Dr. Carolyn Lentzch-Parcells on ADHD and Medications, What They Do, and Do Not Do.

What's up, everyone? Shane here, and I've got an awesome episode for you today. I sat down with the incredible Dr. Carolyn Parcells, aka the ADHD MD, to talk all things ADHD medication. We dive deep into the different types of meds, how they work, and bust some common myths. Dr. Parcells drops some serious knowledge bombs and shares her experience as a board-certified pediatrician specializing in ADHD. Trust me, you don't want to miss this one! We even had a heartwarming moment with a little girl who joined us and asked Dr. Parcells about her own ADHD journey. It's an episode packed with valuable insights and relatable moments. So grab your favorite beverage, get comfy, and let's learn together!

Timestamps:
(00:00) Introduction and welcoming Dr. Carolyn Parcells
(05:15) Why medication is used for treating ADHD and the role it plays
(12:30) Overview of the two main families of ADHD medications: stimulants and non-stimulants
(20:45) Deep dive into methylphenidate medications, how they work, and different formulations
(31:20) Amphetamine medications explained, including side effects and unique formulations
(40:10) Non-stimulant medications for ADHD treatment, including guanfacine, clonidine, and newer options
(48:55) Q&A: Addressing the "honeymoon period" with ADHD meds and potential tolerance
(53:30) Q&A: Rejection sensitivity dysphoria (RSD) and emotional dysregulation in ADHD
(1:02:30) Q&A: Emotional deregulation side effects from certain ADHD medications
(1:08:50) Heartwarming moment: A little girl asks Dr. Parcells about her experience with ADHD in school

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Transcript

 Everyone. I really appreciate everyone making it. This is a pretty decent sized crowd for just a live part, but As always we will be recording this and then sending it out fairly shortly to everyone who did donate so Big big big big shout out to everyone. Thank y'all so much Y'all are what is allowing us to keep moving forward at least until we get these grants.

We're hoping for real soon.  So if y'all haven't caught on, this is going to be about medications, what they, you know, what they do, what they don't do, what to do when that happens. Right. And we want to make sure that everybody understands that there is going to be a Q and a after the fact. So if you have questions or anything like that.

Make sure you hold on to them. Go ahead and throw them in a chat if you want to. Get some conversations going. Remember this is being recorded, so when you get distracted by the chat, you'll be able to watch this later on and get caught up with what's going on. So, without any further ado, I do want to introduce our speaker.

This is Dr. Carolyn Lyntzsch Parcells. She is board certified pediatrician and owner and president of Girls to Women Young Men's Health and Wellness in Fort Worth. Did I say that right? 

Until, well, yes. 

Wait, you were transitioning. 

Monday,  Our Place Adolescent and Young Adult Health, which is a way easier name to say.

There you go. And I'm very excited. I'm very excited. Yeah. 

So as Shane said, I'm Dr. Carolyn Lynch Parcells. I am a board certified pediatrician and I, but I do what's called adolescent medicine.

So I take care of children, but also teens and young adults who have ADHD. And a lot of what I do is taking care of folks with ADHD in large part, because I have ADHD myself, as well as a learning disability. So taking care of our community is something that's very near and dear to my heart. So very long list of objectives here, but really the point is that what I really want everybody to get out of this talk is that no matter what your knowledge base is coming into this, that you get a better comfort level with the medications, what they are, what they do, what they don't do, as well as.

Dispelling some of those myths that we have about ADHD and the medications.  So gonna dive right into it. First question, of course, is always why do we even use medication for the treatment of ADHD? Well, we use medication because the research shows us that  people with ADHD have better results overall when certain medications are made part of their treatment regimen. 

The research shows us that optimal treatment of our ADHD, and for many people including medication, decreases our rates of depression, anxiety, substance abuse, school failure, work failure, accidents. It improves social development and relationships, and may even increase our lifespan. Some of the research done by Dr.

Russell Barkley, who's one of our kind Lead researchers in the field  showed that when we treat our ADHD, we can extend our lives by an average of 13 years. Which was pretty impressive. Now, does that mean that if you don't treat your ADHD, it's going to take 13 years off of your life?

No, it's a statistic. And that statistic is made bigger by some of the things, some of the increased accidents and  honestly, suicide. and other things that can cause us to unalive ourselves earlier on. The other piece of that, though, is that if we take care of ourselves and we take our care of our ADHD, we do a better job of taking care of ourselves overall, including our physical health.

We make better choices. We're more likely to make it to the doctor's appointments or to remember to take our medications for other conditions we may have and overall take better care of ourselves.  So  the medications themselves, the role that they play in ADHD, first of all, the research shows us that medications are actually, the research on medications is better than any other intervention we have for ADHD.

The number one best  data  support for any intervention in ADHD is for medications. The second best data, if you will, is for actually exercise. In mitigating the symptoms of ADHD.  But with all of that said, we are still learning about ADHD, and we're still learning about the medications for ADHD.  We do know, though, that two of the brain's neurotransmitters, dopamine and norepinephrine, do appear to take, play a pretty significant role in ADHD, and thus in the medications we use to treat ADHD.

So what do I mean by that? Well, neurotransmitters are the chemicals that our brain cells make to communicate with one another. So when those neurotransmitters, either we don't make enough of them, or they're processed out of the system too quickly, or they don't work on the receptors the way they should, that, that signaling doesn't happen quite as well.

Dopamine and  norepinephrine in particular affect things that won't surprise you. Attention. Alertness.  motivation. You can see how these are issues in ADHD. So the medications, in particular the stimulant medications, work by increasing available dopamine in the brain, so that signaling can happen better. 

Now, that is not to say that medication is a magic bullet. It doesn't fix everything, and it's certainly not the end all be all. Nor is medication the absolute right choice for everybody. But the data does show us that at least 85 percent of people with ADHD will have a positive response to ADHD medications. 

So,  with all that said,  ADHD is not in and of itself a bad thing.  There are definitely gifts that come along with ADHD. And I bring this up because when we're talking about medication and how we use medication and what we're looking for from medication, there are certain things we don't want to lose.  Our creativity, our passion and enthusiasm, our attention to detail.

This is when I really get on a soapbox about because  this whole thing about we don't, we miss details. We notice every detail.  The problem we have is prioritizing the details.  So, we may notice a detail that other people don't think is as important, and because we focus on that, we miss or we deprioritize a different detail, but that can actually be a gift as well, because we can catch things that other people miss. 

As a result, that brings us to problem solving. We can solve problems in a different way, which is sometimes better than other people can. We can also be very entrepreneurial. And  we can also be willing to take risks. And taking risks is not always a bad thing. That can actually be a really, really good thing. 

With that said,  Pills don't build skills. It's one of my favorite phrases. However, They sure as heck help us use them. We do still need to figure out different ways to do things because our brains work differently,  but the medications do help us. And I'll circle back around to this at the end. The medications help us.

to focus, learn, and retain  those skills. The medication also gives us the impulse control  to say, hold on, how do I want to handle this situation? And gives us that split second to access those skills  and use them appropriately. One of my favorite Russell Barkley quotes is that ADHD is not a disorder of knowing what to do.

It's a disorder of doing what we know.  The medicine helps us to do what we know.  The way I like to really explain this to my patients is I use the X Men analogy, and Shane, I know I'm going to botch it again. Shane actually corrected me after he heard me give this talk, and I don't remember exactly what you said, so you can correct me again when I'm done.

What was it? Go ahead, Shane.  They're force beams. Force beams. I was calling them laser beams. I was saying that Cyclops had laser beams coming out of his eyes. It's force beams. Also, 

you comic book nerds out there who are going to correct me, that's canon.  Anyways. 

There you go. Shane said it, 

not me. I'm going away now.

I'm 

going away now. Take care of Shane. Okay. Shane. Shane. So the analogy I like to use is the X Men analogy, which is, if you think about any of the X Men, Cyclops of course included, Their superpower was thought to be bad, or dangerous, or negative in some way by most people, themselves included.  Some X Men simply have to learn how to control, or manage, or harness their powers, but other X Men, like Cyclops,  cannot control their powers.

He cannot control the force beams  flying out of his eyeballs.  He needs his equipment. He needs his visor.  But really importantly, the visor does not take away the force beams. The visor gives him the control, the power over when he uses them and when he doesn't.  So coming back to those gifts I was talking about, this is what we want from the medicine.

We don't want the medicine to make us feel different or take away our personality or take away any of those gifts that I mentioned. We want the medicine to give us control over when we use those gifts. And when we don't, we want the medicine to help us have control over the ADHD as opposed to the ADHD having control over us. 

Okay, so now jumping on off of that soapbox, we're going to jump into the medications. There are two families of medications for ADHD. There's the stimulants and there's the non stimulants. We're going to start with the stimulants. The stimulant medications are the first line, first choice medications for the treatment of ADHD because they are the ones that have been shown to be the most effective for ADHD.

And by the way, these medications  Not necessarily these current formulations, but the molecules used in these medications have been around  and used for these symptoms since the 1930s and 40s.  So these medications are actually not nearly as new as people think they are.  Now within the stimulants, there are two families of stimulants.

