Could this be a tic?

[kc4braves]

I haven't posted in quite awhile bit something odd is happening with my now 16 yo daughter that I thought someone here might have experience with. She is ADD and takes Daytrana. It is the only thing that has really worked and she has used for years. Added a second patch before school started and things have been going well. She recently started on Sprintec ( birth control) 7 weeks ago due to very irregular cycle and long bouts of meds seemingly not working when estrogen was likely low. That's another story. Anyway, things have been better I thought but yesterday she came to be sobbing with a hand full of her long beautiful hair. She had said once before she had pulled some hair out but it did not register with me that it was an ongoing problem. She has always been a hair twirler but now she is pulling it out and says she doesn't realize when she is doing it. She says she doesn't feel stressed. We actually dropped some of the stress this year by dropping her AP classes. So academically the stress is less but I guess now she has more time to think about how she has no friends. We have tried to help with that but it is hard. So.....is there anything besides trichotillomania that would cause this? I read about it and it doesn't really seem to fit her to me. Just concerned about her socially and she is worried about being bald. Ugghh.....

Thanks for any incite.

Kathy

[healthy11]

I'd definitely ask the doctor who manages her meds about it, especially if it's a relatively new development.

There was a girl in my son's school who got an accommodation to be allowed to wear a hat in school, because she also had beautiful long hair and a tendency to fidget with it and pull it out. I remember seeing her with her hair "loose" when she was younger, but by middle school it was always tied back into a ponytail, to minimize the urge to tug at it.

In lieu of cutting it short, perhaps wearing her hair in a ponytail would also help your daughter, because she'd have to more consciously reach back to grab it, versus not realizing she's pulling at it now?

www.brainphysics.com/hair-pulling.php

[kc4braves]

We did get her a new haircut. Not short but layers and colored tips. Looked pretty. She loves. I guess she was able to control it for a while but the hair pulling is back. She just told me before Christmas. Bought her a stress ball to try but she told me New Years that she is pulling it again and can't seem to stop. She tries pony tails but then pulls the little hairs that fall out or are too short to go up. I did notice her crown is getting thin ( more bald).

I had thought maybe her social issues were causing it but things have been going much better in that area. She has reconnected with a friend from jr high who is now at her school and has several guy friends that text her a lot. She seems very happy.....still a teen but much happier. So I guess it must be a tic. We were hoping it would go away or become less of a problem so we waited to change meds.

Today I was just blown away at the psych provider's apt when she told the provider that she really wants to stop pulling her hair even if that meant changing meds right now in the middle of school. I panicked because I was unprepared for just how upset my daughter is by all of this and because the only options still available were Adderall and straterra, neither of which I want anything to do with. She has had great results with methylphenidate, specifically Daytrana, and I had hoped we could just cut back or something. The provider feels that once a tic starts due to a specific med, that cutting back will not stop the tic. I don't know. She has taken different meds in this group since 4th grade with no real issues. She tried Vyvanse but it did nothing. She has taken most everything trying to find the right combination including intuniv. She had been on just the Daytrana patches this school year.

So, I am panicked because everything has been going well this year in school and life....except for the hair pulling. She starts the busiest time of the year tomorrow. Next week is show week for her musical which means 5-6 hour practices after school every day plus homework. Then choir season and golf season start and she misses 2 days of school a week for several weeks. Not a good time to make changes but I guess we have no choice. The provider says she can permanently damage her hair follicles. She had asked my daughter to try behavior management and wait till summer to change meds but my daughter feels a hat will not help her. We were going to have her try it at home because she doesn't apparently pull her hair out at school. So.....my daughter and the doctor chose straterra.

I was almost in tears just thinking about it. I just don't feel it is the right choice. You may remember that I posted a lot a few years back when my son was trying straterra. it ended up being a nightmare that I would not like to relive. He started it summer after 8th grade and it was a very long summer. Couldn't read a book. No focus. SO we started a low dose stim with it....maybe 18 or 27 of concerta. Worked fairly well, except he was having migraines, low blood sugar type issues when he didn't eat often enough ( sugar was never low but he was often sick), and motion sickness that kept him from being able to go many places. Still we hoped it would improve but the migraines got so bad we were being referred to a neurologist. I said....we have to quit the straterra first. Any good doctor would ask first....what has changed. CAn't change puberty but could quit meds. No more issues after quitting Straterra.....but it was an ordeal for months. Decided we would have to make COncerta work. So this is why I am so concerned. He also gained 30 pounds which he needed to gain but she does not. She has actually been dropping some weight without any effort this year after gaining over 20 pounds while trying to take Concerta ( opposite affect for her). She has been so happy. I just really want to cry and scream. The last two years were so hard and this year has been great.

