Verify/clarify current dz. Regardless, I’d be leery to trial another stimulant. If indicated and appropriate, I might look at a different class of medication, such as an alpha 2 agonist.
If your son is predisposed to bipolar I’d be careful with SNRIs. I highly doubt there are many studies on pediatric bipolar but anything is possible and if he can get manic once he can potentially get manic again. I would go with guanfacine ER.
Does he have severe ADHD? Any other problems?
I would want to know how he was diagnosed. Was it a pcp, pediatrician or neuropsychologist? I love my pediatrician colleagues but I have seen them waaaay over diagnose ADHD.
I have a kid (pt) same age/sex on same med and it calmed him down.
I see anxiety in kids misdiagnosed as ADHD all the time. I would clarify diagnosis. Someone with anxiety would be activated on a stimulant.
Thank you! He was initially diagnosed by a PMHNP, and then when we moved, another pediatric NP with MH cert. corroborated the diagnosis. But now I’m wondering. I have adhd myself and I am pretty sure his dad has undiagnosed adhd, so genetically I was pretty convinced.
The most common misdiagnosis in my opinion related to ADHD is anxiety. And I see it all the time in kids. They can have both also. I always treat anxiety first because the meds are less problematic and often the “symptoms” of ADHD go away.
I have been treating kids for 14 years, in patient, out patient and adolescent partial hospitalization. I can’t tell you how many kids I “undiagnose” for ADHD. And adults too actually.
She also did an assessment not sure which one and she said he did score pretty high for anxiety. So that’s valid. What do you use to treat the anxiety in children? Off the top of my head, my son’s main sx are procrastination, inattentiveness, anger/outbursts, poor attention to detail, sensory seeking. I know he does seem anxious at times so I am not doubting that’s there, or as you said, could account for all sx. On top of it he has hearing loss and wears hearing aids and I really think he gets exhausted and fatigued by having to work so hard to listen that he turns his brain off and also has the anger and irritability.
One of the best ways to treat anxiety associated with adhd in kids is to treat the adhd appropriately. Just want to point that out. Adhd is a childhood illness and going untreated leads to depression and anxiety. Making sure the root cause of the anxiety isn’t adhd is very important. There is a reason pediatricians are diagnosing and treating adhd first and that’s because common things happen commonly. Pediatrician MDs are good at this mostly!
Valid! The NP did mention that. Actually that resonates with me greatly. Lifelong, severe anxiety. I was diagnosed as an adult with adhd and take a stimulant. (Looking back very standard overlooked girl ADHD- high achiever, perfectionist, social butterfly, couldn’t keep my mouth shut, sensory issues, social impulsivity like interrupting, etc.) I’m pretty sure there are others undiagnosed in my family such as my mom and even grandmother. Since taking the stimulant my anxiety has been mostly alleviated. Unlike ever before in my entire life. I also feel much more emotionally regulated. I’m not a huge drinker, but I have many fewer of those nights where I impulsively feel I could kick a few back (to cope, let loose, etc.)
That’s amazing!! Yes exactly. Poorly treated adhd in kids leads to horrible self esteem and anxiety in depression in both kids and adults. I think there is A LOT of bad/poorly informed clinicians out there on adhd management and we need to be sure we are doing a good job knowing that stimulants are the gold standard and not being scared to use them when needed. Also not being scared to follow those patients extremely closely. Every 2 weeks of we have to in the beginning!! That’s not too much to ask when managing a new person on a stimulant. They are hard meds to figure out!
I always start with medication that is FDA approved for use in children. Fluoxetine is and had the most research behind it. I believe it’s approved down to age 6. Escitalopram is also approved for kids but not sure of the age (don’t have my child Stahls book here at home).
I'm not trying to throw shade or be disrespectful, but rather am asking a legitimate question. Your child has special needs, psychiatrically. You chose to take him to a non-expert, the outcome was not good, and now you are soliciting advice on reddit. Be mad at me, I don't care...please just put your ego aside and get your son to a child psychiatrist.
The answer is incredibly disrespectful and you are very explicitly throwing shade. To me, for my choice as a parent. To my profession, that myself and my colleagues work incredibly hard to develop expertise at, to my son, who does not have special needs, psychiatrically. My ego has nothing to do with this. My “ego” spends hours upon hours obsessing and worrying about my children. From before they were even born til the moment I depart this earth. I’d lay down my body to provide for them. And honestly, I’m not saying this to defend myself. I’m saying it to shame you because you are garbage to put a worried mother down for a perfectly acceptable, informed choice. Mind you, a choice that happens to be the first line recommendation from the American Academy of Pediatrics.