There's the methylphenidates and there's the amphetamines. We're going to talk about how they're similar and how they're different.  Within both families, all stimulants have the possibility, have the potential to improve, to increase available dopamine,  and by doing so can improve attention, focus, motivation.

I have organization on here.  I'm going to come back to that. There's a little caveat on that one. Impulsivity, hyperactivity, and emotional regulation.  I have on here a list of common side effects. Note it says common, not all. Because it would take me too many slides.  But in general, these are kind of the most common side effects that we can see with the stimulant medications.

Now that does not mean that everyone's going to have those side effects. It also doesn't mean that if you have side effects with one medication, you will have side effects with even another formulation within the same family, let alone the same side effects in the other family. I point this out because I can't tell you how many times I've had people come to me, they tried maybe one stimulant, they had side effects they didn't like, and just decided that stimulant medications weren't the right thing for them overall without trying anything else.

So that's a point that I think is really important to make.  Now it's also important to understand how we dose these medications. Because I think it sets the expectation.  These are pretty unique medications in, in the grand scheme of medications. In the sense that the dosing is not dependent, not dependent, on your age, your size,  your gender, or the severity of your ADHD. 

Okay?  We dose for everyone. We should be starting at the lowest, or one of the lowest doses.  and titrating, or working our way up in a stepwise fashion until we reach the best tolerated, best effective dose,  or if we can't get that with the medication we're trying, we change medications.  Now, within one human being,  hormones can affect how we respond to the medication, age can have an effect, weight can ha size can have an effect, all of that.

So within one person, those factors can absolutely have an effect on how the dosage that you need changes over time,  but we don't look at somebody and say, oh, you have severe ADHD, or you're this size, or you're this age, we need to start at this dose. If that makes sense.  Now the other thing we have to take into consideration when we're trying to decide how to dose these medications and finding the optimal dose is metabolism.

And when I say metabolism, I don't mean how you metabolize food. It's how your liver  specifically processes these medications. Not even other medications, just these medications.  For some people, they're what we call a typical metabolizer. So that means that whatever the typical standard amount of time that medicine is supposed to last.

So Concerta, for example, supposed to last about 10 to 12 hours. If you're a typical metabolizer, it will last you about 10 to 12 hours. If you are a slow metabolizer, that means you don't process these medications as fast. And they will last longer. So Concerta might last you 14 hours, 16 hours, something like that. 

Somebody who is a fast metabolizer processes the medications too quickly, and the medicine will last a shorter amount of time. So with the Concerta example, it might be more like 8 hours, or 6 hours, or even 4 hours. Yes, I have seen people who metabolize medicine that fast.  So these are all factors we take into consideration when we're choosing the actual formulation of the medicine, as well as how to alter it when needed. 

So, with the methylphenidates, so now we're going to jump into kind of the differences. That was the similarities, we're going to jump into some of the differences. So with the methylphenidates, The mechanism of action, or how it works, is that it increases available dopamine in the brain by inhibiting dopamine reuptake by the neurons.

What that means is there is a receptor on the neurons that its whole job is to basically suck up, like a vacuum, the dopamine that  has been being used by the neurons. It sucks it up, and it recycles it and takes it out of the system.  The medicine blocks the vacuum  so that the dopamine stays in the space where it can help the neurons communicate for longer.

So it helps you use the dopamine you produce better and longer.  All of the medications in this  family use the exact same molecule, methylphenidate. They're just different formulations, meaning they differ in how the medication is released. how and when the medication is released. The two exceptions to that rule are Focalin and Esteris, and I'm going to come back to those two in just a second. 

So,  in each of these families, there are long acting formulations, or extended release is another way of saying that, and there are short acting or immediate release.  The long acting or extended release formulations of,  for both families, are what's preferred. The reason being because  First of all, ADHD affects every aspect of our life, so we need as much coverage as we can get.

The other reason is,  It's hard enough for us to remember to take one dose a day.  We're not going to take multiple doses a day, at least not most of us, and I speak from experience.  So it's best for us, we get the best care for our ADHD if we can get the right medication in one dose. If we can't, we can't, and there's things we can do about that, but that's the goal. 

The dosing is typically in the morning, although there is an exception to that rule that we'll hit on in a second.  I usually recommend taking it before 10 a. m., at least until you know how long it lasts for you, and that's of course assuming that your daily schedule is a typical daily schedule. Obviously you adjust for, for your schedule. 

Onset is about 20 to 60 minutes, meaning the amount of time from when you take it to when it kicks in. That can vary by person. It can also vary by what you've eaten for breakfast.  And duration of action, meaning how long they last, for most of these medications is going to be anywhere from 8 to 8 to 14 hours, depending on the formulation and depending on metabolism, like we talked about. 

The other issue with the long acting formulations, and again, this is actually in both the methylphenidates and the amphetamines, is there's one side effect that we see. With the long acting that we don't necessarily see with the short acting and that's a little bit of increased what we call emotionality or emotional lability towards the end of the day or when the medication is wearing off.

So, for, like, an hour or 2, some people might notice being more irritable, more tearful,  quicker to anger, that kind of thing, and it can be subtle enough that people don't even really realize what's going on. It can be so severe that we have to change the medication. And there are actually things that we can do to ease this side effect, other than just changing the formulation if we need to.

But it's something to be aware of.  These are the name brand, not generic, name brand formulations  of the long acting and extended release formulations. I put these up here because  It's so confusing. It was already confusing, but they continue to make it even more confusing. Okay. So things like, so Concerta, the generic is methylphenidate ER.

And we're going to come back to that one in a little more detail in a second. Ritalin, the generic is methylphenidate SR or methylphenidate  LA. Metadate is methylphenidate CD. You see where I'm going with this.  So when you're getting the bottle, If it's not the name brand, if it's the generic, you gotta basically look at the little letters that are on there to make sure you got the right one. 

And they are not completely equivalent. That is the other thing that's important to know. Now, some of these name brand ones down here, Jornet PM, Cotempla those do not have those do not have generics. Same with Quilavent and Quilichew. Focalin does have a generic, which we'll touch on in a minute.  So Concerta.

I mentioned we'd come back to this one. Concerta is the most commonly prescribed long acting methylphenidate. It is also the one that has been causing everybody  heartburn recently. And yes, I do have a section on the med the med shortage.  Concerta is very unique in the formulation and its release formulation.

The name brand Concerta has what's called an osmotic release.  It mimics, like if you were to take the short acting about three times a day, but it's smoother than that.  The name brand Concerta looks like a tic tac.  The generic  methylphenidate ER has a different release  system, and it looks like a little circle. 

What happened with the shortage was back in January of this, of 23, so about a year ago.  There was name brand Concerta. There was the authorized generic made by a pharmaceutical company called Patriot, which looked exactly the same because it was exactly the same. And then there were the other generics, which were the circle one, which does not have the same delivery system. 

In January, Patriot stopped making the authorized generic. So now, the only generic option is the one that is a different delivery system. Now, for some people, that really doesn't make much of a difference for them. For other people, the generic formulation lasts a little bit less long, if you will, so a little shorter, or isn't quite as effective.

And then for a small number of people, and I've had these patients, It actually creates very significant side effects that they don't get when they get the name brand concerta. So when that happens.  We re, we have to go through the whole rigmarole with insurance to get approved name brand necessary or name brand only to make sure they get the right medication.

So if you've noticed anything like that, that could be what's going on.  JournayPM is another one that I want to point out. It's a very unique one. This is the one that I said when I said we take them in the morning. This is the exception to the rule. JournayPM is what we call a delayed extended release. So you take it at night, and it kicks in approximately 10 hours later, also known as first thing in the morning. 

This is amazing for people who struggle with mornings, which is probably most of us.  It can be really, really helpful. It can also be helpful for people for whom they have trouble remembering to take their medicine in the morning or they, their stomach is not great first thing in the morning, so it's hard for them to eat breakfast and then they take their medicine on an empty stomach and then that doesn't work.

So it can have a lot of different applications. The other thing I love about Journey is it's got about a 14 hour. for duration for typical metabolizers. So it's about the closest we have with the methylphenidates to nearly full day coverage.  The other thing that's great about it is it can be opened up and sprinkled for people who have trouble swallowing capsules. 

Focalin. So I mentioned I'd come back to Focalin and Asteris. So what is different about these two is they utilize what's called dexmethylphenidate  instead of just methylphenidate.  I don't know how many of you got to study racemic mixtures at some point in time in science. But what a racemic mixture is, when, when the methylphenidate itself is in mixture in these other formulations, there's actually two molecules that are both technically methylphenidate.

There's dexmethylphenidate, which is the right handed molecule, and levomethylphenidate, which is the left handed molecule. They're mirror images of each other. In Folklin and Asteris, they utilized dexmethylphenidate only, so they took the left sided one out and only left the right handed one in. The theory behind this was that this is the molecule that does all the good stuff, and this is the one that causes the problems.