I reminded the provider that there is a lot going on and that this is a bad time to change so drastically. She told my daughter that not pulling her hair comes first then school then extracurricular. If there is any problems keeping up, golf or theatre has to be dropped. My daughter has dropped so many things because of focus changes with puberty and is not going to go down without a fight. School will probably drop before activities. I just so feel this decision was wrong. However, my daughter keeps telling me that she and her brother are very different. So.....I guess for the next 5 weeks she will be in school with no stimulant. We have some boosters to use for the ACT and such but....ugghhh...

I do not want to even try Adderall so I am wondering if this doesn't work, will it be different if she goes back after 5 weeks off stims to her patch in a lower does or will the tic still be there? If she went back to Intuniv would it help with the tic? Again my Adderall fear is due to much research in the past and the fact again that her brother has terrible responses to amphetamine salts....moody, depressed, temper, etc. Of course Vyvanse did nothing good or bad for her, so why would Adderall work?

Any thoughts? I really want her to be able to excel her last 3 semesters of HS. There are many decisions to be made this year and I just realize that she is graduating sooner than she thinks.

[eoffg]

Hi Kathy,
That is notable that she apparently doesn't do it at school.

Though something that I would ask, is how she actually pulls her hair out?
For example, does she only use one hand, and always the same hand?
But then, does she grab the hair between her thumb and finger, and pull it?
Or perhaps it's always twirled around one finger and pulled?
Or even around her thumb?

But what I'm thinking of, is that she could try putting something on her thumb and/or finger?
Such as a 'thumb stall', or 'finger stall'?
Another thing, could be to try putting a band-aid or bandage on her thumb and/or finger, that she does it with?
Where you have probably experienced the difficulty of doing something, when you have a band-aid on a finger or your thumb?

With a 'tic', they are usually always done the same way.
So that basically what I'm thinking of, is to make it difficult for her  to either grip the hair her finger and thumb, or to twirl it around her finger?
But I just read in your first post, that 'she has always been a hair twirler'.
So this might be how she does it?
Always using the same finger?

Though you also said that 'she says that she doesn't realize when she is doing it'?
So that while she might still be able to manage to pull it out, with a bandage or finger-stall on that finger?
The difficulty of doing it with the bandage/ finger-stall on it, would bring it to her attention.

Though another thing that occurs to me, is that with this on her finger. She wouldn't be able to 'feel the hair around her finger'?
Where the sensation from twirling hair, is really felt by the finger.

But this is where it is notable, that she doesn't do it school?
As quite possibly, it is her index finger of her writing hand, that she twirls it around.
Where a bandage or finger-stall on her index finger, would make writing, and typing difficult.

Which makes me that a 'finger-stall' might be better?
As she can then easily take it off, when she does something that needs full use of that finger.
Then store her finger away in the finger-stall, when it's not needed.

But the basic premise of this? Is to make it difficult enough, that she will be aware that is trying to do it.
As she wont be able to do it automatically.
Though I see this as a temporary approach?
As her awareness will probably develop, so that she realizes as her hand moves towards twirling her hair?

[healthy11]

I think what both your daughter and Eoffg have said deserve merit. Your daughter is NOT the same as her brother, and her response to meds may not be the same. Since she told the provider that she really wants to stop pulling her hair, even if it means a med change mid-year, it sounds like she's been giving it consideration for awhile. As a teen, it's good for her to begin taking more responsibility for her life, but as a parent, I understand that you don't want her to make major mistakes. In this case, at least she's not "going it alone," as the doctor is there, too. Did I understand correctly that her next appointment is in 5 weeks? I would keep an eye on things, and if you notice significant issues then don't wait to mention them. In the meantime, maybe you could also give Eoffg's suggestions a try.

