Russell Barkley, Ph.D., is considered by many professionals to be the most authoritative expert (researcher), on the cognitive/behavioral aspects of ADHD.
In his book, Adult ADHD (2010), he details a study where he followed a group of non-ADHD young kids to age 30 and compared them to a group of ADHD kids. There were about 100 kids in each group.
The most striking finding in this study is that untreated ADHD impairs functioning in every area of life. They are less likely to be employed, and if employed, make less money, have had more jobs, have less education, worse grades, or took longer to get through school. They were also in greater debt, had more relationship problems, worse health, more traffic tickets, and other legal problems.
In my clinical experience over the past 40 years I have seen more people’s lives dramatically improve with ADHD treatment than any other mental health condition I treat, usually by prescribing a stimulant.
Long-term adherence to treatment is a problem with all medical and mental health problems, but many times it is because patients did not get the right medication(s) at the right dose(s). Sometimes cost is the primary problem but adequate generic medications and sometimes patient assistance programs can solve that issue.
We ADHD personalities are driven by interest rather than importance. We tend to be easily distracted and have way too many things on our mind at any given moment. ADHD medications can help us be calm and focused, and not only cope with our rapidly changing modern world, but actually thrive.

Question: Dr. Jones
My son is 14 yrs. old and has been diagnosed with bipolar more depression than mania. ADHD and Anxiety. He is on 150 mg of Lamitical, and he is starting 36mg of Concerta, and is currently on 80mg. of Prozac. My son has severe social anxiety and performance anxiety. He is a select basketball player and baseball player. He has dropped all sports due to anxiety. The only thing he does now is ride bikes with his dad and works out at the gym. We are looking at also having to home school him due to his condition. He is very smart, talented in music and sports, but locked up with anxiety. Can you please help. We have also tried Xanax, Propanolol (for Physical symptoms) Nothing we have tried has helped the anxiety. Anxiety and panic attacks run in my family. Most of my family are taking Effexor XR. What do you think about my 14 year old son trying this medication. Please help!!
This anxiety is so crippling. Thanks so much for your help!

Answer from Dr. Jones:

Social Anxiety Disorder is the most common anxiety disorder, affecting 16% of people to some degree.  Most patients are somewhat comforted by knowing there is a strong genetic factor.  Studies of pregnant women monitoring the pulse of the fetus with a loud noise or acute stimulation show that those that will have a shy temperament have a much stronger reaction in terms of increased heart rate and their heart rate stays up much longer.  I have found that many people with social anxiety are also ADHD so that is common.  Also, being diagnosed with bipolar is not unusual because all three of these conditions involve the dopamine system of the brain. 

Stimulants are often helpful, although my experience has been that the Adderall Vyvanse, Dexedrine type of medications are often the best.  One of the reasons they are helpful and one of the paradoxical things we find is that stimulants decrease anxiety because they help us to think of one thing at a time and can help with more easily ignoring distractions.  Especially with Social Anxiety distractions come from all directions, mind, body, and other people  -  what if this?, what if they don’t like me?, what if I say the wrong thing?, and what if I draw a blank?.  They may feel their heart racing, or their throat gets tight, or they feel hot or flushed.  Any negative stimulation in the environment affects them.  There can be a thousand people in the room and if somebody yawns when they are talking, they think, “oh no, they think I’m boring”.  Or somebody laughs and they think they are laughing at them, which makes it very hard to stay on track and the anxiety keeps escalating. 

Propranolol is helpful for some types of symptoms as long as asthma is not a problem.  But it has to be the right dose for the individual.  It is especially good for racing heart, shaking muscles, quivering voice and tremor.  It is not particularly good for sweating and blushing but a lot of patients take it along with one of the tranquilizers at least for situational things like giving a talk or being in class if that’s what the problem is.  Xanax is good for anxiety but the tranquilizer that is most commonly effective for social anxiety is Klonopin, or clonazepam.  It is actually the most potent for panic.  Klonopin is also the only medication in that class that has an effect on serotonin which is the worry system and obsessing. It also reduces racing thoughts.  Plus it lasts longer so it does not have to be taken as often as Xanax.