Great in theory, meh in practice. Certainly there are people for whom these formulations are more effective or better tolerated. There's also people for whom they're less. effective or not as well tolerated. So it just depends on the person.  Focalin XR, which also comes in an immediate release formulation, does have a generic.

It's dexmethylphenidate XR. Lasts about 10 to 12 hours and can be sprinkled.  Asteris is a little different. It's what we call a prodrug. It actually has a little bit of the immediate release focalin in it to try to get it going sooner. And then it has this fancy Sirdex methylphenidate, which  enables it to have kind of more of an extended release.

So it lasts about 13 hours.  It can also be sprinkled.  There's a whole lot of formulations. This is actually great. When I first started doing this work, we were very limited for folks who could not swallow pills or preferred not to swallow pills. We now have a whole bunch of options. We have chewable, we have dissolvable, we have liquid we have caps that can be sprinkled.

We have all kinds of options for extended release formulations, which is really, really great.  Okay.  Methylphenidate short acting. So names are listed above. Basic gist of these though, is that they  kick in in about 30 minutes. We usually just use the generics for these. They only last about three to five hours for typical metabolizers.

So how do we use these? When do we use these? Well, we typically only use them as a booster dose in the afternoon.  Although you can also boost in the morning and take the long acting later if that works better for your schedule. So for our folks who, who the long acting just isn't getting them through their whole day, we can give them a short acting in the afternoon. 

We can use it as a single dose agent. I have done this in people who are such slow metabolizers that the immediate release actually is long acting for them,  but also it is cheaper. It's significantly cheaper and more available. So there are times where we use these and they have to be dosed 2 or 3 times a day to get full efficacy or full duration.

The other times where these can actually be really helpful is for folks who have. Wonky schedules or people who maybe switch back and forth between day shift and night shift or my college students who wake up late too late on the weekends. To take their long acting, but still need to study. So there can be different uses for these. 

They come in multiple formulations, tabs, chewable, et cetera. Like I said, cost is a decreased cost is a plus the biggest downside to these other than the dosing issue is that it is the immediate release formulations that are at.  increased risk for diversion or misuse. Diversion is when the medication gets into the hands of the, of somebody it was not prescribed to.

And then misuse is of course when it's used either by people for whom it wasn't prescribed or in an, in an abusive way. 

All righty, moving on to our amphetamines.  So amphetamines work by increasing available dopamine in the brain by actually increasing the release of dopamine from the neurons.  Excuse me.  Now, in this one, the differences in the formulations are similar to what we heard about in the methylphenidates. It's how and when the medication is released, but in addition to that, they can vary in the percentage of dexamphetamines  to the other amphetamine salts.

So this is that same situation I was talking about with the Focalin. Where you've got the right handed molecule dexamphetamine and you've got Levo amphetamine. So most of the amphetamine class is actually about 75 percent dexamphetamine.  There's a couple of exceptions to that that we'll talk about. The other thing that I point out with the amphetamines is while they do carry the same side effect profile or side effect list as the methylphenidates, there's a few side effects that are a little bit higher risk with the amphetamines than with the methylphenidates.

And those are increased risk for decreased appetite, weight loss, and irritability. These side effects are even more prevalent the younger we go. So in our young school age kids, we typically don't recommend these as first line.  So I usually don't go to an amphetamine in a younger kiddo unless we have tried two, if not three methylphenidates, unless there's a really strong family history for the amphetamines working really well.

Now, does that mean I don't have littler kiddos on amphetamines? No, of course I do. It's just not our go to unless there's a really good reason.  Again, long acting, like I said, they vary by delivery system. Onset is about 20 to 60 minutes, like the methylphenidates, and duration also very similar, about eight to 14  hours, depending on the formulation.

My deus is about 16 hours. That's the longest lasting in the amphetamine class. And then they also have the long acting versions also have the same issue with  the emotional liability or can have, I should say the same issue with emotional liability as it's wearing off in the evenings.  Here is our lovely list of name brand for the Amphetamine class.

Adderall XR is the most commonly prescribed in this class, and it  on the, the generic, which is what most people use, usually looks on the bottle, like either mixed amphetamine salts or dexamphetamine dash amphetamine  or dexamphetamine dash Levo amphetamine. It's a very long name. Which is unfortunate at Zenni and Diana are the ones that if I'm gonna use them in a younger kiddo, I might use Adderall.

But those tend to be a little bit better tolerated in the younger ones. We don't use d dioxin or Dexedrine very often. I mentioned my dus already. And then Vyvanse we're gonna talk about here in a minute.  So Adderall XR, like I mentioned, duration is about 8 to 12 hours, 75 percent dexamphetamine, comes in generic, it approximates like to about twice a day dosing, so like if you were to do the immediate release two times a day. 

Now this is the other one we're having, well, we're having supply issues with everything now, but the supply issues started with Adderall. in fall of 2022.  It was then exacerbated by the issues I mentioned with Concerta in January of 23. And then it's just all trickled down from there.  We'll hit on that a little bit more when I talk about the supply issues. 

Vyvanse is an interesting one because this is the original pro drug. This one's called Liz dexamphetamine. It's a hundred percent dexamphetamine, but it's got this little molecule stuck on it. That makes it a quote pro drug. What that molecule is, is when you ingest it, there's an enzyme in the body that cuts that piece off so that your body can then absorb and utilize the medication as it was intended. 

That little extra molecule helps to prevent Vyvanse from being misused and abused. It also helps to smooth out the metabolism of it.  The duration is 12 plus hours. And it is now finally, we have all been waiting for never and ever and ever. Finally hit generic in August of 2023. So lots of big things happened in 23 for A DHD medications.

Now, when this first happened, we weren't sure whether or not it was going to  honestly help or hurt the supply.  We have a Vyvanse shortage. I don't know if it's because we just have a Vyvanse shortage or because of the generic causing issues, but we do now have generic.  Short acting, same thing we again in the short acting medications, we typically just use generic amphetamine to be honest.

There are name brand options, but that's usually what we use  the formulations again come in in several, several shapes and sizes and and formulations chewable dissolvable liquid tablets. Onset is about 30 minutes, and these, the research says these last about three to, four to eight hours, but I'll be honest, it's about the same as the immediate release for the methylphenidates.

And again, like with the methylphenidates, we use these as a booster,  or if we're using it as a single agent, we try to dose it two or three times a day if needed.  Okay, that was the stimulants. We are now jumping into the non stimulants, and we're going to start with the most popular class of non stimulant medications and my personal favorite,  the alpha 2 adrenergic agonists, which is a fancy way of saying old school blood pressure medicines.

Yes, that is what these medications were originally developed for. And what's interesting is, is, we say that we don't really know how they work in ADHD, which is true,  but what we do know about them and why they work for blood pressure  is that these medications stimulate inhibitory neurons  that decrease sympathetic outflow, which is a fancy way of saying they are the literal chill pill. 

That's what I like to call them. Basically, what they do is they tamp down or chill out the sympathetic nervous system, which is our fight or flight system.  If you know that, And then I tell you what they help in ADHD.  Hyperactivity, irritability, impulsivity, aggression, sleep, emotional regulation, and rejection sensitivity dysphoria.

I don't know about you, but to me that kind of seems to make sense.  So the medications in this group, again, we have long acting and short acting. They're Guanfacine and Clonidine are the generic names. Intuniv and Capve are the trade names of the extended release versions. Intuniv or Guanfacine ER. is primarily what we use for long acting.

For two reasons. The cap ve has to be, it doesn't last as long, so it has to be dosed more, and also it's more expensive. So there you go.  Dosing for these we usually do in the morning, once daily in the morning, but you can do it in the evening if that works better for people. We see, we usually see something, With these medicines pretty quickly, but it can take up to two weeks for full effect and you do want to take them every day  duration 12 to 24 hours.

The ideal is that it actually does give us more than 12 hours close to 24 hours coverage, which can be really helpful.  We typically use these as an adjunct to stimulant medication, which means in addition to,  they can be used on their own, but they have not been shown to be as effective for symptoms such as attention and focus as the stimulant medication.

So we're often using them in conjunction with the stimulant medication and they tend to have an additive effect with each other. and work really nicely together. They can be used by themselves though, especially for people who can't tolerate stimulant medication.  Main side effects are sleepiness, fatigue, dizziness, technically I have to say low blood pressure, but at the doses that we use, that's pretty rare.

There is another rare side effect in about 3 5 percent of people where Instead of chilling them out, it actually does the opposite and makes those symptoms worse, makes them more irritable. And that's not fun, but that's a very small, small number of people.  The downsides, like I mentioned, less effective as a lone agent.

The other downside to, to the long acting versions is they only come in a tablet that cannot be crushed or cut. So they have to be swallowed. So for folks that can't swallow pills or prefer not to, that can be a problem.  The other thing I like to point out with these medications is they can actually be really helpful for people with tics because they're actually one of our first line medications for treatment of tics. 