[kc4braves]

I appreciate the comments. I'm not sure what a thumb stall is or if she would be willing to try it. I was a bit frustrated with her that she didn't seem willing to try the behavior modifications. I think she feels like she has but other than pony tails and hats ( which she normally wears often anyway)and the stress ball which we have only had a a week, I don't know what she has tried. I did not think to ask how she pulls it but she brought me a huge wad of hair back in October. I thought it had stopped or improved. I do know that apparently certain pieces draw her attention like pieces that stick up, are not soft or curl. It sounds like she plays with her hair and then feels these "abnormalities" then pulls them out. When the hair tries to grow back on her crown, they stick up and she has been pulling them. I have never seen her pull her hair or anything. She has pretty much always, as far back as I remember, twirled her hair. We have tried to get her to stop because we didn't feel that was good but it has been a habit forever. Her telling the doctor that she was wanting to pull it while sitting in her office was shocking to me because I thought she was only pulling it at night when watching a movie or listening to music...absentmindedly.

So right now the most pressing issue is that life is about to get crazy and she cannot stay awake. yesterday was day 1 on Straterra. Again, I feel like it's a mistake, though not sure what the answer is. She was tired all day. Stopped and bought a coffee on the way home from school. Came in drank it told me about the first day of school, said she had no homework and went to her room. I went to check on her and she was sound asleep in bed. She slept like the dead for 3 hours and would have continued to sleep had I not insisted she eat dinner and got to her voice lesson. She tried to watch tv with me for a while but was asleep again at 10...way early for her norm. Got up this morning and repeated. She told me at lunch she didn't know if she could stay awake for her math class. She again came home drank coffee and worked on a little English. She is fighting sleep so she can go to church youth group but you can tell she is exhausted. I have no idea how her focus is at school or her communication skills which are usually better with teachers and such on her meds. Starting Saturday, she has musical theatre practice for about 6 hours every day then her performances are Friday, Sat and Sunday of the following week. She can't be sleeping and have a shot at staying caught up. I know...I worry too much.

I don't think she has been awake enough to pull her hair.

[healthy11]

((Hugs)) Parenting is definitely one of the most challenging "jobs" there is. Hang in there!
Here's a description of finger cots/stalls: en.wikipedia.org/wiki/Finger_cot

[kc4braves]

She told me she hasn't been pulling her hair this week until Friday. She was reading a book and next thing she knew she had pulled some hair out. So she got out the stress ball I bought her and put it in her left hand. Apparently, she normally holds the paper with her left hand while writing but when reading that hand is free......to pull hair. I was happy that she made the decision to get the stress ball out. She had to take a Ritalin booster to even go to school that day so not sure if introducing the Ritalin again caused the pulling or if it is just still present after only a few days of Straterra. it is very true in my mind that Straterra should not be started during school...but we are on day 6 anyway.

[kc4braves]

Update. She is on the target dose for straterra and isn't sleeping all day anymore. Her grades are ok but I feel like I am having to micromanage again. I was enjoying NOT having to that so much anymore. She can't remember anything. She failed to do any homework two weeks ago which was show week for her musical. She didn't have a lot of homework like last year but she took two tests that she failed to study for and failed one. She had other small assignments not completed and she failed to do basic self advocating such as asking for extra time on an in class assignment. I only figure out how much she was behind because she was sick last week and missed 2 days of school. In getting assignments I realized that she was behind. The teachers have worked with her because she is a good student and maybe because of 504 but she cannot continue this way. It has always been a routine that homework is done first....always...since birth....but now I catch her sitting on her bed reading or singing or watching a video when she was to be doing homework. She looks so surprised when she realizes that while her intention was to do homework, she had forgotten or become distracted. With me micromanaging she is back on track but this is not a healthy thing long term.

She has been so certain she is focused but maybe she is starting to see some problem. I texted her at school about 30 mins before school was out to ask if she had remembered to pay her choir teacher for her ensemble piece. She said no..she had forgotten. I told her to go by after school. She said ok then proceeded to drive home without it ever crossing her mind again. It's terrible to feel you have gone backwards. She may be smart enough to get through her classes without her grades dropping if she continues to focus enough at school but if she can't remember to do things or study, she will miss out on things and her grades will drop.