In terms of your son, I have had a teenager do home schooling for a semester or so but the goal is always to get them back into the normal situation.  They just have to start desensitizing possibly in another environment.  One girl I treated wouldn’t go to school, but got a job during the summer as a hostess in a restaurant and because she was on medication it allowed her to tolerate that situation and it desensitized her to the point that she was able to go back to school.

The most important thing is you can’t get over social anxiety first and then start getting into social situations.  The only way to get over it is to be in the situations
but not having severe symptoms.  Forcing oneself or being forced into situations and having a horrible time, being embarrassed, feeling humiliated, and can’t wait until it’s over doesn’t help, it actually worsens the condition because it more strongly conditions the brain that the situation is bad news. 

The way to get over it is by being in social situations with minimal anxiety or at least less than before and having various techniques, including cognitive techniques to use.  But if you are overwhelmed with anxiety then it is pretty hard to use cognitive techniques. 

If the physical symptoms are severe then managing them is important and things like Propranolol are good, but you have to take the right dose.  So too much can cause additional physical symptoms and too little doesn’t control the symptoms.  For things like sweating, medications like Cardura or anticholinergics are more effective and for blushing sometimes Klonopin helps and sometimes Pindolol helps because it has the serotonin and beta blocking effect. 

It is best to only change one medication at a time.  Lamictal is good for the depression associated with bipolar disorder.  200mg is the most typical dose.  Prozac is effective in terms of OCD or obsessing.  You wouldn’t want to take Prozac and Effexor together.  Effexor does have good studies for social anxiety disorder and covers a wider range of symptoms but you would have to transition it gradually, reducing the Prozac by 20mg each week so you would need to wait a week before starting the Effexor.  Then you would gradually taper off one while adding the other.

So the most important thing is your son can get over Social Anxiety Disorder. It’s common, it’s disabling and there are a lot of medications that can help by taking the right one or combination of medications at the right doses and then getting into the dreaded situations and desensitizing.  He will have to get to where he doesn’t avoid at all because any avoidance reinforces the symptoms.

Don’t give up! Persevere until you find the right medications at the right dose to help your son. Good luck in your efforts to help your son find a normal, healthy life.
Answer:

Dr. Jones
My son is 14 yrs. old and has been diagnosed with bipolar more depression
than mania. ADHD and Anxiety. He is on 150 mg of Lamitical, and he is
starting 36mg of Concerta, and is currently on 80mg. of Prozac. My son has
severe social anxiety and performance anxiety. He is a select basketball
player and baseball player. He has dropped all sports due to anxiety. The
only thing he does now is ride bikes with his dad and works out at the gym.
We are looking at also having to home school him due to his condition. He
is very smart, talented in music and sports, but locked up with anxiety. Can
you please help. We have also tried Xanax, Propanolol (for Physical
symptoms) Nothing we have tried has helped the anxiety. Anxiety and panic
attacks run in my family. Most of my family are taking Effexor XR. What do
you think my 14 year old son trying this medication. Please help!!
This anxiety is so crippling.

From Dr. Jones:
Social Anxiety Disorder is the most common anxiety disorder,
affecting 16% of people to some degree. Most patients are somewhat
comforted by knowing there is a strong genetic factor. Studies of pregnant
women monitoring the pulse of the fetus with a loud noise or acute
stimulation show that those that will have a shy temperament have a much
stronger reaction in terms of increased heart rate and their heart rate
stays up much longer. I have found that many people with social anxiety are
also ADHD so that is common. Also, being diagnosed with bipolar is not
unusual because all three of these conditions involve the dopamine system of
the brain. See social anxiety newsletter