The immediate release versions, clonidine and guanfazine, same medications, they last about 8 hours. These we actually typically use at night time to help with sleep,  because these cause a little bit more sleepiness, or can cause a little bit more sleepiness. But they really, the way I describe it to people is it's like,  they turn down the volume on all the voices in our head and make them take turns. 

So it really kind of  addresses directly the stuff that I call it the ADHD brain spin that makes it difficult for us to get to sleep at night.  Now, the other place we can use these is the, the, the immediate release versions can be crushed. So for people who can't swallow pills, if it doesn't make them too sleepy, we can use these medications during the day and dose them two or three times a day to help get them the same effect as the extended release formulations. 

The newest non stimulant on the block is Kelbree, also known as Vila, Vila, Vila, I'm not saying it.  You can read it there for yourself. This medication is what we call an SNRI.  So Selective Norepinephrine Reuptake Inhibitor. So we've been talking a lot about dopamine, but remember how I mentioned norepinephrine at the beginning of the talk.

Well, this medication primarily affects norepinephrine. It increases available norepinephrine  in the brain by blocking the reuptake and recycling of it out of the system.  It can be used as a solo agent. So by itself, it can also be used in addition to a stimulant. This medication, the company's research at least, does suggest that it can be helpful for all the core symptoms of ADHD, both the impulsive hyperactive symptoms and the inattentive symptoms.

It takes about one week to start seeing some effect and max effect can take up to four weeks. You do have to take it every day, but it provides 24 hour coverage and it's not a stimulant.  Side effects are mainly drowsiness, decreased appetite, tiredness insomnia, nausea, vomiting, irritability. The, in my personal experience with this medication, I haven't been using it a whole lot,  but here's what I and most of my colleagues have seen with this medicine  is, first of all, we need more time to really see what patients is it going to be the most helpful for and, and what we think about it.

But it's kind of like the, we call it the all or nothing medicine  because it seems like our patients either have side effects with little to no. Benefit  or  it's the greatest thing since life spread. And they're like, where has this been?  It just depends on the person.  Stratera is old school, non stimulant.

This is also a selective norepinephrine reuptake inhibitor,  which can also be used as a solo agent or adjunct. I'll be honest. I don't use this medicine very much for most of us in the field. We just don't feel like it has stood the test of time. We don't feel like it's as effective as the stimulant medications  and the side effect profile is not necessarily that much better.

It also takes  forever of consistent usage for it to be effective, which is really difficult for folks like us.  With that said, there certainly are people for whom Stratera works well for. So if it's working well for somebody, you know, if it ain't broke, don't fix it. And there are people, there are professionals in the field who feel like they have seen a significant benefit with it for, for more of their patients than I have. 

Third line options, we're not going to go into these in detail. I mainly have this slide in here just so you know that there are in fact even more options, but they are significantly further down the line. Welbutrin in particular, I like, especially when people also have concomitant depression, that can be a good option for folks. 

So, how do we get started? So this, those are the medications, those are primary medications.  I like to talk a little bit about,  great, so how do we get started? When do we get started? How do we know to get started? Well, first things first, I always tell people just talk first of all with your primary care doctor. 

Not all primary care doctors are comfortable starting these medications or managing these medications, but some are. So it's a good place to start. If they are not comfortable managing these medications, hopefully at least they have a list of people they refer to in your area who can help.  One of the things that's interesting about ADHD is there's different specialties that manage it.

There's pediatrics, there's internal medicine, there's family medicine, there's psychiatry, of course, but also neurology and developmental PEDS. can also be people who manage ADHD. So it kind of depends on your area and who's available. 

Then there's the whole question of how do we choose the medication?  Well, that in part depends on age.  Four to six years old is the only age group where medication is not the first line choice of treatment. The reason being that in the four to six year olds, they can have a higher rate of side effects with this, the stimulant medications in particular. 

Now that does not mean we cannot use stimulant medications in those kiddos. It just means that we want to try other things first, like parent training and classroom interventions. If that is not sufficient and the child is struggling, it is okay to start medication. And we typically recommend methylphenidate, one of the methylphenidate preparations in that scenario. 

For six to eight and 12 to, well, really anybody older than six, medication in particular, stimulant medication is Gold standard first line treatment. In addition to that, depending on age, either parent training, behavioral management, and classroom interventions, or coaching and other accommodations and skills training.

I'm a big fan of coaching. Big, big, big, big fan.  Other things we take into consideration when we're choosing medication, personal history, family history, coexisting conditions such as depression, anxiety, other medical conditions.  But with all of that, even taking all those things into consideration, the fact of the matter is, is we just don't know what's going to work until we try.

And I know that can be kind of, that can be frustrating for folks.  When we start medication, like I mentioned before, we want to start low. So we start with one of the lowest doses and we titrate or adjust our way up as we go. This can take time.  It can also take trial and error. It may take time to find for side effects to improve.

It may take time to find the right medicine. It may take time. We may have to add an adjunct.  So yeah, it's possible we might nail it and hit it right out of the gate, which is awesome, but it's also possible that this process is going to take time. Now,  The good news is, is at least with the stimulant medications, we can actually adjust those medications and that dosing as quickly as every three to five days, assuming someone's not having side effects. 

So we can actually crank pretty quickly on those.  If someone's having side effects, I always tell them if it's mild and tolerable,  take it every day, and you want to give it at least two weeks. After two weeks, what you see is what you're going to get, except for appetite, that can take up to a month to kind of see where it's going to land. 

If it's not, if the side effects aren't going away after two weeks, or they're not tolerable, then that's typically a sign that we may need to consider changing medications.  So, the other thing I like to tell people is this is where I like to try to really set expectations.

Because I, again, I've had so many patients come to me where  they just didn't understand the process or it wasn't explained to them and they didn't know that we were going to have to try different medications, different dosages, all of this thing and it can take time.  And so they stopped or they got frustrated, understandably so, and so I try to lay all of this stuff out for folks so that they know what to expect. 

Okay, medication shortage. So the medication shortage I've touched on a little bit. Again, we tend to have some amount of medication shortage towards the end of the calendar year with the stimulant medications, because they're controlled substances, which means the amount of substrate or the raw materials.

The amphetamine and methylphenidate that these medications are made from is actually controlled by the government, and there's a limit.  In addition to that, though,  we had the situation with Adderall in the fall of 23, which was actually caused by staffing shortages in the manufacturing plants.  Then we can, we compounded that with, as I mentioned, the issue with Concerta. 

There have also been some other issues that come into play with supply, but then the other thing we had, so that's the supply, is we had increased demand. Now, a lot of that is, sorry guys, It's us. It's the ladies. The largest, fastest growing group of people being diagnosed and treated are women ages 35 to 55.

Because we were missed.  We were missed as kids. Not that some of you guys weren't missed, too. Because you were.  The  number of people getting diagnosed is increasing, which I actually consider a good thing. Because, again, people who fell through the cracks before are actually getting identified and treated now.

But as a result, We have really honestly a fairly straightforward supply and demand issue. We have decreased supply with increased demand and that has equaled the  jumble stuff situation that we are dealing with now. So what can we do with the medication shortage? How can we manage that? There's a few things we can do. So, you can, and I know this is so hard, but try to give yourself more time for refills if possible, because  If your pharmacy doesn't have it in stock or if they're not going to get it in stock in a timely fashion.

So first of all, it gives them time to get it in stock, but also if they're not going to be able to get it in stock it gives you time to call around and find another pharmacy, call your provider, have them resend it because you can't just transfer these between pharmacies.  Calling different pharmacies, which I know is a complete pain in the butt.

And let me please, please preface all of this, which I, with the fact that I know it is not ideal and I'm trying to put lipstick on a cow here. Okay. But we're going to try. And yes, I'm from Texas. That's where that analogy comes from. Any who  calling different pharmacies to find your medication or your dosage.

I know it's frustrating, but it can help you find the right Medicaid, the right dosage and the right medication. One of the things to remember is that different chains  have different suppliers. And also, they often have different suppliers from these small mom and pop pharmacies. So sometimes  it's an issue with the distributors, not just the overall supply.

So sometimes when you call different chains or different mom and pop groups or what have you, you might be able to find the medication. If you can, because I know insurance limits  pharmacies you can use. Don't get me started on that.  The other, if you still can't find your medication with that, you can talk to your provider and consider a couple of different options. 

Can you, if your dosage is out, but that medication is available in other dosages, can you put a couple of dosages together to get the right dose? So for example, if you take Adderall XR 15 milligrams and you can't find the 15 milligram dosage, Can you do 5, or can you do 3 5s, if those are available?  If that's not an option, can you, is it an option to change the dose of medicine?

Again, not at all ideal,  but if you haven't tried the next dose up, does it make sense to try that? Or does it make sense to go down a dose, not that it's ideal, but it's better than nothing?  The other option is to try, alternative medications that might be easier to find. So some of those name brand ones that I mentioned  are easier to find than the generics these days, or trying a non stimulant.

Obviously,  all of this is for educational purposes. Do not do anything without speaking to your own provider first. This is not to constitute medical advice.  I think that's a given, but just to make sure.  So if we're needing an alternative to, say, a methylphenidate, some of the medications that are in that class that might be reasonable are listed here.

