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When people are in excited, in danger, or working against a deadline, or if they are physically active or find what they are doing very interesting, the adrenalin level in their body and in their brain goes up, and they become more alert and more focused. If they are really excited, the adrenalin may also cause their heart to start beating faster, and their mouth to get dry. They usually don't want to eat or sleep.

For some reason, the level of adrenalin-like neuro-chemicals in the front part of the brain of a person with ADD is lower than normal. Because of this, in non-stressful situations they may not be able to get started on tasks, or stay focused, or get organized. The stimulant medications act by raising their level of adrenalin-like neuro-chemicals. When it does this, they become more alert, more focused, and better organized.

If most of the stimulant effect is on the brain and relatively little is on the body, the medication has few side effects. But if the medication works more powerfully on the body, the person may have a fast heart beat, an increase in blood pressure, difficulty sleeping, and a loss of appetite.

People who already have a normal level of adrenalin in the brain usually get little or no benefit from raising the level with stimulants.

There is normally a part of the brain that automatically filters thoughts and ideas, letting only the important ones get through to a conscious level. The filter in people with ADD does not work quite right. Stimulant medication stimulates the filter to work better so only important thoughts get through. That often means the person does not get distracted and can stay on task more easily. They can sometimes get to sleep more easily since they are not constantly being bombarded by dozens of relatively unimportant thoughts buzzing around in their minds.

The most serious problem for athletes is for those doing high physical intensity sports in hot weather. The resultant dehydration, increase in body temperature, and heavy energy output can lead to an acute breakdown in muscle tissue called rhabdomyolysis (rhabdo=bundles of rods, myo=muscle, and lysis=breakdown). If this occurs, the muscle tissue gets into the blood stream and can be harmful to the kidneys. Overdoses of stimulants have been found to cause rhabdomyolysis. The combination of heavy exercise and even normal stimulant doses can be fatal.

Can Stimulants Increase Blood Pressure?

Between 5% and 10% of people taking stimulants experience a small increase in their blood pressure. This can also happen to people taking buproprion (Wellbutrin). For most people this is not detrimental to their health. However, if a person's pressure is already elevated or if the elevation caused by the stimulants brings the pressure into the "caution" or "high risk" zone, the person should certainly contact their doctor, who will probably reduce the dose of stimulants, or stop them, or add an antihypertensive medication to their medication program.

It should be borne in mind that blood pressure is remarkably variable in many people and that mild or moderate temporary increases in pressure are common. Blood pressure should be taken after a person has had a time to relax for few minutes.

There are some people whose blood pressure goes down when they take stimulants. This occurs most frequently in people who are overweight and lose weight on stimulants because the medication reduces their appetite.

One published study showed blood levels of DHEA (dihydroepiandrosterone sulfate, a neurosteroid) to be lower in patients with more severe ADHD. Another study found that in children successfully treated with methylphenidate, DHEA blood levels of DHEA rose by 23% and those of a related compound, DHEA-S, rose by over 50%. However, two studies is a very small number upon which to base a treatment strategy. Also the increase after successful treatment might be just a side effect and have nothing to do with the patients' improvement. Nevertheless the findings are provocative and hopefully researchers will follow up on them. If you have been treated for ADD or ADHD with DHEA, kindly click here to send me an email about your experience.

Question: Are brain imaging studies such as SPECT as used by Dr. Amen and some others, MRI, PET scans, or CAT scans helpful in the diagnosis and treatment of ADD?

Answer: It is generally agreed that these tests, some of them quite expensive, presently have no value in the diagnosis of ADD. Some of the tests have shown differences between large groups of individuals with and without ADD, but they have no diagnostic value for an individual being evaluated for the disorder. This is reflected in the diagnostic guidelines of the American Academy of Pediatrics. I was very disappointed when I learned this, since I found the images in Dr. Amen's book quite exciting. For more information on this topic, click here.

Answer: The diagnosis of ADD is made solely by clinical history. It is based on a trained clinician's finding that a person has a set of specific symptoms often elicited by a questionnaire or reported by family members and that these symptoms disturb the person's life in significant ways. While a history of symptoms since childhood or adolescence is very useful in making the diagnosis, not infrequently childhood symptoms cannot be remembered and/or they were masked by the child's ability to compensate for them with hard work or superior intelligence. The diagnosis also requires excluding other conditions that may cause symptoms similar to those of ADD, such as bipolar (manic depressive) disorder or brain damage.

At present, there is no test for ADD. Just because something is called a "test" does not mean that it can add to or replace clinical judgment. The fact is, psychological or neurological tests for ADD rarely improve diagnostic accuracy thought they can sometimes be useful in designing a treatment plan or in monitoring treatment progress. Psychological tests can also be helpful where there appears to be a specific learning problem present or if the patient functioning in some areas, such as math or language skills, relative to the patient’s overall intellectual ability.

Without an objective ADD test, there is, a risk that some people who don't have ADD will be mistakenly treated for it. Despite this uncertainty, it would be unwise not to treat people who seem likely to have ADD and want to try treatment but who don't exactly meet the diagnostic criteria. Experience has shown that many of these people benefit greatly from treatment.