And.....wait for it.....she is hungry all the time. She is not happy with the idea that she is gaining weight ( getting fat is her terminology). She gained a lot of weight on Concerta and had finally started slowly losing it last January. She is not happy with all the stretch marks but has been feeling really good about herself again. She got new clothes for Christmas and had dropped a size and was so pleased. Today she is miserable, crying telling me she would rather pull her out than continue to eat all the time and gain weight. She said her new jeans are tight. I feel for her but I can't also monitor every bite she eats. ( I have a hard enough time with myself. I didn't not at her age, though, have any weight issues but she is 5'3" and I was /am 5'8") I told her that we never took ADHD for weight loss, it just so happened that some meds decrease appetite and some do not. She wants to go back on her old meds now and just try not to pull her hair. She does not pull on straterra she says. She didn't think anything would help before so the doctor made the decision to switch. I don't think she is going to trade hair pulling for more focus and weight maintenance on methylphenidate. If my daughter had not sprung things on me IN the doctors appt. we might could have worked something different out but not sure what her options are now. She was so happy and confidant, except when she would pull her hair and worry about balding, on the other meds. Now she doesn't pull the hair but she is less happy, less put together and less focused.

Has anybody gone from having a great experience with methylphenidate for many years (6-7 years for her)to having issues? Have you then had any luck with Adderall? I have said before I worry about it because of all I have read about needing med breaks, getting to where one doesn't sleep without med breaks, etc. and of course hearing so many bad things in the media and my son having bad reactions to the group ( Vyvanse and Dexedrine) and knowing she tried Vyvanse when it came out a few years ago and it did nothing...good or bad for her. So is trying Adderall worth it? Is it likely to be useful? Just not sure what to even hope for at this point. love my daughter but not thrilled with the doctor who suggested to her that this may not work as well and that she may have to drop more extracurricular activities ( she has given up a lot recently because of ADHD and we don't plan to drop anything else this late in HS)and that she "just has to make good choices with food". I hoped I was wrong but I knew this was not going to work but what do I know? I'm only a parent with 2 very different ADHD kids. We have never given up easily but I know there are some things you sometimes just can't do. I'm just not ready to throw the towel in now.

Thanks for reading this far. I hate feeling like every time one of my kids opens their mouth the doctor runs with whatever they say instead of listening to me...who KNOWS them and LIVES with them. I have appreciated this doctor but she is the same one who thought my son was going to do well in college on 36 mg of Concerta when he had needed 81 in HS just 3 months prior....and who wouldn't listen to me because he turned 18 between graduating and starting college which of course made him suddenly mature. ( I get the legal ramifications but she made a bunch of changes that had to be undone seemingly to prove to me that I was not needed anymore. He had to tell her on his own that he wanted me there. He is currently on 72 mgs and is complaining to her that it isn't working well anymore. He is managing to come from behind every semester and get the grades back up though.) So...I feel upset that she made major decisions knowing I was very concerned for my daughter. I like it better when we work together. oh well...any thought?

[healthy11]

((more hugs)) I don't have experience switching from other medications to Adderall, but my son has used Adderall and/or Adderall XR (the extended release version) for more than a dozen years. As you know, every person seems to respond differently, but I have yet to meet anyone whose child gained weight on it. Typically appetite suppression is a concern, but that side-effect will usually dissipate over time, with regular use. My son has always been slender (now age 25, 6 ft. tall, only 145 lbs.) and what I originally thought was irritability from rebound when the Adderall was wearing off, we now believe was compounded by hypoglycemia (low blood sugar) because he wasn't eating or even drinking much to stay hydrated. Now, he just uses the short-acting Adderall, and he makes sure to eat "between doses."

For what it's worth, in my son's case, I also felt like I was having to micromanage his homework/scheduling in high school. I definitely see improved concentration and focus while "on" Adderall, but memory has always been a weak link for him. One of the things that has definitely made a difference for him is use of technology, specifically putting reminders/alarms on his own cell phone, because he's always got it with him. I wonder if your daughter might try something similar? (ie, have a note that pops up on her screen before school gets out, asking if she paid the choir teacher...and leave herself a note on the seat of the car, that she'd see before driving home.) If she can "develop those habits" now, they'll probably continue to help her during college/adulthood.

[kc4braves]

I think all of this is harder than it should be because it was my son that had so many issues not my daughter but things started looking up for him in HS and by jr year, he was almost independent in many areas. I could just nudge him a bit and he could mostly handle things. She was always very independent and now I'm having to return to micromanaging and neither of us likes it. She is frustrated because she really doesn't want to need help and I am frustrated because she needs help. I just don't think Straterra is doing anything other than making her tired...and she would say "fat". We just thought she was forgetful, unorganized, etc. before. I think we really appreciate how great she was doing before. LOL