We mentioned them a little bit earlier.  If it's an amphetamine and we're looking for a name brand that might have better availability, these are our options there, other than the Vyvanse. Vyvanse is Vyvanse. There's not a great equivalent to that. Or an exact equivalent to that, I should say.   So we've talked about the medications, how to get them, how to start them, and what they can do for us. But what we haven't touched on yet is what are the limitations of ADHD medications, stimulants in particular? What do they not do? I know I mentioned organization is something that they do help with.

And  ADHD medications, sort of. The reason I have that on here is this.  According to the research and anything you will read,  the medications do not assist us with executive functioning skills, such as organization, time management, prioritizing tasks I put time management both. Wow, I'm on fire today.

Point being,  those skills, also working memory, and rejection sensitivity, question mark, I'll come back to that one. So why do I say sort of?  Technically speaking,  sure, the medication doesn't. automatically  off the, out of the gate fix those things. It's not a magic bullet for those things. However, the reason I say sort of  is When our focus and attention and impulsivity are improved,  at least in my experience, not just personally, but with my patients, I feel like oftentimes  we're actually able to better prioritize our tasks  because we're no longer avoiding as much the tasks that require sustained mental effort or physical effort.

Thank you. entail boredom or things like that.  I find that oftentimes we are better at managing our time.  Not because actually that particular part of our brain is being addressed, but because we're more focused on it. We are paying more attention to our schedule or our calendar or alarms or whatever structure we've put into place for ourselves.

And as I mentioned before, the pills do help us build and develop and use our time. the skills we need. So while we do have to develop skills to actually help with the issues we have with executive functioning, the medication actually does help us use those skills better,  which to me then in turn does, or can at least, can, because everybody's different, help with those issues.

Working memory is another one that it technically doesn't help with. I personally find that  mine seems a little bit better sometimes. And then rejection sensitivity, I put question mark because that's one we used to list as not being helped by medication because it's not typically helped by stimulant medication.

But there's now evidence that guanfacine and clonidine, the alpha adrenergics,  actually do help rejection sensitivity. So that's cool.  Okay. Couple of myths and misconceptions, and then I'm going to get to the 40 questions.  That are already, well, I haven't looked at the chat. I'm assuming those are questions.

Maybe they're y'all having a conversation with each other and if so, yay.  Myths and misconceptions. Okay, these are just a few of my favorites because goodness knows there is a lot of them.  Stimulant medications cause addiction.  No.  I want to be very, very, very clear about this one because this myth is one of the ones  that is very detrimental.

And it keeps people from treating their ADHD, and it makes it hard for us to get the medications we need for ADHD. The fact is,  that when used properly, under the supervision and guidance of a medical provider,  in appropriate doses,  stimulant medications have a very, very low risk of dependence, dependence, dependence, misuse or addiction. 

Furthermore, treating our ADHD has been shown in reams of data to decrease our risk of drug abuse,  misuse, and dependence.  Huge amounts of research on this.  This misconception  is one of the things that makes it so hard for us to seek and obtain appropriate care.  Next,  one of my other all time favorites,  the myth that medication should be used as a last resort. 

No,  we should not be waiting for people to be an outright crisis.  before we start gold standard preventative medical treatment.  By definition, if we are diagnosing ADHD, part of the diagnostic criteria is that it is causing a problem, that it is causing dysfunction. So if it is causing a problem, we need to be treating it and we need to be treating it with gold standard care.

At least in pediatrics, there is no other chronic condition  that we wait for someone to be overtly in crisis to treat unless it's Unless we just didn't get, unless we didn't know about it earlier. Asthma, we don't wait to start people on inhalers until they're in the ICU, on a ventilator. Diabetes, we don't wait until they're in the ICU to start insulin unless we just, it didn't present until they were that sick.

So we shouldn't be waiting for people with ADHD to be in full out crisis to start medication. Because here's the other thing, ADHD is not just about school, which I know all of you know. 

We compensate and we mask to a point. By the time we are in crisis,  we have been suffering longer than anybody realizes, and it can have its toll on our mental and even our physical health. 

Last,  but absolutely not least, 

there is this  myth, misconception, that  turning to medication either for ourselves as adults or for our children is failure, 

and this one drives me crazy.  We have this feeling that we should be able to.  Do X, Y, and Z. I am a physician. I am a business owner. I am a mother.  I should be able to find my keys in the morning. I should be able to find my shoes. I should be able to find my shoes after yelling at my kids for 30 minutes to find their shoes. 

I should be able to do those things without medication. I should be able to manage my children without medication for myself or medication for them.  If I can't parent my children to the point where they don't need medication, then I'm a failure as a parent. 

No, just no.  It is not failure  to seek out and advocate  for the care that you need, or that your family member needs,  or that the person you love needs.  That is never failure. 

We need to reframe that  for ourselves.  And for our communities.  Thank you all so much for listening to me rant and ramble. Here's my contact stuff. I will mention the YouTube channel. I put it up there to try to get myself to start loading videos on there. I have not done that yet, but I do have stuff in the other places.

So feel free to follow me wherever you do that stuff. And thank you guys so much for listening. 

 So, I just want to say something really quick Carrie, while you were talking, Shane and I were messaging each other one on one, talking about how fire and amazing this whole thing was.

That was great. .

So, we did have a lot of questions kind of popping up. So I kind of took a bunch of them and kind of compiled a few of them. Some of the people I will call on you and you can ask your question on here if you want to. If you have a question and you want to ask the question, you use the raise hand feature, and then we'll call on you so that you, you know, we'll forget the unmute yourself, and then we'll have to tell you to unmute.

Anyway, sorry.  

And then here's the other thing, and then here's the other thing that I will say.  To be clear, I know I said it earlier, and I know you all get this, but I'm just going to say it again, because it is being recorded. This is not individual medical advice. Okay, this is for educational purposes.

I'm not going to answer individual medical questions.  I will answer, like, broader, if this general situation is occurring,  that kind of stuff. So, just to set the expectations. Right. 

And Bailey, I'll call on you next after this one, I'm going to do a question cause I was really curious about this one as a medical professional and you know, you, you have a lot of experience when you see clients come in who are burnt out, right?

Yes. Okay. You know, they're, you know, they've been masking for so long. You, you kind of touched on it a little bit. You have experienced as well. How do you treat burnout? 

Oh,  that is an excellent question. The honest answer is it really depends, right? Because.  We're all individuals, we all manifest and experience our ADHD and fairly, like, yes, we have some commonalities, but we also manifest it in different ways.

The same things that burn me out or drain me  may not be the same things that drain Mark or drain Shane, right? And so really the way I try to approach it is, is first and foremost getting to the root of what  the burnout really is. Thanks. what it really represents. Is it,  do we need to take a break  from our medication?

Do we need to change our medication? Do we need to take a look at our environment? Are there self care things that have nothing to do with medicine? Non pharmaceutical things that we're not doing, that we could do? Exercise,  sleep,  Nutrition,  big three,  big three for survival. Important for all humans, but crazy important for ADHD humans, right?

If we're not getting, I tell my patients all the time, honey, if you're not getting enough sleep, it doesn't matter how much Vyvanse I give you.  Brain's not going to function on a hundred at a hundred percent. Right?  Exercise can be an absolute game changer for folks with ADHD. One of my favorite books on this, Spark, by Dr.

Rady.  Fascinating. Absolutely fascinating stuff. And nutrition, right? And of course nutrition is always a,  eh, that's a loaded one for us.  Because we can do everything from forget to eat, to overeat,  to eat without even noticing we're doing it.  So that one can be a tricky one. And everything in between, right?

But yeah, it, it really, it honestly depends on the person, depends on the scenario, depends on,  also depends on what can they change.  Right? I mean, we have to be realistic. Yes. I would love to tell everybody to get 8 to 10 hours of sleep and, you know, have all the protein they need and not eat processed foods and blah, blah, blah, blah. 

It's not going to happen. It's not for a lot of people. It's not going to happen or it's going to be really difficult to happen. So I also try to take into consideration.  What is our.  What are the, the, the, what's the situation we're in? What's our motivation? And what do we have the resources and support to do?

Yeah,  I liken it to  when you feel your, your hamstring kind of give you a little wonkiness, right? But you know, you're, you tough it out. So especially us guys, we're like you, but then like, Oh man, my knee is sore.

Like, especially in our older years. Right. Like I used to run an eight minute mile. What are you talking about? And then after a while it starts getting worse and worse. And then all of a sudden like torn hamstring. Right. And that's kind of like, that's kind of how I compare it. Like, it's the first part is like, you're, you're starting to be overwhelmed, right?

If, especially like if you hate your job and you're, you're having issues at home and there's a lot of stress, right? We feel things more. So there's a lot of stress and you, you ignore it, right? As men, we just.  Keep going  and then eventually our bodies start to shut down and that's when you tore your hamstring right now. You're, you're going to your doctor and you're trying to explain to them what all you're talking about and that could sound like depression  may not be depression. It may just be, you know, ADHD, autistic burnout. Yes. And so this is why. This is why working with a medical professional who gets it guys is important.