Stimulants are often helpful, although my experience has been that the
Adderall Vyvanse, Dexedrine type of medications are often the best. One of
the reasons they are helpful and one of the paradoxical things we find is
that stimulants decrease anxiety because they help us to think of one thing
at a time and can help with more easily ignoring distractions. Especially
with Social Anxiety distractions come from all directions, mind, body, and
other people – what if this?, what if they don’t like me?, what if I say
the wrong thing?, and what if I draw a blank?. They may feel their heart
racing, or their throat gets tight, or they feel hot or flushed. Any
negative stimulation in the environment affects them. There can be a
thousand people in the room and if somebody yawns when they are talking,
they think, “oh no, they think I’m boring”. Or somebody laughs and they
think they are laughing at them, which makes it very hard to stay on track
and the anxiety keeps escalating.

Propranolol is helpful for some types of symptoms as long as asthma is not a
problem. But it has to be the right dose for the individual. It is
especially good for racing heart, shaking muscles, quivering voice and
tremor. It is not particularly good for sweating and blushing but a lot of
patients take it along with one of the tranquilizers at least for
situational things like giving a talk or being in class if that’s what the
problem is. Xanax is good for anxiety but the tranquilizer that is most
commonly effective for social anxiety is Klonopin, or clonazepam. It is
actually the most potent for panic. Klonopin is also the only medication in
that class that has an effect on serotonin which is the worry system and
obsessing. It also reduces racing thoughts. Plus it lasts longer so it does
not have to be taken as often as Xanax.

In terms of your son, I have had a teenager do home schooling for a semester
or so but the goal is always to get them back into the normal situation.
They just have to start desensitizing possibly in another environment. One
girl I treated wouldn’t go to school, but got a job during the summer as a
hostess in a restaurant and because she was on medication it allowed her to
tolerate that situation and it desensitized her to the point that she was
able to go back to school.

The most important thing is you can’t get over social anxiety first and then
start getting into social situations. The only way to get over it is to be
in the situations
but not having severe symptoms. Forcing oneself or being forced into
situations and having a horrible time, being embarrassed, feeling
humiliated, and can’t wait until it’s over doesn’t help, it actually worsens
the condition because it more strongly conditions the brain that the
situation is bad news.

The way to get over it is by being in social situations with minimal anxiety
or at least less than before and having various techniques, including
cognitive techniques to use. But if you are overwhelmed with anxiety then
it is pretty hard to use cognitive techniques.

If the physical symptoms are severe then managing them is important and
things like Propranolol are good, but you have to take the right dose. So
too much can cause additional physical symptoms and too little doesn’t
control the symptoms. For things like sweating, medications like Cardura or
anticholinergics are more effective and for blushing sometimes Klonopin
helps and sometimes Pindolol helps because it has the serotonin and beta
blocking effect.

It is best to only change one medication at a time. Lamictal is good for
the depression associated with bipolar disorder. 200mg is the most typical
dose. Prozac is effective in terms of OCD or obsessing. You wouldn’t want
to take Prozac and Effexor together. Effexor does have good studies for
social anxiety disorder and covers a wider range of symptoms but you would
have to transition it gradually, reducing the Prozac by 20mg each week so
you would need to wait a week before starting the Effexor. Then you would
gradually taper off one while adding the other.

So the most important thing is your son can get over Social Anxiety
Disorder. It’s common, it’s disabling and there are a lot of medications
that can help by taking the right one or combination of medications at the
right doses and then getting into the dreaded situations and desensitizing.
He will have to get to where he doesn’t avoid at all because any avoidance
reinforces the symptoms.

Don’t give up! Persevere until you find the right medications at the right
dose to help your son. Good luck in your efforts to help your son find a
normal, healthy life.

I have not seen previous reports of permanent growth suppression from long-term use of stimulants during childhood.  Expert consensus and my clinical experience is that height may be slightly delayed but is genetically determined (assuming adequate nutrition).

The package insert for methylphenidate products (Ritalin, Concerta, Focalin, Daytrana, Metadate), cautions that daily use in a controlled study versus a controlled group did show on average 2cm less height after 3 years – but it is assumed to eventually catch up.