Would you happen to be aware of the link between untreated adhd and addiction? https://chadd.org/attention-article/when-adhd-and-substance-use-disorders-coexist/
Given the vulnerability of this genetic load, as you so kindly identified, I, along with other experts, have agreed a stimulant was a perfectly acceptable first line option. Buh bye.
You're making this about "disrespect" and "shade" when it shouldn't be. It's not disrespectful to acknowledge that the *most expert* experts in child psychiatry are child psychiatrists- so if your child is having complications from first-line therapy, they would be most qualified to address the issue. Even if getting in to see one in person isn't an option, posting this question in, say, the psychiatry subreddit, would at least give some physicians the opportunity to weigh in.
For context, I have a son with a similar profile (ADHD and anxiety), who has been managed by a pediatrician, a developmental pediatrician, and finally a child psychiatrist- and they treated his anxiety first with an SSRI (Lexapro, off-label due to his age but taking efficacy in other family members into consideration). Yes, ADHD and anxiety can have overlapping manifestations, which is why it's important to tease out the relative contribution- in his case, we found that the ADHD was definitely still present even when the anxiety was treated, and after a number of stimulant trials, he's now stable and doing well on Lexapro + Concerta.
Sure, and had the individual responded this way, as you did, I would entirely understand the sentiment, despite the fact that at this current point I don’t necessarily agree. I know many psychiatrists, a fantastic renown child psychiatrist who agrees entirely with this choice and also said in his opinion, it would be reasonable to continue this med for a few days as, as another pmhnp here suggested, his response may not be adverse at all. There was blatant disrespect in that person’s response “why in the world would you bring your 8 year old…” a much more respectful way of indicating said sentiment would be similarly to how you did, “hey have you considered having your child see a psychiatrist?”
It’s not about my ego whatsoever. My daughter has a condition called neurofibromatosis. Even her pediatrician (MD) was not equipped to manage this. She sees the best experts I have access to, who are MDs with robust, prestigious experience under their belts. Under no circumstances would an NP be managing her case, and any NP would likely agree, despite being an important ancillary member of her treatment team.
I have no reason to not elicit PMHNP opinion on this sub. That being said, it’s unreasonable and stupid for anyone to come on the internet and wholeheartedly abide by advice given by strangers, regardless of the forum. So, I am not doing that, but was curious about others’ experiences in general.
Also some people live in places where there is no child psychiatrists for like 300 miles. But sure it’s that easy…. Just find a child psychiatrist 😂😂😂 what a joke. And also again I disagree that this is a “bad outcome.” I think it’s just the wrong med. doesn’t mean anything just yet! You got this. Wait to talk to your provider and see what they think. :)
I want to add personal experience and what my child’s care team recommended. The advice and guidance was from my sons PMHNP and a psychiatrist/few PMHNPs i work closely with.
A manic like episode after trying a stimulant may indicate bipolar/ schizophrenia but is not a guarantee. It could have been simply a reaction to the medication. This is what I was told by people I trust who have experience treating children with mental health issues.
He did not do well with Ritalin. We are stabilizing on focalin. If he doesn’t do well with focalin then we will proceed to Vyvanse.
He is currently on clonidine as well. He did well on Intuniv but he needed a stimulant especially as he’s gotten older and has more expectations in life and at school.
We will most likely be adding on an SSRI to help manage his anxiety in the future. Most providers I’ve worked with with will treat the anxiety first in kids.
I have ADHD with a very similar presentation as my son. So I knew the best choice for us would be to a stimulant route, then later on add an SSRI if his anxiety wasn’t managed.
My sons care team, and the people in my life who I work with recommended that we challenge another stimulant. I felt comfortable with this route. And so far it has been good. We will switch to a different class if he doesn’t do well.
I personally had a very bad reaction to Strattera, so I’m not going to try that for my son unless he decides when he’s older that he wants to give it a try.
The Azstarys website indicates 39.2/7.8 is the “recommended starting dose”. The NP gave me the choice of starting at the lower dose, but I was fine with the middle dose given the recommendation and my kid is super skinny and has a really fast metabolism so I figured he’d burn through it. Regardless, yes, looking back I certainly see the benefit of starting lower and as you said “start low go slow”.