No doubt. No doubt. One thing I just do want to say, and I would love to hear your perspective on this Carrie. But Shane mentioned  obviously the fact that those of us with ADHD feel emotions pretty dang heavily. And it was answered in the comments, but I'd love to hear your perspective too. But somebody asked what the heck does rejection have to do with ADHD? 

I'm curious to hear how you 

answer that. 

Okay, I'm going to get up my soapbox. Okay,  so  I have mixed feelings about the term rejection sensitivity dysphoria. I'll be totally honest with you. For those of you who don't know rejection sensitivity or rejection sensitivity dysphoria. Is a term that is it's not technically at this point an official medical term, but it's a term that's being coined and used to describe honestly, kind of just what we used to call being sensitive.

Right back in my day, like, or so, for example, it is.  Responding even more negatively than other people to  being actually rejected, or even the perception that you've been rejected. And I know when we hear that, we think necess like, romantically, or, or, like, directly in a relationship. But it can even be something like you know, at work, somebody doesn't want to use your idea. 

Right? Or they go with some, or even, doesn't say anything negative about your idea, just decides to go with somebody else's idea over yours. And you perseverate that and get stuck on that and then start going, oh my god, I'm stupid, or what's wrong with them, or what's wrong with me, or da da da da da da da, spiral, spiral. 

Right?  My thing with rejection sensitivity is this. I, I don't know that we really,  when it first happened, I was like, we don't need a term for this. We don't need a, yet another term.  I've shifted my thought process on that a little bit because I do think it helps give us a common language to describe a very common  experience for folks with ADHD.

Now, to be clear, we are not saying that only people with ADHD. Experience this, nor are we saying that all people with ADHD experience this, but it does seem to occur more often in the ADHD population. My personal theory on this, and this is Dr. Parcells observations, not research based, please note is it completely makes sense to me that we would have this issue. 

Because, first of all, again, as we mentioned, we tend to be big feelers. So we feel emotions more intensely than typical people, a lot of us at least. So, that already sets us up to be more upset about some of these situations. Then you take into consideration the impulsivity and emotional dysregulation. So now you take that big feeling about something that maybe somebody else wouldn't have felt that intensely about, and not only do we feel it intensely, but now we're struggling to manage it. 

Okay, we, we struggle to go, you know what, that's stupid. Of course they went with that idea, because it's going to be a little more efficient. That's totally fine, they went with your idea yesterday. Fine, right, move on.  The other piece of it is the, I think, is the hyperfocus.  We don't just hyperfocus on tasks. 

We hyper focus on things that are said, or done, or we perceive, and we can perseverate on it, and lock on, and we're like a dog with a bone, and we can't let it go, and then we're like  

Yep. Right? It's like 

You put all that together,  and you have rejection sensitivity! 

Yeah,  it's like I will have a post that goes really viral, right? And everybody's loving it. And that one comment that's saying it's stupid is in the back of my mind all day. 

My best example of this for myself, given the scenario. Very first time I gave this medication lecture at the conference. Years ago, it was virtual, so I couldn't see people, right? I couldn't see the reaction, I couldn't feed off the energy, which I hate because I'm a theater kid, okay?

Gotten used to it, but still not my favorite.  400 and something people  came to or watched that talk. It's the biggest audience I've ever had.  I was like, that's amazing!  Well, of that  460 something people,  only maybe 20 people returned the survey. Of those 20 people, 19 of them gave me 5 out of 5 on everything. 

One person gave me 1 out of 1 on everything, which actually makes me wonder if she meant to do the other one and got confused, and yet, because there was no comments.  But what did I focus on? 

Now, by the way, the other thing that I think contributes to rejection sensitivity,  Is our life experience. Mm  hmm.  Because most of us have gone through life  getting rejected, or being told we're annoying, or, or, or, or, or, or. And so when you have those experiences that give you evidence to support  the feeling you're having, In your own brain, even if it doesn't apply in that scenario, you go through enough of that trauma, you go through enough of those negative experiences, you get enough of those negative messages throughout our lives, and we know kids with ADHD get significantly more negative messages from authority figures throughout their life.

Yeah! You're gonna kind of assume  the worst,  because life has told you that.  . Yeah. So, which is a argument, by the way, for treating people young. 

Mm-Hmm,  . That's one of the reasons why every time somebody says, you know, how, what do I do for my treatment for my A DHD? Like, first talk to your doctor, like you said earlier, but the, like, the very next thing that comes outta my mouth.

But work with an ADHD informed trauma therapist, somebody who understands trauma because. We're like 86 percent more likely to deal with childhood trauma. 

That's the other pieces, you know, and I.  Again, trauma is one of the words that I try to be careful with how I use because I do think it's gotten,  it can be overused sometimes.

But with that said,  we have a significantly higher rate of experiencing child abuse.  We have a significantly higher rate of experiencing accidents. We have a higher rate of negative messaging. 

At the minimum, right? So yeah, we do have higher rates of all of those things.  And those things compound and affect not only our A DH adhd, but just the way we, we move through the world, right? And the way we see our, the way we see ourselves, our own self-concept, but then also the way we see the world and how we expect the world to treat us, right?

So in our expectation, based on experience.  is that we're right to assume the worst,  and then that's where our brain goes anyway.  And then of course, when we react that way, we're more likely to get a negative response. So it becomes a self fulfilling prophecy too.  

I mean,  there's a,  there's an extreme example that I've used out there in the group is we see them pop up on Facebook, that guy where the girl says, Oh, I'm just looking to be friends. 

 And   this is the  400th person that said that, and they react, and they start saying a lot of the crazy stuff.  And that is a, that is an emotional dysregulation moment, because they had a perceived rejection. Right? Even if it was just Or real rejection.

Right, or real rejection. It's that reaction afterwards.  Right? Our impulsivity does not stop the feelings and the feelings are super strong and our fingers type faster than our words.  Yeah. 

So, and, and, and sometimes we need to type and delete.  

I talked to CHATGPT. I rave at CHATGPT. If the government are watching that one, I'm in trouble. 

We don't, don't hit return,

delete. 

I also use CHATGPT whenever I have those emails  for people  say this in a nice office speak for me, please. Oh, I love that. I have feelings. I have feelings. Bailey, you've been very patient. Thank you very much.  Yeah. Adam. I got you next.  

Hi. Hi. How are you doing? Dr.

Parcells? This is Bailey. I just had a,  I guess 1 or 2 questions, but I wondered if you'd ever encountered patients who started on a stimulant medication like Adderall  and did very well on it.  For a short period of time and then  proceeded to have almost like very little response to it. 

Oh, yeah. Yeah, we call it a honeymoon period. 

What do you call it?  Honeymoon period. Honeymoon, right. So, so there are, there's a couple of different scenarios that that can occur with the stimulant medications. So certainly I have situations where people will start a medication of any of the families and They're like, oh, my gosh, this is great.

Greatest thing since sliced bread and about a month or so goes by and that kind of initial kind of tapers off right and either plateaus or actually goes back down. Okay.  When it happens initially, like, we can definitely see that that's not necessarily like tolerance.  It's just, it's kind of like.  The way I like to describe it is like your brain is like, Whoa,  this is fun.

The first time I ride the roller coaster, this is super exhilarating. And then the second time I write it, it's great, but not quite as exciting because I know it's coming like, right. That kind of thing. Now  the efficacy side effects and dosage of our medication can change not just in the short term, but throughout the lifespan. 

Okay, and this can happen for a whole slew of reasons. It can happen because of hormonal shifts. And yes, gentlemen, you do have hormonal shifts. Okay. It's not just us,  but hormonal shifts, changes in brain chemistry, changes in brain development.  You know, other factors, health factors, et cetera, but there are, there is one of the kind of  key question areas right now in ADHD medication and research that's ongoing is, is this concept of tolerance, you know, clinically, we don't, we don't really know exactly what's going on, but we know clinically that there are people that over time seem to experience less efficacy.

From their medication and seem to build tolerance for lack of a better word, because we don't know exactly what's going on molecularly. But and and sometimes that is remedied by simply increasing the dose.  And sometimes we need to actually change formulations and there are a few, there are some people out there that unfortunately for them, just kind of constantly formulation or medication it is. 

And so for those people. There is actually thought that taking medication holidays  might be beneficial and might help prevent the building of tolerance. The problem with that is again, lack of data.  Okay. So we don't really know how effective that is. We don't know how much time, like how often for how long, et cetera.

And so with my patients, I always weigh the pluses and minuses of taking a medication holiday versus not having our medication on board.  Right. And that really depends on the person.  

That's the thing that we see a lot in men's group. Like, am I getting tolerant? Well, that's kind of why we titrate up. Like one of the first questions I like to ask is like, you know, How long have you been on this medication? Because I know they start people low.  And then like, if you've been on a low dosage medication, like have you started titrating up?