Kids who don’t take medication on weekends or during summer don’t show this delay.  The presumed mechanism of the delay is that norepinephrine (increased by methylphenidate) leads to a decreased release of growth hormone during deep sleep, (normally in the first 3 hours).  This suppression of growth hormone can probably be prevented by use of Clonidine or possibly Guanfacine  taken at bedtime.

In the reader’s comment amphetamines were referenced but the statement was also made that the person referred to was treated with methylphenidate.  Of course both are stimulants but are significantly different.

The package insert on amphetamines (including Adderall and Vyvanse) cautions about below average weight gain over a one year period of daily use.  In the Vyvanse study the evidence was that at the beginning of the study the average child was at the 62nd percentile of body weight – since food is a natural booster of dopamine in the nucleus accumbens, patients on amphetamines are less likely to eat out of boredom and they usually lose weight.

In fairness, we do have more studies using methylphenidate in kids than amphetamines.  The longest controlled study ever, the MTA study was also predominantly methylphenidate.  Intuitively it would make sense that amphetamines would raise norepinephrine levels even more since they increase release in addition to blocking reuptake.  Empirically however, methylphenidate is associated with increased excretion of norepinephrine and amphetamines are associated with a decrease.  Presumably amphetamines are more likely to down regulate, ie, modulate norepinephrine levels.

The hardcore science for all of this is in its infancy.  We will undoubtedly find that there are “outliers”, but at this time with all the evidence I know of the long-term benefits outweigh potential risks for the spectrum of Attention Deficit Hyperactivity Disorder.

What does it mean when stimulants stop working and/or start causing anxiety or moodiness?  Stimulants usually have a stronger effect when they are first started and then the dose has to be increased to achieve a good response.  Some patients will become tolerant to at least some of the stimulant effects and have to increase the dose gradually over time.  This is not a major problem as long as the total daily dose doesn’t exceed the maximum.

Dosing chart:

Your problem may just be an inadequate dosing issue.

The anxiety and moodiness that you are having may be a side-effect or a rebound effect depending on when it is occurring.  If your mood symptoms are at their worst between 3 1/2 to 5 hours of taking Vyvanse it is probably a side-effect.  If they are  occurring later it more likely is rebound and you need a second dose – probably around lunch time.  Rebound symptoms are more likely with Adderall XR than Vyvanse – short acting Adderall or Dexedrine tablets are even worse.

The majority of my patients have done better on and preferred Vyvanse.  There are some patients however who do better on Adderall XR, presumably because they need the added norepinephrine effect.  More patients on Adderall need to add Tenex, but it can also be helpful with Vyvanse.

Anxiety and moodiness starting after taking stimulants for a while can also be due to underlying genetics of mood disorder, especially bipolar.  Any significant family history of major mood disorder increases the risk.  Patients with ADHD and bipolar genetics do best on a combination of a mood stabilizer and a stimulant.

There are occasional patients who become sluggish or sedated with methylphenidate for reasons that aren’t clear.  If you are taking Effexor or Lexapro in the am then these could interfere with the activating effects of the stimulant.  Lexapro and Effexor are usually taken in am when first started, but after a few weeks they generally work better taking them at night (Lexapro) or supper (Effexor XR), and this is especially true when combining with stimulants. 

See how to take Effexor: http://www.askdrjones.com/2005/12/29/how-to-take-effexor/

The most effective stimulant for appetite suppression and weight loss is Dexedrine (Vyvanse is the most effective form).  Adderall is the next best.  Methylphenidate is the least effective for appetite/weight.