She just seems like she is in slow motion in a way. It just takes forever to get a little done and then she is falling asleep. I think she is finally seeing that this isn't working so well. Today she tried to be so prepared for dance classes. She packed her dance shoes and everything in her car before starting homework so she wouldn't forget. Calls me between dance classes to tell me a jazz shoe is missing. She has searched the car. Where could it be? What should she do? ( When her brother was forgetting things, I would have run something to him but she is driving my car so....) She left one shoe in her box at home and grabbed something else. She was mortified. I told her she wasn't the first kid to forget their shoes but that's just it.....she didn't forget. She just isn't put together anymore. She also forgot a third test. Luckily she got a high B anyway but that's not the point. So...yes both kids forgot things before. It is one of their big ADHD traits, however, it has greatly worsened. I can't imagine it being worse OFF the meds completely.

I guess we will ask to try Adderall or to return to lower dosage of previous med + Intuniv. I have read that Intuniv is actually used to treat tics so am wondering if taking it away a year or so ago might have been a bad move. Oh well. Live isn't dull, I guess. I just want things straightened out so she can enjoy the rest of HS like she did 1st-8th....and first semester this year.

[eoffg]

KC4,
I would like to question your psych providers instant decision to change meds, when your daughter told them that she wanted to stop pulling her hair?
As it seems that your daughter was doing fine on the Daytrana.
Where the benefits that Daytrana were providing your daughter?
Have been ignored, with the focus shifting to her 'hair pulling' as the main issue?
When I suggest that it is a secondary issue?
That the benefits that Daytrana were providing, shouldn't be sacrificed, to possibly stop the hair pulling?

Turning up to dance class, with a 'bald spot'.
Is probably much less of a problem, than 'turning up with one shoe'?

Being able to manage herself, is far more important than keeping a full head of hair.
You wrote earlier that: "She told my daughter that not pulling her hair comes first then school then extracurricular."

Failing school with a full head of hair.
Is more important than passing with a few bald spots?

[healthy11]

I know teens are concerned about their image/appearance, but I agree with eoffg about hair pulling being less important than being able to manage the rest of her life.

It doesn't sound like Strattera's "pros" outweigh the "cons." I believe you said that your daughter's next scheduled appointment with the doctor is still two weeks away; I don't know if you can move it up...between now and whenever it is, I'd suggest talking directly with her, and try to present a "unified position" to the doctor about whether you prefer to go back to her former meds, or try something new. You might want to read more about ADHD meds at www.additudemag.com/resource-center/adhd-medications.html and www.additudemag.com/slideshow/4/slide-1.html

[dw]

As a female, and a mother of a female, and as a health care professional with experience with patients who experience various types of emotional/psychosocial problems, I think that trichotillomania is a serious problem that deserves attention. Perhaps you are familiar with this web site: trich.org
It looks like it has reliable information that is very useful.

I don't think you need to be afraid of adderal products, simply because these products are under the category of amphetamines. Millions of ADHD affected people benefit greatly from amphetamine, and others from methylphenadate. One class is not better than the other or less addicting or safer or more addicting or less safe. Although healthy11's son's many years experience with amphetamine products (adderall) is anecdotal about one young person's experience (and success), it is not atypical, and in fact, healthy11's son's experience is typical with students with ADHD, backed up by lots of scientific studies.

Someday, there may be blood tests that show gene markers that will tell us which people will best respond to methylphenidate, and which will best respond to the amphetamines,and that will take out much of the guess work of finding ADHD medication, but the technology is not there yet.

KC4, I am saying this with the experience that my ADHD-inattentive dtr who could not adjust to any ADHD medications, which occurs in about 10-20 per cent, perhaps more often in ADHD inattentive. Nonetheless, I think the vast majority of ADHD affected young folk respond to and benefit from the stimulants.

[kc4braves]

Ok. Let me try to address some of the questions/comments. eoffg, We had mentioned the hair pulling prior to the apt where the meds were changed. The provider had hoped the hair pulling would resolve itself but it seemingly worsened or at least to my daughter it did. I do think bald spots are problematic certainly with self-esteem...and hair follicles can be permanently damaged, so it would have been great to do something to help that behavior go away while maintaining the benefits of the stimulant med. I was kinda shocked that she pushed straterra and didn't feel we could try another methylphenidate med or decrease the one she was using. Also, I don't think she meant that my daughter should fail to save her hair nor do we feel she will fail. I think she was giving a new problem immediate attn. but hoped not to sacrifice anything. I think the point was lets fix this new problem and maintain school but both are more important that dance, theater, golf, etc. We aren't sure we agree at this point. All are important and part of my daughters life balance. I have come to the conclusion that she can't be all school all the time. I think if Straterra is all she can take, we will not take any meds but hopefully, we are not there yet. I guess I am not ready to throw the towel in on anything right now ( except for Straterra).