If no, you actually may be getting used to that and it's not an effective dosage for you. So I appreciate that, Adam. Thank you for being patient. Go ahead with your question.  

All right. Hello, everyone. Carolyn. I'm Chad, Los Angeles. I had the pleasure of meeting you at the conference last year. And yeah, well, I had a pizza with you and Shane. 

It's nice to see you again. Very cool.  I had a question, but actually now I have to and I want to just go back to the RSD for a moment. I have been having a skepticism of RSD being a thing. I think it's just the same. It's  A car just been relabeled as something else. And what I mean by that  from what I've been seeing on people who grow up unmanaged ADHD or now well managed is almost a guarantee of codependency traits.

And with with ADHD involved, it's just hyper focused on those unhealthy codependency traits. So that's where the RSD really much got relabeled as RSD because  codependency sounds pretty good. Almost the same can't say unsolicited advice. Can't can't take criticism voiding patterns, all, all that stuff.

And it's just something that I've been on a suspicious theory of mine. I wanted to see you get your.  

It's an interesting theory. I definitely see some, I can see where you're going with that. I definitely can see some, similarities there, but,  I guess, where it breaks down for me on that analogy is that, I  mean, it kind of, codependency, right?

Because, you know,  Codependency tends to be, you can have a codependent personality, but codependency tends to be  geared towards or aimed at.  One or two, like a small number of really particular individuals. Not that somebody can't have obviously those traits and those tendencies in their relationships, but  the rejection sensitivity I feel like is a broader thing and a broader term because it can apply to a whole lot of different scenarios and not even just  situations that are necessarily interpersonal relationships.

Does that make sense? And so, yeah, but I agree with you that I think it's,  it's an additional term for something that already, it's not a new thing,  and it's not a separate thing. It is a thing that, it is a common experience that we share because of some of these common traits that we have.  So that, but that part I absolutely agree with, but it's, it's very interesting.

It's a very interesting, um, thought you're going to, I'm going to be milling on that one for a little bit. Yeah. 

Yeah. I've been, I've been milling on that for a while because that has a lot of comparative characteristics  and also the answer to that, a lot of letting go practices, you know, trying to help the person,  the question that I came here for I wanted, I wanted to get your take on Why do some of these medications actually induce some emotional deregulation?

I'll just put a personal story in because I've been recently taking Vyvanse for like two weeks straight and I had a side effect that only happened two weeks in that I had like emotional dysregulation, like near breakdown status kind of thing.  So, that's something that was like covert on that Vyvanse and I've tried most of other stimulants and it just did not do that.

Yeah, yeah. That's a great question. So,  when I talk about side effects with these medicines,  I always tell them like,  I kind of describe it's like two different sides of the coin. You can either, it can either, one of the possibilities is that you feel like more irritable, more agitated, more revved up, more emotional, more anxious,  or you can feel more blunted out, flat, blah, meh, not your usual fabulous self. 

The, what you just described. I see a lot more often with Vyvanse than any other formulation.  

Ah, that, that solves a lot of my suspicions. You helped me, like, greatly looking into this. 

That dexamphetamine, it's potent, it gets the job done, but if it gets the job done a little too well, you get a little too much dopamine. 

And you overshoot the mark, right? And that's why, honestly, and, and, I'm, I know I'm, I don't know if I'm in the minority on this, but those of us who do a lot of ADHD I feel like actually kind of lean more towards this, but Vyvanse is actually the last thing I start, not the first thing I start. And it's not that it's not, it's not that it's not a great medication.

For the right people, it's incredibly effective. The problem is the side effects are more common and I, in my experience, and especially again, remember I'm dealing with teenagers and young adults and kids. If I give those side effects to one of them, their parents are like,  you know, and they're, they don't tolerate side effects very well.

I see that especially in young kids. So I really don't go to Vyvanse until I've tried just about everything else. In my, in my little bitties, but, but that's why, because it can be, it can be a little too much. Could be a little too much dopamine there, can overshoot the mark, and then it increase, it can increase anxiety, it can increase emotional dysregulation. 

We just, it overshoots the mark sometimes for some people.  

Yeah, all right. Thank you for the info. You have saved me a rabbit hole of research going into. You're welcome. And the next conference here in Anaheim, that's my town, I'll invite you to pizza, okay? Yes! Yeah. 

I'm excited. I'm excited about Disney.

What about me? Yeah.  Come on. Come on. I couldn't help it. I had to do the rejection. Sorry. 

Yeah, the rejection sensitivity.  

Does Adam hate me?  That's how I feel now. 

Oh, okay. I have to share this. I actually have to share this. This is like, this is so fabulous. So one of the amazing things about working with the, this group of people and all my friends and colleagues that I've met through the, the conference circuit, right?

It's so many of us have ADHD that we're very forgiving of each other. And we're very understanding of each other when our ADHD kicks in. The downside is.  And I have experienced this, and I won't say with whom.  But when we text each other, and then we forget to text each other back, and the person who did the texting, on the one he was like, wait, are they just forgetting because they're ADHD like me, or did I do something?

Did I say something? Oh my god, what did I do? I have, you can ask Brendan. Brendan Mahan.  I have called Brendan, and gone, I need you to talk me down off the ledge.  Is it, is it my rejection sensitivity? Or like, and he's like, breathe? You know, this person has a tendency to forget to respond. It is them, not you.

You're okay. And then sure enough, when they responded, it was like nothing. I was like,  so, 

One of the things that I, I think that a lot of the talk with, like.  Rejection sensitivity rejection sensitivity dysphoria because those are supposed to be two separate things and then our, you know, honestly, we'll talk about like the different what's the word that Adam used?

Codependency,  right? And, you know, different things like that. I think that we are overcomplicating just emotional dysregulation as a whole. We feel all things more. I said this in a chat, but we are super excitable. How many times have you had your hyper focus and you're like, Hey, I want to tell you about the butterfly that lives out in South America and everyone thought it's absolutely amazing, but they're killing all the trees.

And now we're dealing with the deforestation and everybody's like, yeah,  

I, I completely agree with you. And that's part of why I think it makes complete sense to me that the only medications that we have found that help with rejection sensitivity dysphoria. Is the medication that helps with impulsivity and emotional regulation. 

I have to take both. I have severe rage issues. And so, and I've got toddlers. And guess what? You can't have with toddlers, right? Like, you know, but 

under the best circumstances, by the way, for those of you who don't know, I have two boys. 

And, you know, actually you have a large number of them because  you're like our person voice. 

Yeah. I have many boys. 

So, so one of the things that, I keep telling people like, look, it's all a part of the whole, we deal with a lot of trauma issues. So there's going to be a significant amount of negativity and we have to start. 

You know, with the people who are around us building up positivity so that we get to feel that more to the point of where we recognize that more, right? Like, there's plenty of times at 2 a. m, Mark's been like, hey man, I really appreciate you. It's 2 fucking a. m, but okay, cool. I actually was awake because no sleep.

So.  

Yeah, it's actually bad. That's when Shane and I have our best ideas when we should be sleeping.  

Well, yeah, because we have delayed chronophenotype. 

Yeah. Oh, okay. No, no. Go into that. Like, I see this a lot in the group and a lot of people are like, I need to be asleep by 9pm,  but I can't. I'm in bed until 12.

So here's the deal. Okay. So there, it's called delayed chronophenotype. Okay. Fancy pants way of saying we're night owls but people with ADHD, and again, this is not everybody, but for a lot of us, we have a higher rate of having delayed chronophenotype, chronophenotype, I can't talk today, and it's  on average about an hour and a half later than same age, same gender peers. 

Okay,  so, if you think about it, it makes sense if,  you know, people your age typically go to bed at 10 or 11 o'clock, that you're not going to bed until  midnight, 1 o'clock, 12. right?  What's really fascinating about this,  There's a lot of theories out there, right? So please note everything I'm about to say. Theory. 

Okay.  As they're starting to do some really fascinating research on,  like, sociology, anthropology,  genetics, epigenetics, all the things, right? Where has this Why did we develop this in the first place? What were the advantageous parts of it? And throughout history and blah blah blah blah blah blah, right? 

So, you think about back when we were nomadic populations,  okay? You needed somebody to be the night watchman.  Do you want the person who falls asleep, who focuses on only the important details being the night watchman? Or do you want the person who notices, hears, and sees literally everything and reacts impulsively, quickly, and intensely to it, protecting the tribe? 

You want  Now, do you want us in the hunting party?  Not really.  Not really. We're gonna scare the deer off. We don't have the patience to sit there and stare at the deer. Until we can shoot the deer. But you know what we can do?  You do want us on the outskirts of the hunting party so that we notice the lion that is sneaking up on the party that the party doesn't notice because they're focused on the deer. 

We are the watchmen.  Okay?  I find that utterly fascinating. Now, unfortunately, we, for not all of us, but a lot of us, we live in a, in a, our schedules are such that we're not, that are, they're not conducive to our natural circadian rhythms.  And that's why we struggle with that.  In my world, if my kids didn't have to go to school when they go to school,  I would probably get up around 9 o'clock.