Clinicians must be careful evaluating the effects of stimulants on women who may have low estrogen levels. For example, at the outset of treatment, premenstrual symptoms may be misperceived as side effects of the stimulant, with result that the use of the stimulant may be rejected unnecessarily. Or the effects of the stimulant may not be as pronounced premenstrually as they are later in the patient's cycle. Once successful treatment with a stimulant has been established, its effects my seem to wane during a woman's premenstrual days.

Other low estrogen states occur during the post-partum period, peri-menopause, and post-menopause.

Sometimes the use of a SSRI medication (Prozac, Zoloft, Celexa or their generics) during the premenstrual phase overcomes this problem, and sometimes increasing the dose of the stimulant for a few days helps. Only the treating clinician and the patient can decide how best to deal with this situation.

The stimulants have a number of effects each of which lasts for a different length of time. The effects on cognitive functions such as distractibility, focus, concentration, organization seem to last for about four hours for the short acting stimulants and about eight hours for the long acting stimulants, though Vyvanse seems to last a few hours longer. The shortest acting effect of stimulants is on appetite which may last only a few hours. (If you don't want to lose weight, it's best to take the medication after you eat.) Alerting effects, which interfere with sleep last longer than the cognitive effects so many people find they can't get to sleep long after the cognitive effects have worn off. The effects on muscle tension, causing jaw tension, may last twenty four hours or longer.

Question: "What is the difference between the "stimulants" Adderall and Ritalin?"

Answer: To answer this question, I will group the stimulant medications into two groups: the Adderall type medications (Adderall, Dexedrine, etc and their generics) and the Ritalin type medications (Ritalin, Concerta, Focalin, Methylin, etc and the generic methylphenidate).

The most important difference between them is whether they work or not for a particular patient. In my experience more people respond positively to Adderall than to Ritalin, and Adderall has a slightly stronger effect. But there are many people who respond positively to Ritalin and not Adderall. Most people with ADD respond to either. Click here for details about my patients' experience with these medications.

A second difference is the length of action. Adderall has a somewhat longer period of action than does Ritalin, even if only the long acting versions are compared. Also, the higher the dose of Adderall, the longer the action. This can be an advantage to some people, but for those for whom medication interferes with sleep, it can be a disadvantage. Some patients can't sleep well even if they take an Adderall early in the morning. In fact, some people find Ritalin medications help them sleep better, both by relaxing them and by stopping their minds from thinking so much while they are trying to doze off. In addition, short acting Ritalin type medications tend to wear off abruptly. This can be helpful if stimulants are taken later in the day, and the time they wear off is bed time.

Some people take Adderall in the morning and afternoon and Ritalin in the late afternoon or early evening. They find that Ritalin's shorter period of action is preferable towards the end of the day since it interferes with sleep less or not at all.

Some patients find Ritalin type medications make them a bit more anxious and irritable than do Adderall type medications.

Question: "Is there a guideline by weight for the amount of Adderall to be taken? I am 6'3," 190 pounds. I take 5 mg in the morning, and it doesn't seem to make much difference. Should I take another 5 mg in the afternoon or would it be better for me to take 10 mg in the morning?"

Answer: Regardless of weight, the general rule for prescribing a stimulant like Adderall is to start low (2.5 mg to 5 mg of Adderall taken once or twice a day) and build up each dose slowly, increasing it by 2.5 mg to 10 mg every three days or so until a good effect is achieved or the patient gets unacceptably unpleasant side effects (like jitters, fast heart beat, or sleeplessness). Mild side effects usually wear off in a day or two. If there is a positive response to a dose of the medication, the patient should continue on that dose for three to five days and then try a slightly higher dose to see if even more benefit can be obtained. If the higher dose gives no further improvement, then the patient should return to the previously beneficial dose.

In the case of unpleasant side effects and no good effects, the medication should be discontinued. However, if there are both good effects and side effects, it may be worthwhile continuing the medication for a few days to see if the side effects wear off.

The effect of each dose of Adderall or Ritalin usually lasts from three to five hours, with higher doses of Adderall lasting longer than lower doses. Longer acting forms of most ADD medications are now available. These generally work for between 7 and 12 hours.

There are no good guidelines for determining what is the best dose of ADD medication for any individual. Trial and error are required. Upper limits of dosing were established years ago when stimulants were used only with children and taken only once a day (and gave a four hour effect). Now it is recognized that adults, who weigh more than children, generally need much higher doses, especially if they want the medication to work for more than four or five hours.

Currently, the maximum dose of Adderall is thought by many doctors, including the Harvard University ADD group, to be 3/4 of a milligram per pound of body weight (120 mg per day for a 160 pound person). The maximum dose for Ritalin is thought by many doctors to be 1 milligram per pound of body weight (160 mg per day for a 160 pound person.) While these maximum doses are considerably higher than the 60 mg per day approved by the US Food and Drug Administration and more than most people need, many adults do not get much benefit from doses of 60 - 80 mg per day. Please work with your doctor to find the correct dose for you.

Question: My breakfast dose of Dexedrine doesn't "kick in" early enough, and I keep getting to work late. What can I do about this?

