Archive: August 2022

BVBV

Q: Hi ,

Any success stories on Guanfacine? My son is 9 years old, suffers from hyperactivity, impulsivity, and tics. Stimulants are no longer an option and after meeting with his new Pediatric Neurologist, he suggested trying Guanfacine next. We are on day 4, and will slowly titrate up in dosage. He also takes “natural” supplements as well.

Thank you!

Chestnut Hill CAP A: Just out of curiosity, why can your son no longer take stimulants? If it's because of an increase in tics, that is not usually a contraindication unless it is so severe that it is interfering with normal functioning.

Guanfacine is great but it is thought to be more effective for hyperactivity and impulsivity than with focus / concentration. Like Onthemove1971 mentioned, guanfacine is often combined with stimulants -- particularly in the afternoon and evening hours when a stimulant can't be used.

Is he on the immediate release (Tenex) or extended release (Intuniv)? I find that Intuniv tends to be a little less sedating and generally better tolerated.

I wish you good luck! Guanfacine (in either form) can be a very effective medication.

Enrisner

Q: Hello. We are located in Ohio and I have struggled with finding doctors that truly understand what we are dealing with. I was listening to the additude podcast on Spotify episode 56 and they suggested asking here for advice on doctors to start with in hopes of it not going to 11 different doctors first. We have a referral in at Akron Children's pediatric psychology but not sure which doctor. Any suggestions?

Chesnut Hill CAP I'm sorry that I'm unable to give you a specific recommendation / referral because, like most here I imagine, I don't live in your area.

However, ADHD and ODD are "bread and butter" issues for child psychiatrists. Like any other profession, there are a range of styles in the profession but probably the most important factor in selecting a provider for straightforward ADHD/ODD is availability.

There is still a shortage of Child and Adolescent Psychiatrists (CAPs), and though the situation is improving, it probably won't be quickly enough to help our currently adolescent children.

So, why am I writing? Well, for when you do finally get a CAP, it might facilitate the process to have ready your child's medical history, family history, your own personal observations and your priorities when it comes to treatment.

Why am I saying this? Though ADHD/ODD are common disorders, they can be exacerbated by any number of factors (genetics, environment, parental approach...) and every family has different priorities when it comes to treatment (school performance, impulsivity/safety, sibling conflict, home defiant behaviors, tantrums...).

ODD is often related to an underlying ADHD condition -- the child "needs to have what he wants when he wants it" because of poor frustration-tolerance related to ADHD. But sometimes it's largely unrelated and due to something else entirely (like a mood condition). Your CAP will want to understand those differences so she can recommend the most appropriate treatment.

As far as meds go, if not entirely define your stance on medication, come with a preference and a list of questions/concerns about meds. Also, the vast majority of CAPs do not actually directly perform non-medication management of these conditions -- instead they will refer you to a non-medical provider who specializes in these types of interventions.

I hope this of some help. Good luck!

HanDor

Q: My 15 yo son just began straterra/atomoxetine. How long has it taken for your body to get used to the medication? He is complaining he's so tired.

Chestnut Hill CAP Elijah is correct about the prevalence of poor-metabolizers in the population (primarily due to deficits in CYP2D6, a hepatic enzyme that catalyzes the metabolism of this sort of drug). But it's uncommon to undergo gene testing to direct management once a med is started because of the time it takes and the weak evidence of meaningful differences in outcome.

However, just because one is a poor metabolizer doesn't necessarily mean they're a poor responder -- it just might take longer to reach steady-state and ultimately show a response. Typically, steady state is reached in several days with this medication and therapeutic response starts after a couple weeks and reaches a maximum in 4-6 weeks.

Strattera is usually given in the morning, but it can be taken at night if it causes daytime fatigue and does not interfere with sleep when taken later. Unlike stimulant medications, this medication works through a longer-term mechanism (though some patients report a short-term "immediate" response as well), so giving it consistently at night should have the same long-term response in terms of controlling ADHD symptoms.

To why your child might be experiencing fatigue right now... this medication (and many oral medications) undergoes what is called first-pass metabolism. This greatly decreases the amount of native compound that enters circulation. Of course, in people with decreased or variant CYP2D6 this amount can be much higher than with typical patients.

It is actually usual for the liver to upregulate production of enzymes when there is a demand, so it might be very possible that your child will adapt very well to this medication given some time. How long? Well, it's variable but on the order of 1-2 weeks at least.

Hope this helps!