I'd start my clinic around 11 o'clock because I'd work out before that.  And I'd probably eat 9 o'clock at night, go to bed 1 o'clock in the morning, 2 o'clock in the morning. And I'd be highly productive from 10 to 2.  That's me. 

I do the same thing.  It's actually why a lot of us become entrepreneurs too.

It's one of the reasons we get to make our own schedule up. And you know, we hear a lot of guys in the group talk about, you know, I, I work overnight and I love it. And I'm like, yeah, because you're already going to give me 

away. Very specifically for this group, as I was doing the talk, one of the adjustments I made for this group was,  if your schedule allows, based on when your schedule happens. 

Yeah. Because I figured I probably had some, some third shift people or otherwise night owl folks in the group.  

So I also wanted to kind of touch on another one. I want to go back to something you had said you said that stimulants are the first line of treatment for for adults and you had it in your slide earlier on but in the group, we're seeing a lot of times where the, it seems like non stimulants are the first thing that get it.

Promoted for us. Is that because a lot of our audience is older men or late diagnosed men who may have blood pressure issues? Or is it just because they think we're meth heads from Florida or something like that? I'm not, not that I'm calling out Florida methheads. I 

understand. I mean, obviously it depends.

Right? I, my personal experience.  is that I think there is, there's several factors that play into this and why non stimulants are being, not just in, in adult medicine, sometimes in pediatric medicine, why they're being recommended ahead of stimulants.  Some of it is knowledge  on the part of the provider.

Some of it is comfort level. On the part of the provider, a lot of the myths and misconceptions that I talked about, unfortunately, still exist in the medical community. Okay, especially medical folks who do not do ADHD on a regular basis. The, there's kind of this general.  Thought that the non stimulants are safer than the stimulants, which is not correct, but this is part of why, you know, they're controlled substances, and they are controlled substances for a reason.

I'm not saying they shouldn't be, but there's this stigma  associated with it being a controlled substance. Right. That it must be more dangerous. It must be have more addiction potential. It must have more this. It must have more that. And so I think for some physicians, they're just more comfortable with the non stimulants for those reasons.

There are also some people who right now are promoting non stimulus just because of supply issues, which I totally understand. The.  And yes, there are also those situations where, like you said, if they already have high blood pressure, if they already have other things going on, there might be a propensity to try the non stimulants before the stimulants, which is also reasonable.

But the other thing, too, is, especially in primary care,  adult physicians, so meaning, like, internal medicine physicians, or family practice physicians who have focused on adults, For the majority of their career may not have actually gotten very much training on ADHD at all, especially if they're, you know, my age or older,  Gen X or above because it was still considered more of a pediatric issue, and there was, you know, the old school thought process that you grew out of it, donk. 

But as a result, a lot of adult physicians just simply weren't trained on it.  And if, and, and so that's really difficult. Last but not least, and I have to say this because I have to, I have to defend my, my fellow physicians and  support my fellow physicians that are in really, really difficult situations right now.

I am incredibly lucky. I own my own practice. So I get to determine how much time I spend with my patients.  Most of my colleagues are not in that circumstance. Most physicians these days are in employed positions, which means they oftentimes have little to no control over how many patients they see in a day, how much time they have with their patients, or what their staffing looks like. 

I have 45 minutes  for a follow up.  They typically have 10 or 15 minutes. 

So,  very well meaning physicians who want to do well by their patients and want to do this work well for their patients  may simply just not have the time to do it well, and if they can't do it well, they're just not going to do it,  right? Which I understand. I wouldn't want them to do it if they can't do it well,  right? 

And so that is a big reason, I think, education, comfort level, and time constraints.  are some of the biggest things I hear from other physicians as far as  just when it comes to treating ADHD in general, let alone what medications they're choosing or comfortable choosing and managing. Yeah. We see this a lot.

They have to know everything. They have to know a little bit of everything, right. Or a lot of everything these days. And it's overwhelming.  

Yeah. We see a lot of guys in the group and it kind of goes to the emotional dysregulation  thing. My psychiatrist literally has me in and out in 15 minutes.  Yeah, that they may, that may be all they have because they've got 25 other clients that they've got to see by noon.

Well, and I'll and again, I'll tell you, like, I said, I own my own practice and I spend 45 minutes with patients. So y'all might be going, okay, well, why doesn't everybody do that?  The honest answer is  what I'm doing right now is not sustainable. We're looking at changing our business model. To try to still be able to have the time we have with our patients. 

But taking insurance, it's not sustainable.  It's not sustainable. So that's the problem is in order to keep your doors open,  let alone pay yourself with what insurance is paying us.  You can't do what I do.  Yeah.  That's why a lot of psychiatrists, by the way, don't take insurance.  

 So this is kind of a controversial question, so you don't have to make a stance on it, but  I've heard some doctors tell me that ADHD, if you have ADHD, you can't or it's very difficult to get addicted to stimulants.  Is that true? Is that a myth?  

I appreciate that question.

Anyone, okay, I'm going  to start with repeating what I had in the slide, just so that that's there for this  when these medications are used  appropriate dosages  in an appropriate way  under the care  of a medical professional,  they have a very low risk.  Okay,  that does not mean people cannot get addicted to them  and that includes ADHD people because ADHD people have a higher risk of addiction  Anywho,  okay,  but it is not at the dosages we use to treat ADHD,  okay, typically where you see  abuse and dependence  therefore leading into addiction,  is when people are using  more often or and or higher doses, but ultimately like in, in, in conglomerate, higher doses  than what is considered appropriate or safe in the context of ADHD. 

Does that make sense?  Yeah. Fortunately too, there are people who will use them in a way that they are not intended, like,  well, I don't want to give ideas, but not taking them  the route that they're intended. 

Not giving nobody no ideas. All right. 

Yeah. And I just saw that Chris had his hand up. Go for it, Chris. . 

 All right. And we're if I may take what I have an incredible daughter that just joined us a few minutes ago, just before bed.

And I'm blessed in the fact that Alexandra has a brain like Daddy, with ADHD, and she's just learning about it. So she's interested in knowing how, as a woman, growing up and learning, as a doctor, correct? Did you want to ask your question? How do you? How do  I learn? How did you focus in school? 

Great question, because you know what? 

I am really lucky. Because I was diagnosed when I was in high school, which for ladies as old as I am, didn't happen a whole lot.  Okay? But, I didn't take medication until I was older. Kinda wish I had taken it when I was younger.  But, there's a lot of things I did to help myself. That's funny. Yes. When I was studying, you know what I would do? 

I would go in a room by myself.  I would read out loud. I would use my finger to track, so that I could keep track of it, because my eyes would go everywhere. I would read aloud to myself, and I would do it in a room by myself. So that I was using my eyes,  my hands,  and my ears.  So that none of those things could get distracted. 

That happens to me a lot. I get distracted.  

Preach, sister. Preach. So that was really helpful for me. And then there's other times where I would study with friends.  Because if it's the right friends, Some friends are distracting,  but with the right friends, some of the things I would study with my friends and talk through things because that was way more fun and interesting  and kept me more engaged. 

Oh. Depended on what I was studying.  Yeah. And you know who else would help me? Who? My mom and dad.  Yep. My dad used to read my summer reading out loud to me. Because I had a hard time reading, and so I'd follow along the words. This is before, I'm so old, this is before audiobooks.  So, he would read out loud to me, and I would follow the words with my finger.

And that's how I would get through my summer reading.  



Awesome. Thank you. Thank you. You are so welcome, cutie.  

Thank you very much. 



That's probably the most adorable moment we've had in a Q& A. That was amazing. 

It's so cute. I'm like, I need, I wish I could reach through the screen and give her one of my NeuroSparkly stickers.

Yeah. And, and you talking about like what your experience was. She's all like, I do that too. Oh my god.  . 

thank you so much. It's a super cute spot to stop, right? I and I Yeah, absolutely Right. I really appreciate it.

If people are interested in following up with you or if they're interested in, in kind of learning more about your, your practice or how you do things. Yeah.  

So, probably the best way is Instagram at the. adhd. md.  The other, and, and because we do have a website for the clinic, but it's in the process of shifting.

It will be www. ourhealth.  org, but it's in process.  So Instagram's probably the best way right now.  

All right. Y'all we'll have all those links and everything in the in the do, but the do below  Mark finishing words. 

Yeah, nothing, nothing much else other than that was really amazing. And I, I appreciate you taking the time and yeah, thanks everybody for, for coming on and listening into this.

I hope everybody gets value from this and yeah, I'm just excited to, to continue to follow your journey, Dr. Parcells, aka the ADHD mama.  

Oh yeah. Yeah.  

And I mean, I figured this would be a cool way to just  mention that the international ADHD conference is a thing. And next November, 

where are we going to be?

We're going to be in Anaheim.  Go Disney. Disney. Yeah. So yes, yes. And I am, I am heading up the party again. So  come party with us. Can't 

wait.  

everybody for coming along and this was super 

fun.  Thanks, Eric. Bye guys. Thanks 

for having me.  

See ya.