healthy11, I would have liked a unified position when we saw the doctor last time but I had no idea my daughter was feeling like she was or that she felt the hair pulling was worse. I was way-layed. Or that is how I felt. Straterra has NO good points that I can see at this point. it is not responsible, I don't think, for her not pulling her hair. I think that is more being off the Daytrana. So I see nothing good so far about Straterra. We are not opposed to new meds and I have done tons of research. There isn't much if anything she hasn't tried. Metadate CD is one she never used but my son did. It was awesome for him but he had to take 2x a day because it didn't last long. Our doctor doesn't seem to think highly of it but not sure why. She has taken Focalin....worked good for 8 hours but the day is much longer. Concerta for some reason didn't work well and she gained and gained weight with it. ( Weird, I know.) Vyvanse....not noticeable results good or bad. Trial med that is not yet approved my FDA worked good at highest dose but she had to go off of it after test because not approved. Intuniv, tried alone and with stims. I wasn't sure it did anything so she never went back on it after going off meds for the drug trial. It may have worked with the stim and helped prevent the tic earlier. Not sure though. Adderall has not been tried yet. Didn't seem the way to go after Vyvanse failed but Concerta and Daytrana are both methylphenidate and one worked way better than the other so maybe.

dw, I am not yet convinced she has trichotillomania because if the urge/behavior stops when the med stops, it doesn't seem to fit the definition. If she does have it it is not as severe as many of those I have read about, thank God. As for adderal, I don't fear it simply because of the med group it is in but from all the reading I have done on adult message boards. I do know a couple of people who have taken it successfully. I know quite a few who like my son couldn't handle the side effects. I have done some more research over the past week where a neuro doc explained how different meds work and talk about how metabolism, etc. I am willing for her to try it but just dread trying new meds just...because it's a pain and it wreaks havoc in her little brain changing things so much. She wants to continue to be able to succeed at school, golf, theatre, dance and socially and I know messing with the meds can drastically effect all or some of these areas.

So...I don't know. She is doing ok at school.....I think....with me helping her to get organized. I'm not sure how other aspects are going. She is probably a little more socially outgoing OFF the stims but the other areas...not sure AND I don't know that her decision making is as good which isn't always a good thing socially or otherwise.

Tonight she got home from theatre at 9, ate a sandwhich, watched a few mins of tv, took a shower and was out in her room with hair in towel and light still on ( unsure if homework was finished)and I tried to wake her to ask about homework but she couldn't put together and intelligent sentence. I hate this drugged sleep....and I don't think she remembered to take the straterra before falling asleep. Oh....and I was watching her eat, then get chips, etc. I asked if she was still hungry or did she just feel chips goes with a sandwhich so she got some out of habit. She said, " I don't know how to answer that since I am hungry ALL the time.I never feel full anymore." I don't get it.

Thanks for your input. I do appreciate your perspectives.

[healthy11]

You mentioned that your daughter has taken Focalin before, with good results except it didn't last more than 8 hours. I'm not sure what age she was when she used it, but given how puberty/hormones can affect kids, it might be worth trying again. If it doesn't last more than 8 hours, could she take a 2nd dose?

My son has a fast metabolism, and even extended release Adderall XR doesn't seem to last long with him, so the psychiatrist who handles his prescriptions suggested trying another, slightly smaller dosage (because the Dr. said even though it looked like the first had "worn off" there was likely some left in his system, so the 2nd dose didn't have to be as strong to still get positive behavior effects...) The biggest problem with that was when my son had after-school activities in High School, he didn't always remember to take the 2nd dose right away, and then if he took it later (ie, after dinner, to do homework) then he had trouble falling asleep. The solution for that was to take Adderall XR for during the school day, and then use regular-short-acting Adderall for after dinner, to work on his homework. (In college, he switched to just using short-acting Adderall, because he didn't have "solid classes" all day long, like he did in H.S. The short-acting allows him to eat more between doses, and keep his blood sugar levels in better check... I'm pretty sure he continues to use just the short-acting Adderall for work, taking another dose after lunch on the days he needs it.)