as you fight the cancer with your son. xoxo.

    • Thanks for your comment! I was actually diagnosed with generalized anxiety disorder in the early 2000’s, but like you I think that was just secondary to having to cope with all the ADHD problems. Medication has been a love/hate thing for me. When everything clicks I can understand what it might be like not to have ADHD, but it is maddeningly difficult to get the dosage just right.
      Thanks for the positive thoughts about our son. He’s doing quite well at the moment, though we’re at an in-between place in his treatment. It’s better to know what’s going on and be treating it than having mystery symptoms (for him and for me!),

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