In general, using stimulants to lose weight needs to be a long term commitment.  If the stimulant is stopped the weight is almost always regained – usually with 5 extra pounds for good measure.  This is not usually the case if weight gain only occurred on an antidepressant and the antidepressant is no longer being taken.  All antidepressants except Wellbutrin are sometimes associated with weight gain, but may not occur until several months of being on the medication.  Weight gain is partly due to changing set points for serotonin receptors that help regulate carbohydrate intake.  Another possible mechanism is that serotonin up regulation by antidepressants can down regulate dopamine and eating is one way to stimulate the dopamine system.  Stimulants, especially amphetamines (Dexedrine, Vyvanse, Adderall) increase dopamine release to counteract the serotonin effect.

It is usually better to start low and increase until no additional benefits or side-effects.

Weight can be used to determine maximum dose, 2mg/kg for methylphenidate and 1.5mg/kg for amphetamines.  The following chart was published by Biederman and Wilens at the Harvard department of psychiatry.

 More people prefer amphetamines.  Only 16% prefer methyphenidate.  This fits my clinical experience over the past 40 years.  The following chart shows a meta-analysis study that was done that confirms this.

 So, if your brother weighs 150 pounds (or 70kg) he may need doses of methyphenidate up to 140mg, or Concerta 54mg 3x per day, or 1-2 Daytrana patches, or 90-150mg Adderall, or Vyvanse 70mg 3x per day for optimal effect.

Over the past several weeks I have tried Vyvanse in over 300 patients, many of whom were previously on Adderall.  The majority of patients prefer Vyvanse – they report that it is smoother, has less side-effects, less rebound in the afternoon, and more efficacy throughout the day.  Vyvanse has less risk to blood pressure or the cardiovascular system and has a mode of action that prevents using it to get high.  There are still some patients that prefer and do better on Adderall.  The lowest dose of Vyvanse is 30mg, which is equal to 10mg of Dexedrine or 20mg of Ritalin (methylphenidate).  

How much medication should your brother take?

Enough, not too much.   It takes time and trial and error to find the best dose for each individual.

Vyvanse has less effect on the cardiovascular system than Adderall but all stimulants have possible cardiovascular side-effects.  You should stop taking it and see if the symptoms go away.  If not you need to see your cardiologist or internist.  If the side-effects do go away you may want to discuss options with your doctor. 

Generic Tenex helps with distractibility www.askdrjones.com/2006/11/07/tenex/ and can be taken with Toprol if it doesn’t lower the blood pressure too much.  You may tolerate a lower dose of Vyvanse, possibly with Tenex or you may do better on one of the forms of methylphenidate, or possibly Provigil.

Vyvanse is a new delivery system for a medication we have used for 70 years.  Extra precaution needs to be taken with CV issues like Mitral Valve Prolapse.  I’m not aware of a specific study with MVP, but a study was done at Harvard of patients with ADHD and high blood pressure.  The blood pressure was gotten under control first – then the patients were treated for ADHD and tolerated stimulants as well as patients with normal blood pressure.

Starting low and going slow would be essential with decreased dose or stopping if you have any side-effects that could be related to the drug, such as palpitations, dizziness, etc.

I have many patients who do great on 60-90 mg of Adderall per day and have for up to 13 years.  Anybody like yourself who is not doing well needs to make changes.  You need to start with a re-evaluation with a physician.

One simple option may be to change to the new Vyvanse and possibly just one/day (70mg).

Many of my patients require Tenex with Adderall.  Patients on Vyvanse are much less likely to need it.

One of the most important things I learned in training in the ‘60s – if what you are doing isn’t working, do something else, even if it is wrong it gets you unstuck.

Some important lifestyle issues to consider include:   quality sleep, exercise, bright light every day, good diet, omega 3 fatty acids, and possibly Cerefolin, and personality issues.  If you need medication work with your doctor until you find “the right medication at the right dose” for you.

I have just posted an article on preschoolers and ADHD:

www.askdrjones.com/2007/09/06/behavioral-treatment-for-adhd-in-preschoolers/

Most research in preschoolers is with methylphenidate even though it is only FDA approved down to the age of 6.  The patch works fine if cut in half.  Be aware that after six weeks of daily use blood levels may go up and the dose may need to be reduced further.