Answer: You might try putting your dose of medication on your bedside table along with a glass of water. Put two alarm clocks there too. Set one for an hour before you usually get up. Set the other one for your usual wake-up time. When the first alarm goes off, turn it off, take your medication, and go back to sleep. When the second alarm clock goes off, you should wake up more alert and ready for the day.

Answer: Some people have found it helpful to grind up the pill and take it with some milk. Consult your doctor about other possible causes of the heartburn to be sure it is being caused by the Adderall.

Exposing amphetamines to high or low temperature or high moisture for more than a few hours can actually reduce the medication's effectiveness.

Stimulants can make people irritable or depressed in a few ways. Sometimes, if the dose is too high for a person, the stimulants can make the person irritable or depressed. In my experience, irritability occurs somewhat more often with the methylphenidate stimulants (Ritalin, Concerta, Focalin) than it does with the amphetamine stimulants (Adderall, Vyvance, Dexedrine). A few times, at the outset of treatment, while a patient was increasing his dose every few days seeking his optimal dose, he got depressed on one dose. Without checking with me, he increased the dose and found the depressive effect went away at the higher dose and his ADD symptoms improved satisfactorily. (If he had checked with me, I would have told him to discontinue the medication. )

More often the irritability occurs when a long acting medication is wearing off, often in the late afternoon or in the early evening. One way of dealing with that is to take a dose of short acting medication in the mid or late afternoon so the medication will wear off around bed-time. I have not had this problem with Vyvanse, which seems to wear off more smoothly.

Side effects that are common at first but tend to go away in most people: nervousness, loss of appetite, stomach ache, headache, cold fingers or toes, difficulty getting to sleep.

Side effects that tend to remain: dry mouth, nervousness, mild difficulty urinating, feeling of tenseness sometimes most marked in the jaw muscles.

Unusual or rare side effects that suggest the medication should be stopped: suspiciousness, paranoia, unusual heart rhythms, very fast heart rate, consistently elevated blood pressure, more than mild difficulty urinating (men), panicky feelings (may be controlled by anti-anxiety medication), manic behavior (overly elevated mood, excitability, poor judgment, sleeplessness, strange behavior).

For information about less common side effects, click here. For a complete list of side effects, click here.

They can, but they usually don't. A study of 71 children with ADHD and Tourette's disorder or chronic motor tics treated with methylphenidate found no increase in tics. In fact, teachers' ratings of tics was lower on medication than on placebo, perhaps because the children were better able to inhibit their tics in the classroom (J Amer Acad Child and Adolescent Psych 2007: 46 840-848).

Rarely a patient has a seizure while taking stimulants. These medications are contraindicated in patients with a history of seizures but probably very rarely they do cause seizures in patients who have not had seizures in the past. However, sometimes patients who being assessed for treatment of ADD forget or minimize their seizure history, especially if they have not had a seizure in many years. As unimportant as the seizure history may seem to the patient, he should tell his clinician about it.

Sometimes patients with ADD who cannot take stimulants or find that stimulants do not work for them are treated with buproprion (Wellbutrin). This medication is generally not effective for ADD. In addition, it does has a much higher risk than the stimulants for causing seizures.

Yes, you can. Hyperactive ADD (ADHD) is more common among boys than girls. Girls with ADD often suffer more from distractibility and attention problems then from hyperactivity. Hyperactivity disappears in about 3/4 of children by the time they become young adults. However, inattentive symptoms fade away in only about half of children, though the symptoms in adulthood are often not so severe as they were in childhood.

Modafanil was developed and approved for the treatment of excessive sleepiness that is associated with narcolepsy or shift work. It is marketed for improving alertness and reducing excessive daytime sleepiness. Although that would seem to make it an ideal treatment for some patients with ADD, I have found it only rarely effective.

Generally patients can stay on the same dose of stimulants they found effective at the beginning of treatment for as long as they take the medication. Occasionally, though, a patient may have to increase the dose within a few months one time after treatment begins to get the optimal effect.

Sometimes, when a person is under added stress or there are greater demands on his or her abilities, the medication may not work as well. Some people have found that during these times a slightly higher dose is more effective. Usually they return to the usual dose after the stressful period is over. It is wise to keep a careful eye on blood pressure during these times because the combination of stimulant and stress is more likely to raise the blood pressure.

Rarely, a patient will find that, after taking a stimulant for many months or years, its effects slowly wear off. Sometimes they try increasing their dose in the hopes of regaining the original effect. This may work briefly but, soon after, another increase seems to be needed. The problem may be that the medication has started blocking the very receptors in the brain that make it work. In these cases, some patients have found it helpful to stop the medication for a few days to let the receptors reset, then restart the medication. Often they then find the original strong effect has resumed. Some patients may thereafter routinely stop their medication for a weekend every month or two. They usually feel tired during the first few days after they've stopped the medication, and their ADD symptoms return, but the symptoms disappear once they restart the medication.

There is a small percentage of patients who find that their medication works very well when they start it, but days or weeks later, it seems to stop working. Sometimes when they stop the medication for few weeks and restart it, the same thing happens. In my experience this seems to happen to these patients with each new stimulant they try.