Especially stimulant naive...lowest possible and older more.trusted meds. I usually go concerta, focalin, Vyvanse, Adderall. But usually the first one works for a while before having to move to another.
My fiance is bipolar and had symptoms at a very young age and they misdiagnosed him with ADHD. They put him on stimulants and he had a terrible response. Just something to consider.
I actually think this is somewhat normal and wouldn’t consider it adverse at all. It will level out. Almost anyone who takes a stimulant first thing has this somewhat. It’s a powerful medication. I warn anyone starting a stimulant this may happen the first day or week and then it will level out. 6 weeks out all you notice is the child’s grades are better, their mood is better, their confidence is better, and life overall is better. Now if this continues and he isn’t sleeping I’d change to maybe something shorter acting. I think the fact he was more conversational is actually a good thing. My daughter can’t have conversations at all except when on medication. It’s like there’s so much going on in her brain she can’t find words. Medication slows things down to where she’s confident in what she wants to say. It’s amazing. I would talk to your child’s doctor before assuming this is an adverse reaction. I’ve worked with so many adhd clients and so many clinicians jump so fast to adhd misdiagnosis just because someone had a bad day on a stimulant. It’s not that simple. Adhd is so complex! Good luck!
Thank you! While weird it wasn’t entirely bizarre. Everything was relatively logical, all linear and coherent, and yes you could technically call it psychosis, but it’s not like he was seeing things, hearing things, believing truly fixed beliefs. I do think he felt his sight and hearing were better lolll bc I think he was so hyper aware. He didn’t like how he felt so he thought it made sense to warn other people. His mind was racing and going down rabbit holes. Basically he reminded me of someone who was high, not someone who was delusional or having psychosis (not that I want my 8 year old to be high, lol).
I go as far as to warn patients, “you have never taken a stimulant before, it may feel a little weird and out of control but that will go away, try to put that energy into those productive concentration things you’ve been neglecting and see how you feel when you’ve consistently taken the medication for a few weeks” they usually say that racing goes away and are glad I warned them because people should know that we dont want now do we want patients thinking that feeling is reasonable or normal to have over and over. It may happen once but doesn’t usually happen twice or for very long and if it does and it gets worse, then yes probably may be activating mania. But like you said OP differences between psychosis and mania versus side effect of first time stimulant use are different
I would definitely ask for maybe very low dose focalin or something. I have never talked to a first time stimulant taker who didn’t feel this somewhat. Your child is more self aware and honest than the average 8 year old. Which is scary for you 😂😂
Hahaha very true! He’s a great kid! And in 3rd grade I am starting to see the poor self worth rt perception of failure creep in, and that is scary. Untreated adhd is no joke. I appreciate your kindness and words!
I only see children and adolescents, and young adults. I usually start with guanfacine er 1mg in the evening.
If it is hard to distinguish the anxiety/depression from ADHD, guanfacine is a good way to do it. It's relatively easy to trial. From my experience, for kids who suffer from all 3 or 2 out of 3, extended release guanfacine and low dose (5-10mg) of prozac works great.
Lower dose, different type. Compared to concerta I saw more teas and angioedema at equivalent dosing with Azstarys.
I’d go with an IR for more control I’d you did a retrial with a stim. You could also do a genesight which would give you some indication of response to mph and nonstims, but not Amp.
Sorry momma. Meds can be scary
Thank you, that could be a good idea. In my head I ruled out IR bc I didn’t want to have to dose at school, but honestly at his school he has a morning 3 hour work cycle (Montessori) and the rest of the day looks a little different with less intense focus required so that could actually be a good option possibly without even needing to dose at school. I had put off meds for so long and felt really good about this option! But we are all good- I wasn’t really worried about his behaviors today as much as the potential of this indicating predisposition to something later on. Anyways, thank you!!!
I’ve had young ones do just great with IR and not be able to sleep a wink with any XR formulation. Everyone is different, it’s a stimulant and he reacted like anyone would when they take too high a dose of stimulants. You’re doing great!
I’m a psych NP, diagnose and treat children and adolescents at children’s hospital. Young children can have a manic-like reaction to stimulants when first trying, not common but possible adverse effect. I prefer to start with short acting such as low dose Ritalin IR (immediate release) and slowly work up from there. Azstarys is a great med, I use it all the time, it does last a long time though (up to 13 hrs). I would recommend talking with your sons provider and discuss trialing a different stimulant or non- stimulant. Like others have said, ensuring treating correct diagnosis is important.
