Expert: Dr Billy Levin - 10/9/2008

Question
My daughter is 10 years old and in the 5th grade. She was diagnosed
combined type in K at age 5. She started on Adderall XR 10 mg then with
much success. Every few (5-6) months, the effects of the adderall would
diminish. Her pdoc would up the XR dose by 5mg and she was good to go
again. Well, she ended up at Adderall XR 30mg at the end of first grade with
us knowing this was a fairly high dose. This worked well for about 1 1/2
years until she seemed to need a higher dose. Instead of raising her adderall
dose we have spent the past 1 1/2 years trying different stimulants. She has
been on daytrana, concerta, Focalin XR and vyvanse all with some success but
we keep returnig to the adderall XR 30 mg because it works the best for her.
If she has been on another stimulant for a couple of months, and we return to
the adderall XR 30, it works well for about a 4-6 weeks before it starts to give
out on her. She is currently taking adderall XR 30mg and .5mg of tenex
morning and afternoon. She also takes a booster of adderall 15mg 3-4
afternoons a week. This is not giving her the control and focus she needs. She
is not completing classwork, makes lots of careless mistakes and is pretty
hyper. She has always and continues to eat and sleep great on adderall. We
added the tenex last April in hopes of helping with her hyperactivity without
raising her adderall dose. It does help some with hyperactivity and also helps
smooth out some of the anxiety that the stimulants cause (she doesn't bite
her nails as much) but she it is not enough. She is 5 feet tall and weighs 87
pounds. Would you ever prescribe above adderall XR 30 mg for her knowing
she takes a booster as well or is it better to switch between stimulants every
couple of months? Concerta controls her behavior but does not give her the
focus she needs. We may give Vyvanse another shot but it wore off after only
6-7 hours when she tried it before. We are just at a loss of what to do with
hers meds. SHe is a smart, easy going, sweet, very emotionally even child but
very hyper, impulsive, unorganized and immature. SHe struggles  socially as
well. Any suggestions?

Thanks in advance! Callie

Answer
I have a major problem understanding why she needs an increase in medication as you describe. Perhaps you will understand if I tell you that in 30 years and over 23,000 cases I have never encountered a similar problem. It is a well known fact that there is almost never a need to readjust a dose that is optimal except for minor seldom adjustments. Next for your information the age, weight and height plays no part ever in optimizing a dose. It is entirely dependant on response, evaluated with rating scales from parent and teacher, on a monthly basis. However there are very often  many good reasons why a previous effective dose does not work. Most of the stimulants, with few exceptions, will work provided the dose is for an entire day, is big enough to work and is in fact taken regularly every day.  Swopping makes no sense. Find out why it is not working. Here a doctor with experience would soon find out the reason. Unfortunately there are far too many reasons for the problem, to attempt  to advise in a simple answer on a website. Get expert advise with no intention to belittle your doctor.