There is no better example of the importance of collaboration between doctor and patient than in the process of deciding the best dose of stimulants for a patient with ADD. Doctors (myself included) usually follow some general rules for dosing, for example "start low, go slow"; maximum dose no higher than x; take only one type of stimulant at a time; take stimulants seven days a week; and find a dose that works and stick with it.

For better and for worse, I have found that many of my patients don't always follow my instructions on how to take their medication, and I have learned from their experiments. For example, many of my patients who have had a good response to stimulants sooner or later wonder whether their ADD may have just gone away and "accidentally" or deliberately stop their medication to find out if this is so. While the result of this experiment rarely fulfills their wishes, it is often reassuring to them to know that they are not taking the medication unnecessarily.

Another example. Usually I instruct my patients to take a certain dose of medication each day. But a few patients have found, on their own, that a different dosing schedule serves them better. (Before experimenting with your dose of medication, make sure you check first with your doctor.) For example, one patient's job involved regularly "putting out fires" that is, multi-tasking. He found that he got sufficient benefit from 10 mg per day of a stimulant to make him less distractible but was still able to multi-task. However, a few times a year, for periods of a month or two, he took training programs where he needed to study steadily for hours on end. He found that he was able to do this only by taking 50 mg per day. At the higher dose, he experienced no side effects, had no blood pressure problems, and had no problems with sleep, whereas that dose would have given him anxiety and insomnia when he was not under pressure to study and learn. For him, at least, high stress or high demand on his abilities seemed to change how the medication worked. By working together we were able to find a dosing strategy that addressed his need some times for multi-tasking and for some times perseverance.

Every month or two a patient tells me about being mistreated by a pharmacist after presenting a prescription for a stimulant medication. The mistreatment takes the form of suspicious questions, whispering to colleagues, distrustful comments, vaguely accusatory remarks. On a recent occasion a pharmacist outright refused to fill a prescription and sent the patient away without calling me because he felt the patient was not taking the right dose.

While rude, the pharmacists' behavior is motivated by legitimate concerns about some people's reselling their medication or giving it to friends or family members. Some people take higher doses than were prescribed, some forge prescriptions, and some abuse stimulants. Stimulants are "controlled" drugs and can only be filled with a written prescription. The Federal Narcotics Bureau oversees the sale of stimulants and can impose harsh penalties on pharmacists for minor infractions of the law so they have to be extra cautious about filling prescriptions for people they don't know.

Whatever their concerns are, they do not justify rude or critical treatment of customers. When faced with such behavior, some people have found it helpful to ask to speak to the pharmacist or pharmacy manager and, in a calm voice, telling him or her that you are being treated for ADD with stimulant medication and, while you understand that the pharmacy wants to be sure that it is handing stimulant prescriptions carefully and responsibly, there is no reason to treat customers who take stimulants with suspicion or rudely or disrespectfully. If it is a chain pharmacy, and the manager is not responsive to your concerns, politely ask for his or her name and write it down and ask how you can contact the pharmacy's national office. This is often all that is required to get you the respect you deserve.

Not infrequently I refer a person to an ADD coach. Not infrequently the person sees the coach a few times, makes some progress and, for a variety of reasons (finances, time, "problem solved", attention turned elsewhere, etc), the person decides to go it alone or to see the coach when things get out of hand again. I believe that there is something wrong with this model. Working with a coach to change a life-time habit is like taking lessons to learn to play the piano: six lessons won't do it. Regular sessions, perhaps more frequent at first, are essential.

When people respond well to stimulant medication, I usually ask them what was the most important thing that changed when they started using the medication. Most often they say that they are no longer so distracted by extraneous thoughts and don't so easily forget things (appointments, keys, etc.) It almost appears like the normal brain has a "strainer" that keeps out of awareness anything but the most important items. In ADD, the strainer doesn't work right, and unimportant thoughts keep flowing in all the time. For some people, this is especially troublesome at bed time when they would like to just shut their brain off and get to sleep. But thoughts keep flowing in. Stimulant medication seem to be able to fix the strainer and make focus (and sleep) possible. This is part of the explanation of the seeming contradiction that stimulants seem to calm people down.

When Strattera first came on the market a few years ago, I tried a number of patients on it. Only one benefited from it, and only at a fairly high dose (120 mg per day). All the others had unacceptable side effects, most often of the gastrointestinal tract, or had headaches. Since that time I have encountered many patients who were treated by another physician for their ADD and had the same experiences that my patients did. None reported good results with it. (Of course, most patients that had good results with it would probably not have come to me for help unless they moved to my geographic area or their treating physician left practice.) My colleagues have had the same experience prescribing Strattera as I have had. I see only adults. Perhaps it works differently with children, perhaps patients seen in a studies funded by the manufacturer are different in some ways from those seen in my or similar practices. I am told that if the dose is started quite low and only slowly increased, fewer patients have unacceptable side effects.

A set of guidelines for evaluating and monitoring patients with ADD was published in early 2007 by the American Academy of Child and Adolescent Psychiatry. The guidelines are based on a review by a committee of experts of more than 5,000 papers published since 1996.