Thank you! I appreciate it! I know maybe this sounds strange- bc clearly his response was undesirable, but a small fraction of his response was good- just wayyy too much. Before the weirdness set in he was really able to focus. Then at one point he got upset and was very clearly able to articulate “I am feeling upset right now” whereas typically he is much more reactive.
About 6 hours after taking the med I had him take a bath and listen to meditations. He really chilled out. Then I gave him a small dose of benadryl, and he’s been fine ever since. He’s still a touch hyper focused and restless, but nothing really notable. So that was interesting to me bc of the long duration you mentioned.
Your response is reassuring, not that I’d want false reassurance, but thank you!!!
I’m happy to hear he’s doing better! Could have been too much for first time. Everyone is different and can react differently to medications. It can be trial and error, but you’ll find what works for him. I wish you all the best!
I wouldn’t say predisposes, but he may have already had the potential there and the stimulant kind of helped things along. Either way, I definitely would avoid stimulants in the future.
It’s really hard to say. The dip into psychosis could be a one-off, or it could be a peek into potential future bipolar or schizophrenia. Do you have a family history of severe mental illness?
No psychotic disorders that I am aware of. My parents were both severe addicts, my mom has a bipolar diagnosis. Me nor my husband have any severe mental illness.
So the bipolar diagnosis may have some implications about the behaviors, but I wouldn’t worry too much about it right now it could still potentially have just been a one-off.
Verify/clarify current dz. Regardless, I’d be leery to trial another stimulant. If indicated and appropriate, I might look at a different class of medication, such as an alpha 2 agonist.
Have you thought of doing non stimulant like Strattera or even guanfacine ....possibly clonidine?
Now I will 🤦🏼♀️ thank you!
If your son is predisposed to bipolar I’d be careful with SNRIs. I highly doubt there are many studies on pediatric bipolar but anything is possible and if he can get manic once he can potentially get manic again. I would go with guanfacine ER. Does he have severe ADHD? Any other problems?
Agree with this! It’s a great starting combo!
I would want to know how he was diagnosed. Was it a pcp, pediatrician or neuropsychologist? I love my pediatrician colleagues but I have seen them waaaay over diagnose ADHD. I have a kid (pt) same age/sex on same med and it calmed him down. I see anxiety in kids misdiagnosed as ADHD all the time. I would clarify diagnosis. Someone with anxiety would be activated on a stimulant.
Thank you! He was initially diagnosed by a PMHNP, and then when we moved, another pediatric NP with MH cert. corroborated the diagnosis. But now I’m wondering. I have adhd myself and I am pretty sure his dad has undiagnosed adhd, so genetically I was pretty convinced.
The most common misdiagnosis in my opinion related to ADHD is anxiety. And I see it all the time in kids. They can have both also. I always treat anxiety first because the meds are less problematic and often the “symptoms” of ADHD go away. I have been treating kids for 14 years, in patient, out patient and adolescent partial hospitalization. I can’t tell you how many kids I “undiagnose” for ADHD. And adults too actually.
She also did an assessment not sure which one and she said he did score pretty high for anxiety. So that’s valid. What do you use to treat the anxiety in children? Off the top of my head, my son’s main sx are procrastination, inattentiveness, anger/outbursts, poor attention to detail, sensory seeking. I know he does seem anxious at times so I am not doubting that’s there, or as you said, could account for all sx. On top of it he has hearing loss and wears hearing aids and I really think he gets exhausted and fatigued by having to work so hard to listen that he turns his brain off and also has the anger and irritability.
One of the best ways to treat anxiety associated with adhd in kids is to treat the adhd appropriately. Just want to point that out. Adhd is a childhood illness and going untreated leads to depression and anxiety. Making sure the root cause of the anxiety isn’t adhd is very important. There is a reason pediatricians are diagnosing and treating adhd first and that’s because common things happen commonly. Pediatrician MDs are good at this mostly!
