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. 

Brain functioning is genetically variable (polymorphic) and has plasticity – adaptability to conditions and experience.  When you learn a new skill  or habit – at any age  (though easier when in childhood) it changes your brain.  Neurons establish new connections.  Connections are strengthened – more receptors and nerve impulses are made faster and more myelin (insulation) is enhanced. 

Now new research is showing that giving more structure to a preschooler’s day can improve ADHD symptoms.  A recent study of treating preschoolers with medication found that the medication did help but not as much as in older kids and with more side-effects – leading to the conclusion that the need and potential benefits have to be greater in younger kids to justify use. 

Having behavioral alternatives is much more acceptable to most parents who worry that medication may not be the right answer.

I know you’re thinking, why not do the same thing with school age kids?  Probably the most elaborate research study in psychiatry ever was the MTA study.  Medication was unequivocally the superior treatment for school age children. 

MTA link:  www.askdrjones.com/

Although I don’t treat a lot of preschoolers I have treated a few and I generally recommend medication with the following conditions:

1.    If I don’t treat the kid’s ADHD I’m going to have to treat the parents and siblings for major stress symptoms

2.    If I don’t treat the kid no day care will keep them and mother (frequently a single parent) or father won’t be able to work and they’ll be standing in soup lines and bunking down at the Salvation Army

3.    Extreme impulsivity resulting in dangerous behavior like running out in the street

Ironically, methylphenidate has been the most studied in preschoolers but only dextroamphetamine is approved down to age three.

Estimates of incidence of significant ADHD symptoms in preschoolers are 1 to 4%.  The best test is to be in a room with them for a while – how bad do you need a drink or a Xanax afterwards?  The second best test is how much does mother look like the “before pictures” of the woman in the mattress commercials?  (Or in the case of the one with Lindsay Wagner even the after picture looks pretty haggard.)

A five year old study sponsored by the National Institute of Mental Health provided a range of behavioral therapies to135 preschool kids with severe ADHD:

1.    Families were given parent education classes only

2.    Or classes and home visits by researchers who gave individualized behavioral therapy for each child’s particular needs

After one year aggressive behavior and learning had improved by 30%.  One parent said the most effective technique was providing predictability, such as, we are going to be leaving the playground in 5 minutes, 4 minutes, etc.  (She didn’t mention having to use a lasso or pepper spray when it was time to actually leave).  She also thought it was helpful to praise the child for doing things like behaving during a boring activity, helping with cleanup, or other positive behaviors.  (This study was reported in School Psychology Review Sept 07).

Classic behavioral management principles of parenting are:

1.    Behavior you like and want more of (praise, reward)

2.    Behavior you don’t like but that doesn’t bother you or others particularly (so you ignore)

3.    Behavior you can’t stand or is bothering others (punish) 

Note: Time-outs work well.  They provide the first opportunity to use the power of the “pop” (e.g., when they refuse to go to time-out).

The problem is that classic parenting doesn’t always work so great.  As Dennis the Menace said in one cartoon, “by the time I realize the consequences of my action I’ve already done it”.     www.askdrjones.com/2007/07/16/vyvanse-new-treatment-for-adhd/

A study of 3,000 randomly selected kids ages 8-15 was funded by the National Institute of Health (with no pharmaceutical company support).  The main author was Tanya Froehlich, a developmental behavior pediatrician.   The study was published in Archives of Pediatric & Adolescent Medicine Sept 07.

Originally the objective was to see if ADHD in kids was being over diagnosed and over treated.  Actual findings showed only 3% of those without ADHD were receiving medical treatment – and they could have represented kids who had improved so no longer met criteria.  They also found that 9% of the 3,000 kids had ADHD of which only 1/3 were consistently being treated.

That finding or worse has been repeatedly found – the question is, WHY?

I believe the most common reason is that the patient has not taken “the right medication at the right dose”.

 In consulting with physicians in their offices a frequently mentioned problem is getting kids to take their meds.  My approach is to first redefine the problem for kids and their families.

ADHD is a type of personality that makes it difficult to focus on things that aren’t interesting.

Like what?  Like school mostly.  The cause is genetic (polymorphism).  Mother Nature doesn’t want ADHD kids or adults spending time with boring, repetitive stuff.  ADHD people are the explorers, challengers, and changers of the world.

One of the problems with being ADHD is that in order for us to go to the best schools and get the best jobs, starting with the 9th grade we need to perform well in school and keep up with boring details (and at work boring reports, etc.)

The GOOD news is that medication – especially stimulants make our lives better by giving us the ability to do well on the boring stuff.  It also helps us stay calm and still when appropriate, and in control.

THE GOAL

The goal is to find a medication that kids, teens, and adults like.  Their lives are easier – they’re getting things done effectively and side-effects from the meds if any, are minimal.  HINT:  The medication probably isn’t Strattera.

If medication makes kids feel bad they shouldn’t take it.  I worry more about kids/teens who take meds that make them feel bad or detached or flat or racy.  I worry about parents who keep giving kids the wrong medication or the wrong dose.

Another reason for poor consistent compliance with treatment is that usually at least one of the parents is also ADHD.  Only 10% of ADHD adults are being treated.  So the parents forget, lose the med, are running late, or don’t have time.  They can’t stay organized to keep up with getting refills, scheduling and keeping follow-up appointments, much less filing insurance forms, etc.

Again this year at the American Psychiatric Association annual meeting a group of loud marchers picketed the main conference center.  “Stop poisoning our children” and other banners were being waved.  They were mostly Scientologists who are a blend of idiocy and nuttiness.  They should be sentenced for life to be locked up with a hyperactive kid like our son was in childhood.

Unfortunately, some patients give up too quickly on one or more meds because they don’t understand all the nuances of dosing and side-effects.  But, fortunately, we keep getting better and better medications that are more effective and last all day and are safer with less side-effects.

 Newest med:www.askdrjones.com/2007/07/16/vyvanse-new-treatment-for-adhd/