Lukesmom14

8/12/2022 My son (7. 8 in October) was diagnosed with ADHD at 5 . When he was diagnosed he was having frequent bathroom accidents and the doctor recommended seeing a specialist to rule out a medical issue. Both the urologist and gastroenterologist ruled out medical saying it was most likely his ADHD. That he was missing the signals his body was giving. I was told it wasn't uncommon for kids with ADHD but nothing the doctors have recommended has worked. It's gotten a little better. Lately other kids have started to notice. His pediatrician said he'll have to grow out of it. That might be case but I just wish I could help. I don't want him to be made fun of or feel ashamed. Has anyone else gone through this?

Chestnut Hill CAP This is pretty common actually with ADHD kids (and kids in general... it's not actually considered pathological until the age of 10).

If an anatomical or obvious medical conditions have already been ruled out then doing what others here have already mentioned is an effective strategy called "timed voiding".

Behavioral interventions including profuse praise / reward for early success can also be helpful.

Medications (like ddAVP) can help but I think a lot of doctors are reluctant to try this except for intermittent use (like occasional sleepovers, but probably not every school day).

It is also possible that treating the underlying ADHD can also help. Though treatment with medications (like stimulants) are the quickest way to reduce ADHD symptoms, there are other approaches including sleep optimization, supplements, and therapy.

Sisymay

8/15/22 Q: Hi, I'm here for my 10yr old grandson. He was 48" tall and 48 lbs almost 2 years ago. He Looks more like 7 yrs old. He has been taking concerta for the last 3 years until about 2 months ago. It's good for him, but he will not grow and will not eat. Plus, it makes him have horrible constipation to the point of having to go to the hospital sometimes. He went to a gastro dr and was given miralax, it helped a little. Then, I found out it's very bad, so I stopped it.

l found out concerta causes stunted growth, no appetite and constipation. We tried other medicines to see if the side effects would stop. First was intuniv - after one pill, he slept for 18 hours, barely breathing, very slow heart rate.

Then, focalin. - No appetite, no growth . Then, risperdal - very bad nose sniffing tic to the point of crying and teacher keeping him out of class. Kept doing this for a month. Trileptal. - Started a new psych for insurance reasons. New psych very concerned, said it was for seizures. Stopped it. Focalin - no appetite, weight loss. Clonodine - very serious mouth tic for 4 months. Had to wait or neurologist appt, tic stopped before the appt. Strattera - took to stop tic from clonodine. Took one pill, was like a wound up monkey. Couldn't even stay in school that day. So I stopped that.

All these meds no appetite, lost weight, bad constipation . Concerta was the last one tried and helped the most with symptoms. That's 8 medicines in all.

Right now he's taking natural supplements. 3 types of magnesium, and creekside focused mind Jr. All summer, he has been fine. Constipation gone, eating normal, gained 10 lbs. Grew 2 inches.

School started last week, and just today teacher told me he's all over the place, can't concentrate, very hyper. It's very expensive to keep jumping around finding natural remedies that work.

I asked his last psych about all this. He said all stimulants and nonstimulants cause all these things. About 6 months ago he had genesight test done. It didn't test all meds for this. The ones he tested for showed the right ones for him are the ones he already tried.

I'm trying to find list of every medicine for adhd. If anyone knows them all, could you let me know what they are? I know this is very long and I'm sorry. Thanks. So much for reading this !

Chestnut Hill CAP A: Hello Sisymay,

I might have missed it in your post but it doesn't look like your grandson has been tried on the amphetamine-based meds.

Stimulant medications fall into 2 broad categories: 1) the methylphenidate derivatives (Concerta, Ritalin, Focalin, Metadate, Jornay...), 2) the amphetamine derivatives (Adderall, Vyvanse, Dexedrine...)

If your grandson was tried also on Risperdal and Trileptal, I suspect that he may have also been diagnosed with DMDD or some other type of mood disorder (which, unfortunately, can be exacerbated by stimulant medications).

A common protocol for this combination of disorders would be to stabilize the patient with either a neuroleptic (like Risperdal or Abilify) or an antiseizure med (like Depakote or Trileptal). Once the patient is stabilized then there should be a careful attempt at introducing stimulant medications -- during this process the amount of mood-stabilizing agent may need to be increased as well.

This approach usually identifies the lowest effective dose of medications for the child.

For the type of hyperactivity I believe you are describing, my guess is that stimulant medications may be needed to control his ADHD enough to tolerate school.

However, you can also try supplementing his diet with fish oils which have been shown to be helpful in controlling ADHD, but this takes weeks of consistent high levels for there to be an effect. In fact Omega-3's and PS's were shown to be so effective there was once a prescription "medication" that was just a combination of these. It was called Vayarin but it has since been taken of the market.

Good luck with everything!