The guidelines state that the diagnosis of ADD should be based on a clinical assessment of the patient. Expensive neurological or psychological tests add little or no information to what the clinician can learn from interviewing the patient, reviewing the patient's reported symptoms, and exploring the social, medical, and family history. In uncommon circumstances during the evaluation process, diagnostic questions may arise about a neurological or psychological condition that may require neuropsychological testing. Tests should also be performed if the patient appears to have low general cognitive ability or low achievement in language or mathematics despite having a normal intellectual ability.

However, the guidelines state that there is no scientific justification for electronic or radiological imaging of the brain (CT scans, Pet scans, EEG, etc) for the purpose of establishing a diagnosis of ADHD/ADD.

Bear in mind that these guidelines were written mainly by psychiatrists. Psychologists who do such testing might place more emphasis on testing. In my experience, routine testing has only rarely provided me with information upon which to base my diagnosis or treatment, whereas testing has been useful when I had a specific question about a patient that I asked the tester to answer for me.

Students and others who request special accommodations for their ADD are often asked by school or employer disability specialists to take costly tests to certify their diagnosis of ADD. Such tests may give the diagnosis and appearance of science and certainty but in fact, they provide very little or no diagnostic information beyond that obtained by a good history and clinical examination. Nevertheless, school staff who are not knowledgeable about ADD may insist on such testing.

It's hard to be sure which person with ADD will benefit most from stimulants, but one clue I've noted is this: if at the end of the first appointment, the person, without prompting, writes down the time of the next appointment, he or she is more likely to respond well to stimulants. In my experience, about a quarter of those with ADD have major problems with time awareness and time management. These are the ones that are often late, forget appointment, don't plan well, put things off till the last minute. Stimulants help, but don't eliminate those time management problems. (This is one area where coaching can be important.) If a person doesn't have time problems to contend with, their overall improvement from stimulants may appear more dramatic.

I saw a middle aged lawyer a few months ago for an ADD evaluation. One of his main problems was memory difficulties. Although these are common with ADD, his seemed a little worse that the usual ones I have seen with ADD. He responded better to long acting methylphenidate (Concerta) than to mixed amphetamine salts (Adderall) but in both cases, the medication helped his ADD symptoms only for a few days at most, then seemed to wear off or made his memory problems worse and sometimes made him feel depressed. After some experimentation with timing of the doses of his medication, including his taking a few drug-free days between short courses of medication, it became clear that the problem was that the stimulant medication was making his anxiety worse, and this was adversely affecting his memory. He responded very well with the addition of an anti-anxiety medication, alprazolam (Xanax) to the long acting methylphenidate. After a month on this treatment, his memory seemed normal and his other ADD symptoms much improved.

I started a tall, muscular 360 pound man on Adderall. I usually begin treatment with a 10 mg XR per day dose, but since dosing is known to be somewhat related to weight, I decided to start him on 20 mg XR per day. Within a few days he began feeling and functioning better, but he also noted that he felt a little too good, a little anxious, and a little not himself. He stopped the 20 mg XR per day dose for a day then restarted it on the urging of his wife, who felt the medication had been very helpful to him. After a day or two on 20 mg per day he no longer had the anxious, too-good feeling, and his functioning was much improved. He ended up taking 40 mg XR per day with excellent benefit and no side effects.

A recent study showed that eighty percent of people with ADD don't take their medication as often as prescribed. Those who are seen once or twice a year only fill about a third of the prescriptions for ADD medication they are given. Those who are seen every month fill 70% of their prescriptions. These findings baffle me because my records indicate that my patients fill over 80% of their prescriptions. This may be because my patients, most of whom have out-of-network insurance, function at a fairly high level. My office is also careful to follow up on patients and calls them if they do not request an appointment at least a few weeks before their medications should have been used up. But just to be sure, I plan, with each patient's permission, to call their pharmacies and find out how many prescriptions they have actually filled. If my patients' percentages are much lower than I believe, I will need to explore why and see if something in the refill procedure needs to be fixed.

Stimulants make some people anxious. But it makes some others with ADD less anxious. I've wondered what the mechanism for the anxiety reduction might be. There seems to be at least two possibilities: the first is that it is biological mechanism since the effect starts at about the same time the medication starts working. The second is that the mechanism is psychological. With these patients, it appears to reduce the fear they have felt each day about being criticized for not getting things done on time or in a well organized way or for being spacey and distractible. Over a period of a few weeks, as their functioning improves, their fearful apprehension slowly dies down and they begin to feel more calm, even peaceful.

People with ADD often lose sight of the forest (the big picture) and get lost in the trees (the details). For example, when they go into a hardware store, they often walk in, look around, and get interested in all the useful gadgets they see. Not infrequently they end up leaving the store with items they don’t really need and without some of the items they intended to buy. They lost sight of the big picture, their overall goal in going to the store.

Getting and keeping the big picture in mind before an event can be very helpful. In the case of the hardware store, it will help to bring a written list of items to be bought and to review the list before entering and leaving the store. (You might buy some extra items but at least you’ll be more likely to buy what you want.)