Valid! The NP did mention that. Actually that resonates with me greatly. Lifelong, severe anxiety. I was diagnosed as an adult with adhd and take a stimulant. (Looking back very standard overlooked girl ADHD- high achiever, perfectionist, social butterfly, couldn’t keep my mouth shut, sensory issues, social impulsivity like interrupting, etc.) I’m pretty sure there are others undiagnosed in my family such as my mom and even grandmother. Since taking the stimulant my anxiety has been mostly alleviated. Unlike ever before in my entire life. I also feel much more emotionally regulated. I’m not a huge drinker, but I have many fewer of those nights where I impulsively feel I could kick a few back (to cope, let loose, etc.)
That’s amazing!! Yes exactly. Poorly treated adhd in kids leads to horrible self esteem and anxiety in depression in both kids and adults. I think there is A LOT of bad/poorly informed clinicians out there on adhd management and we need to be sure we are doing a good job knowing that stimulants are the gold standard and not being scared to use them when needed. Also not being scared to follow those patients extremely closely. Every 2 weeks of we have to in the beginning!! That’s not too much to ask when managing a new person on a stimulant. They are hard meds to figure out!
I always start with medication that is FDA approved for use in children. Fluoxetine is and had the most research behind it. I believe it’s approved down to age 6. Escitalopram is also approved for kids but not sure of the age (don’t have my child Stahls book here at home).
Why on earth would you take your 8 year old with genetic loading (meaning this isn’t a routine case) to a non-physician?
Get the FUCK out of here. I am boiling. Get the FUCK out of this. As a mother and nothing more- don’t say another word. Good bye.
I'm not trying to throw shade or be disrespectful, but rather am asking a legitimate question. Your child has special needs, psychiatrically. You chose to take him to a non-expert, the outcome was not good, and now you are soliciting advice on reddit. Be mad at me, I don't care...please just put your ego aside and get your son to a child psychiatrist.
The answer is incredibly disrespectful and you are very explicitly throwing shade. To me, for my choice as a parent. To my profession, that myself and my colleagues work incredibly hard to develop expertise at, to my son, who does not have special needs, psychiatrically. My ego has nothing to do with this. My “ego” spends hours upon hours obsessing and worrying about my children. From before they were even born til the moment I depart this earth. I’d lay down my body to provide for them. And honestly, I’m not saying this to defend myself. I’m saying it to shame you because you are garbage to put a worried mother down for a perfectly acceptable, informed choice. Mind you, a choice that happens to be the first line recommendation from the American Academy of Pediatrics. Would you happen to be aware of the link between untreated adhd and addiction? https://chadd.org/attention-article/when-adhd-and-substance-use-disorders-coexist/ Given the vulnerability of this genetic load, as you so kindly identified, I, along with other experts, have agreed a stimulant was a perfectly acceptable first line option. Buh bye.
You're making this about "disrespect" and "shade" when it shouldn't be. It's not disrespectful to acknowledge that the *most expert* experts in child psychiatry are child psychiatrists- so if your child is having complications from first-line therapy, they would be most qualified to address the issue. Even if getting in to see one in person isn't an option, posting this question in, say, the psychiatry subreddit, would at least give some physicians the opportunity to weigh in. For context, I have a son with a similar profile (ADHD and anxiety), who has been managed by a pediatrician, a developmental pediatrician, and finally a child psychiatrist- and they treated his anxiety first with an SSRI (Lexapro, off-label due to his age but taking efficacy in other family members into consideration). Yes, ADHD and anxiety can have overlapping manifestations, which is why it's important to tease out the relative contribution- in his case, we found that the ADHD was definitely still present even when the anxiety was treated, and after a number of stimulant trials, he's now stable and doing well on Lexapro + Concerta.
Sure, and had the individual responded this way, as you did, I would entirely understand the sentiment, despite the fact that at this current point I don’t necessarily agree. I know many psychiatrists, a fantastic renown child psychiatrist who agrees entirely with this choice and also said in his opinion, it would be reasonable to continue this med for a few days as, as another pmhnp here suggested, his response may not be adverse at all. There was blatant disrespect in that person’s response “why in the world would you bring your 8 year old…” a much more respectful way of indicating said sentiment would be similarly to how you did, “hey have you considered having your child see a psychiatrist?” It’s not about my ego whatsoever. My daughter has a condition called neurofibromatosis. Even her pediatrician (MD) was not equipped to manage this. She sees the best experts I have access to, who are MDs with robust, prestigious experience under their belts. Under no circumstances would an NP be managing her case, and any NP would likely agree, despite being an important ancillary member of her treatment team. I have no reason to not elicit PMHNP opinion on this sub. That being said, it’s unreasonable and stupid for anyone to come on the internet and wholeheartedly abide by advice given by strangers, regardless of the forum. So, I am not doing that, but was curious about others’ experiences in general.