On a grander scale, if you have ADD, you may find it useful to keep a calendar on which you write down all the appointments and events you have planned. These should be written down on the day the appointment was made. If you don’t carry your schedule with you, write down the appointments on a piece of paper. Every evening, sit down with the calendar, take out the scraps of appointment notes from your pocket, write down the event, and throw away the piece of paper.

Then review the next day’s schedule (the big picture) and make a list made of tasks, events, or items listed for the next day. Think about them - do you need to do anything special to prepare for them, is there anything you need to bring with you? When you’ve done that, make a check mark on that date of the calendar. You may be surprised find how helpful this is.

As people get nearer to the time or place when a task has to be done, the more likely they are to experience a twinge of anxiety about not having fully prepared for it. (For someone with ADD, the twinge may occur the night before an important presentation, when there is hardly any time to do anything about it.) It seems that people with ADD have to get closer to a task or place for that helpful anxiety to kick in. Having a way to crank up the anxiety sooner can be very helpful. Reminder systems can help. Working with a group can help. Visualizing the task or situation can help if you can imagine it and the consequences of messing up vividly enough. Just getting started on something even if it's way too early can help. Just stopping before you leave your home each day to check whether you have everything you will need can help. Have you found other methods or techniques that work. Click here to let me know about them.

Very many people have some isolated symptoms of ADD, like forgetfulness or a tendency to put things off until the last minute. If their "symptoms" are not numerous or severe enough to interfere with their lives, they do not qualify for the diagnosis of ADD. Very little research has been done on the effects of stimulants on such people. In clinical practice, however, some of these people are treated with stimulants, and some of them experience significant benefit. This seems particularly true with patients who have difficulty maintaining their focus while reading for more than a short period of time.

There are two ways what you eat or drink can affect drug metabolism: one is by affecting how much drug is absorbed from the gut, and the other is by affecting how quickly you excrete the drug via your kidneys. In the case of the amphetamines, more acid food decreased the absorption of the medication and more acid urine increases it excretion. Exactly the reverse happens when people have foods such as antacids like Tums that make their urine alkaline.

It might be assumed that any acid food, like orange juice, would reduce amphetamine levels by both of these mechanisms. But that turns out not to be true. For example, orange juice is a highly acidic food due to its high citric acid content, but after being metabolized it causes the (body and) urine to become more alkaline. So the effects of orange juice on amphetamine blood levels are mixed, and I don't know what effect predominates.

Cranberry juice is a drink that acidifies the urine. It is possible that people who have trouble sleeping after taking amphetamines may be able to more quickly excrete it before bedtime by drinking a couple of glasses of cranberry juice or a Vitamin C pill at dinner time. I have one patient who tried Vitamin C, and it worked. If you try this, please click here to let me know the results.

Fatty food interferes with the absorption of the amphetamines so less of each dose taken around meal time gets into the blood stream.

List of food that make the urine more alkaline or acid (note that some alkalizing foods are very acid - after the body metabolizes them, they make the body and urine more alkaline. This seems counter-intuitive but seems to be generally agreed upon by nutritionists.)

Alkalinizing Foods (Some of these are quite acid before the body metabolizes them)

Acidifying Foods

Vegetables
Asparagus
Artichokes
Cabbage
Lettuce
Onion
Cauliflower
Radish
Swede
Lambs Lettuce
Peas
Courgette
Red Cabbage
Leeks
Watercress
Spinach
Turnip
Chives
Carrot
Green Beans
Beetroot
Garlic
Celery
Grasses (wheat, straw, barley, dog, kamut etc.)
Cucumber
Broccoli
Kale
Brussels Sprouts

Fruits
Lemon
Lime
Avocado
Tomato
Grapefruit
Watermelon (is neutral)
Rhubarb
Meats
Pork
Lamb
Beef
Chicken
Turkey
Crustaceans
Other Seafood (apart from occasional oily fish such as salmon)

Dairy Products
Milk
Eggs
Cheese
Cream
Yogurt
Ice Cream

Drinks
'Green Drinks'
Fresh vegetable juice
Pure water (distilled, reverse osmosis, ionised)
Lemon water (pure water + fresh lemon or lime).
Herbal Tea
Vegetable broth
Non-sweetened Soy Milk
Almond Milk

Others
Vinegar
White Pasta
White Bread
Whole meal Bread
Biscuits
Soy Sauce
Tamari
Condiments (Tomato Sauce, Mayonnaise etc.)
Artificial Sweeteners
Honey
Drinks
Fizzy Drinks
Coffee
Tea
Beers
Spirits
Fruit Juice
Dairy Smoothies
Milk
Traditional Tea

Seeds, Nuts & Grains
Almonds
Pumpkin
Sunflower
Sesame
Flax
Buckwheat Groats
Spelt
Lentils
Cumin Seeds
Any sprouted seed

Convenience Foods
Sweets
Chocolate
Microwave Meals
Tinned Foods
Powdered Soups
Instant Meals
Fast Food

Fats & Oils
Saturated Fats
Hydrogenated Oils
Margarine (worse than Butter)
Corn Oil
Vegetable Oil
Sunflower Oil

Fats & Oils
Flax
Hemp
Avocado
Olive
Evening Primrose
Borage
Oil Blends (such as Udos Choice)
Others
Sprouts (soy, alfalfa, mung bean, wheat, little radish , chickpea, broccoli etc)
Bragg Liquid Aminos (Soy Sauce Alternative)
Hummus
Tannin

Fruits
All fruits aside from those listed in the alkaline column.
Seeds & Nuts
Peanuts
Cashew Nuts
Pistachio Nuts

Coffee (caffeine) is a stimulant that has a number of effects on most people that are similar to the amphetamines and methylphenidate: it energizes them, helps them concentrate, and can keep them awake. It can raise their blood pressure. It can make them feel better. Withdrawal can cause some tiredness. In some ways, it is a poor man's stimulant, and many people with ADD who do not have access to medication or do not wish to take it for some other reason rely on it to help them function more normally.

I know of no controlled studies comparing the effects of stimulants and coffee on ADD, but in my experience, no patient with ADD who had previously used coffee to treat their symptoms has ever preferred coffee once they had been successfully treated with stimulants. The stimulants clearly help more with memory, focus, concentration, and distractibility.

Since both coffee and stimulants can be energizing, taking both at the same time can lead to anxiety and difficulties with sleep. The combination is also more likely to lead to upset stomach or heartburn. It can also make it difficult to accurately evaluate the effects of the stimulants if a person drinks coffee at the same time they are taking stimulants.

If a person takes multiple doses each day, there may be times when one dose wears off before the next one kicks in. In that case it is sometimes useful to take the second dose about a half hour sooner, even though the first dose is still working. By the time the first dose starts wearing off, the second one will start taking effect, and the overall effect will be smoother.

Vyvanse seems to be the smoothest acting of the long acting stimulants and, for many people, lasts 12 hours. Unfortunately it is quite expensive if you do not have medication insurance to cover its cost.

Over 55,000 children between 3 and 20 years of age who were newly diagnosed with ADHD were followed up for a number of years. Some never took stimulants, some took stimulants but stopped, and some continued to take stimulants. Each group averaged about the same number of years of follow up. Two cardiac deaths occurred in the group that never took stimulants, three cardiac deaths occurred among former users, and no deaths occurred among current users. This is very reassuring for those taking stimulants. Still, current stimulant users were about 20% more likely to visit the ER for cardiac causes than were non-users. This is not surprising since stimulants not infrequently increase pulse and blood pressure. However, the authors of this study do not report whether the increase in ER visits was related to the use of other drugs by those taking stimulants, to a greater level of anxiety among those taking stimulants, or to cardiac disease. The study was reported in the journal Pediatrics in December 20007.

Sometimes that is helpful. Just be sure that you and your doctor remember that there is an interaction between Strattera and both Prozac (fluoxetine) and Paxil (paroxetine) that may require adjusting the dose of your Strattera.

Vyvanse (rhymes with advance) is a new ADD medication. Well, it's really an old medication, dextroamphetamine (brand names Dexedrine, Dextrostat, etc) that uses a new delivery system to get into a person's blood stream. How the new system was developed is interesting*.

The more rapidly a stimulant gets into the blood stream, the higher and more excited, even high, a person can get on it. For most people, taking a stimulant by mouth gets medication into their blood stream fairly slowly, so few people get high on it. But some people grind up these medications, then sniff them or inject them into their veins. They got high, but they also can quickly became addicted and some have died of overdose. Scientists have searched for a way to prevent this from happening.

A few years ago, someone invented a process that makes medications inactive by attaching the amino acid lysine to them. If someone grinds up the medication attached to the lysine and sniffs or injects it, they would not get high. But if someone swallows it, intestinal enzymes would break the bond between the medication and the lysine, and the medication would become active.

Vyvanse is dextroamphetamine attached to lysine. When a Vyvanse pill is swallowed, the dextroamphetamine is slowly freed from the lysine and seeps into the blood stream. An unexpected benefit of this system is that the dextroamphetamine gets into the blood stream very steadily and over a period of ten hours or so after it is taken. This means it acts over a longer period of time than do other long acting ADD medications. In my experience, it also appears to have a slightly stronger effect than Adderall, which in turn has a slightly stronger effect than Ritalin or Concerta for many people. For these reasons, it is usually my first choice of medications to treat ADD.

The major downside of Vyvanse is that it is expensive. If your insurance covers all but a small co-pay, that may not be an issue. But some insurance companies require a larger co-pay for Vyvanse than for other stimulants, and some people don't have medication insurance coverage. In addition, because it is more expensive, some insurance companies require that the prescribing clinician submit a written request justifying its use.

Stimulants posed a widespread and serious addiction problem sixty years ago when they were widely used for weight loss and could be obtained without a prescription. Since prescription controls were put into place about fifty years ago, addiction has become a minor problem for the vast majority of people who take them.

The exception is the illegal stimulant methamphetamine, which is quite addictive and destructive to the brain. Addiction can also be seen sometimes when legal stimulants like dextroamphetamine are taken by vein or by snorting.

The reason the legal stimulants are rarely addictive is because the pleasure most people get from taking them is fairly mild or non-existent. In addition, while they may occur, I have never seen any withdrawal symptoms or pains when patients stop taking them, just a tired feeling for a day or two. Nevertheless, many people with ADD get such great benefit from stimulants that they feel very badly when they stop functioning normally after they've stopped taking them. This is not a sign of addiction but a sign the medications have been helpful.