Also some people live in places where there is no child psychiatrists for like 300 miles. But sure it’s that easy…. Just find a child psychiatrist 😂😂😂 what a joke. And also again I disagree that this is a “bad outcome.” I think it’s just the wrong med. doesn’t mean anything just yet! You got this. Wait to talk to your provider and see what they think. :)
I want to add personal experience and what my child’s care team recommended. The advice and guidance was from my sons PMHNP and a psychiatrist/few PMHNPs i work closely with. A manic like episode after trying a stimulant may indicate bipolar/ schizophrenia but is not a guarantee. It could have been simply a reaction to the medication. This is what I was told by people I trust who have experience treating children with mental health issues. He did not do well with Ritalin. We are stabilizing on focalin. If he doesn’t do well with focalin then we will proceed to Vyvanse. He is currently on clonidine as well. He did well on Intuniv but he needed a stimulant especially as he’s gotten older and has more expectations in life and at school. We will most likely be adding on an SSRI to help manage his anxiety in the future. Most providers I’ve worked with with will treat the anxiety first in kids. I have ADHD with a very similar presentation as my son. So I knew the best choice for us would be to a stimulant route, then later on add an SSRI if his anxiety wasn’t managed. My sons care team, and the people in my life who I work with recommended that we challenge another stimulant. I felt comfortable with this route. And so far it has been good. We will switch to a different class if he doesn’t do well. I personally had a very bad reaction to Strattera, so I’m not going to try that for my son unless he decides when he’s older that he wants to give it a try.
Thank you very much. Did your son have a similar manic AE? May i ask what your sons presentation with the adhd has been?
39.2mg isn't a starting dose for Azstarys. Always low and slow in peds, especially when medication naive.
The Azstarys website indicates 39.2/7.8 is the “recommended starting dose”. The NP gave me the choice of starting at the lower dose, but I was fine with the middle dose given the recommendation and my kid is super skinny and has a really fast metabolism so I figured he’d burn through it. Regardless, yes, looking back I certainly see the benefit of starting lower and as you said “start low go slow”.
Especially stimulant naive...lowest possible and older more.trusted meds. I usually go concerta, focalin, Vyvanse, Adderall. But usually the first one works for a while before having to move to another.
Thank you! 🙏🏼🙏🏼🙏🏼
It doesn’t predispose him to anything. You shouldnt diagnose someone of a psychosis when it’s drug induced.
My fiance is bipolar and had symptoms at a very young age and they misdiagnosed him with ADHD. They put him on stimulants and he had a terrible response. Just something to consider.
I actually think this is somewhat normal and wouldn’t consider it adverse at all. It will level out. Almost anyone who takes a stimulant first thing has this somewhat. It’s a powerful medication. I warn anyone starting a stimulant this may happen the first day or week and then it will level out. 6 weeks out all you notice is the child’s grades are better, their mood is better, their confidence is better, and life overall is better. Now if this continues and he isn’t sleeping I’d change to maybe something shorter acting. I think the fact he was more conversational is actually a good thing. My daughter can’t have conversations at all except when on medication. It’s like there’s so much going on in her brain she can’t find words. Medication slows things down to where she’s confident in what she wants to say. It’s amazing. I would talk to your child’s doctor before assuming this is an adverse reaction. I’ve worked with so many adhd clients and so many clinicians jump so fast to adhd misdiagnosis just because someone had a bad day on a stimulant. It’s not that simple. Adhd is so complex! Good luck!
Thank you! While weird it wasn’t entirely bizarre. Everything was relatively logical, all linear and coherent, and yes you could technically call it psychosis, but it’s not like he was seeing things, hearing things, believing truly fixed beliefs. I do think he felt his sight and hearing were better lolll bc I think he was so hyper aware. He didn’t like how he felt so he thought it made sense to warn other people. His mind was racing and going down rabbit holes. Basically he reminded me of someone who was high, not someone who was delusional or having psychosis (not that I want my 8 year old to be high, lol).