Some people without ADD take stimulants in order to stay alert even when they have had insufficient sleep. The more tired they get, the more they need stimulants to keep going. This can appear to be an addiction because, sleep-deprived, they feel enormously exhausted when they stop. People surrounded by others taking stimulants recreationally and those under stress or suffering from post-traumatic syndromes may be at particular risk of addiction.

Addiction is different from misuse or abuse. Addiction means you physically need the medication to feel all right and crave it if you don't get it. Abuse and misuse include recreational use of stimulants at parties, selling or giving stimulants to others, etc. A group likely to abuse stimulants is troubled or "oppositional defiant" adolescents.

Human psychology and physiology vary so that there will always be people who will get addicted to something, including stimulants.

As of March 2008, from my search of the literature there does not appear to be any evidence that the stimulants adversely affect sperm. To be absolutely certain of avoiding any effect, the man could stop taking stimulants for three months before conception, the time it takes for sperm to develop. For personal advice and updated information about this issue, I would suggest you consult with your personal physician.

This is a question you should ask your physician about. Stimulants can decrease the blood flow to the hands and feet, and this might make diabetic neuropathy worse. They may also increase the pulse rate and blood pressure in about 8% of people and, if you have cardiovascular problems, this might be a concern.

Since the excretion of amphetamines is increased in acid urine, some people have found it helpful to take a Vitamin C pill (which makes the urine acid) at dinner time. Keep in mind that not all acid foods or drinks make the urine acid. For example, orange and lemon juice do not. The body metabolizes them in a way that ends up making the urine less acid. For a list of which foods make the urine acid or alkaline, click here.

While there is no difference between the effects of most generic and brand name medications, a number of patients have reported that the brand name of dextroamphetamine, Dextrostat, is superior to the generic made by Barr pharmaceuticals.

Many studies have strongly established a hereditary cause for over 75% of cases of ADD. At least a dozen different genes can contribute to ADD symptoms, partly explaining why everyone with ADD does not have the same symptom profile and why some people have much worse symptoms than others. There are genes for attention problems, others for hyperactivity, and others for both. To further complicate the picture, some of the genes start having their actions in early childhood and others not till later in life.

And what makes up the other 25% of the cause of ADD? As with most studies of the genetics of psychological disorders, the influence of the home environment seems slight. Most of the 25% of causative influence seems related to the unique life and health experience of each individual. Otherwise identical twins brought up in the same home would have identical symptoms, but it turns out that in about 25% of the time their symptoms are different from each others.

Amphetamines can be detected in saliva for 3 days, in urine for 1 - 4 days, and in hair up to 90 days. However these numbers may vary with individual metabolism, diet, and exercise patterns and well as with frequency and length of use. For more detailed information, click here.

Alkalinizing Foods (Some of these are quite acid before the body metabolizes them)		Acidifying Foods
Vegetables Asparagus Artichokes Cabbage Lettuce Onion Cauliflower Radish Swede Lambs Lettuce Peas Courgette Red Cabbage Leeks Watercress Spinach Turnip Chives Carrot Green Beans Beetroot Garlic Celery Grasses (wheat, straw, barley, dog, kamut etc.) Cucumber Broccoli Kale Brussels Sprouts	Fruits Lemon Lime Avocado Tomato Grapefruit Watermelon (is neutral) Rhubarb	Meats Pork Lamb Beef Chicken Turkey Crustaceans Other Seafood (apart from occasional oily fish such as salmon)	Dairy Products Milk Eggs Cheese Cream Yogurt Ice Cream
	Drinks 'Green Drinks' Fresh vegetable juice Pure water (distilled, reverse osmosis, ionised) Lemon water (pure water + fresh lemon or lime). Herbal Tea Vegetable broth Non-sweetened Soy Milk Almond Milk	Others Vinegar White Pasta White Bread Whole meal Bread Biscuits Soy Sauce Tamari Condiments (Tomato Sauce, Mayonnaise etc.) Artificial Sweeteners Honey	Drinks Fizzy Drinks Coffee Tea Beers Spirits Fruit Juice Dairy Smoothies Milk Traditional Tea
	Seeds, Nuts & Grains Almonds Pumpkin Sunflower Sesame Flax Buckwheat Groats Spelt Lentils Cumin Seeds Any sprouted seed	Convenience Foods Sweets Chocolate Microwave Meals Tinned Foods Powdered Soups Instant Meals Fast Food	Fats & Oils Saturated Fats Hydrogenated Oils Margarine (worse than Butter) Corn Oil Vegetable Oil Sunflower Oil
Fats & Oils Flax Hemp Avocado Olive Evening Primrose Borage Oil Blends (such as Udos Choice)	Others Sprouts (soy, alfalfa, mung bean, wheat, little radish , chickpea, broccoli etc) Bragg Liquid Aminos (Soy Sauce Alternative) Hummus Tannin	Fruits All fruits aside from those listed in the alkaline column.	Seeds & Nuts Peanuts Cashew Nuts Pistachio Nuts

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