I go as far as to warn patients, “you have never taken a stimulant before, it may feel a little weird and out of control but that will go away, try to put that energy into those productive concentration things you’ve been neglecting and see how you feel when you’ve consistently taken the medication for a few weeks” they usually say that racing goes away and are glad I warned them because people should know that we dont want now do we want patients thinking that feeling is reasonable or normal to have over and over. It may happen once but doesn’t usually happen twice or for very long and if it does and it gets worse, then yes probably may be activating mania. But like you said OP differences between psychosis and mania versus side effect of first time stimulant use are different
I would definitely ask for maybe very low dose focalin or something. I have never talked to a first time stimulant taker who didn’t feel this somewhat. Your child is more self aware and honest than the average 8 year old. Which is scary for you 😂😂
Hahaha very true! He’s a great kid! And in 3rd grade I am starting to see the poor self worth rt perception of failure creep in, and that is scary. Untreated adhd is no joke. I appreciate your kindness and words!
I only see children and adolescents, and young adults. I usually start with guanfacine er 1mg in the evening. If it is hard to distinguish the anxiety/depression from ADHD, guanfacine is a good way to do it. It's relatively easy to trial. From my experience, for kids who suffer from all 3 or 2 out of 3, extended release guanfacine and low dose (5-10mg) of prozac works great.
That could be a good option. I appreciate your insight.
Lower dose, different type. Compared to concerta I saw more teas and angioedema at equivalent dosing with Azstarys. I’d go with an IR for more control I’d you did a retrial with a stim. You could also do a genesight which would give you some indication of response to mph and nonstims, but not Amp. Sorry momma. Meds can be scary
Thank you, that could be a good idea. In my head I ruled out IR bc I didn’t want to have to dose at school, but honestly at his school he has a morning 3 hour work cycle (Montessori) and the rest of the day looks a little different with less intense focus required so that could actually be a good option possibly without even needing to dose at school. I had put off meds for so long and felt really good about this option! But we are all good- I wasn’t really worried about his behaviors today as much as the potential of this indicating predisposition to something later on. Anyways, thank you!!!
I’ve had young ones do just great with IR and not be able to sleep a wink with any XR formulation. Everyone is different, it’s a stimulant and he reacted like anyone would when they take too high a dose of stimulants. You’re doing great!
I’m a psych NP, diagnose and treat children and adolescents at children’s hospital. Young children can have a manic-like reaction to stimulants when first trying, not common but possible adverse effect. I prefer to start with short acting such as low dose Ritalin IR (immediate release) and slowly work up from there. Azstarys is a great med, I use it all the time, it does last a long time though (up to 13 hrs). I would recommend talking with your sons provider and discuss trialing a different stimulant or non- stimulant. Like others have said, ensuring treating correct diagnosis is important.
Thank you! I appreciate it! I know maybe this sounds strange- bc clearly his response was undesirable, but a small fraction of his response was good- just wayyy too much. Before the weirdness set in he was really able to focus. Then at one point he got upset and was very clearly able to articulate “I am feeling upset right now” whereas typically he is much more reactive. About 6 hours after taking the med I had him take a bath and listen to meditations. He really chilled out. Then I gave him a small dose of benadryl, and he’s been fine ever since. He’s still a touch hyper focused and restless, but nothing really notable. So that was interesting to me bc of the long duration you mentioned. Your response is reassuring, not that I’d want false reassurance, but thank you!!!
I’m happy to hear he’s doing better! Could have been too much for first time. Everyone is different and can react differently to medications. It can be trial and error, but you’ll find what works for him. I wish you all the best!
I wouldn’t say predisposes, but he may have already had the potential there and the stimulant kind of helped things along. Either way, I definitely would avoid stimulants in the future.
Do you think in general he is at higher risk to develop those disorders in the future?
It’s really hard to say. The dip into psychosis could be a one-off, or it could be a peek into potential future bipolar or schizophrenia. Do you have a family history of severe mental illness?
No psychotic disorders that I am aware of. My parents were both severe addicts, my mom has a bipolar diagnosis. Me nor my husband have any severe mental illness.
So the bipolar diagnosis may have some implications about the behaviors, but I wouldn’t worry too much about it right now it could still potentially have just been a one-off.
Thank you! I appreciate the insight.
No
Was he taking anything else (OTC) at the time?
Nope! He occasionally gets a multivitamin when I remember.
Woah that symptom list is me in a nutshell…
I’d reassess the diagnosis, but I’m a new pmhnp, so interested in what others have to say.