My son, age 7 with ADHD…
Posted by AnneFentonMD in ADD, ADHD, Children, Medication, Treatment on June 22nd, 2017
Question: My son,age 7, has been diagnosed with ADHD thru various neuro physc. tests including “Quotient” exam. He struggles in school and home to focus. He basically can’t complete any school assingment without 1/1 help for redirection etc.
I currently have him in cranio sacral therapy in hopes that midline and coordination therapy will help him. (he cant military crawl, crab crawl etc.) He will also starts vision therapy soon for a tracking problem.
I have a family history of hypothyroid My son shows no outward signs of it,, weight gain etc. But I have heard that it can cause ADHD symptoms in children. Is it worth it to have him checked?
If his thyroid levels come back normal, would anyone do a trial medication for him? My levels were normal despite numerous debilitating symptoms of hypo. Also, I cut my thyroid meds in half during the summer months as I recognize my needs changing. Then my hypo symptoms come back with a vengeance during winter months. I notice that my son has more difficulties in the winter and is moody. He has frequent skin problems (extremely dry, rashes, bumps etc) all winter.
I am cautious about ADHD meds. and I want to be certain there is no other underlying problems before I subject such a young child to them, but I worry I am looking at too many aspects when trying to help him.
Dr. Anne Fenton: You raise some interesting questions. First, let me say that there is some research supporting the existence of “subclinical hypothyroidism”. This is a condition in which some of the symptoms of hypothyroidism occur, but blood levels of thyroid hormone fall within normal range.
In the absence of lab data supporting clinical intervention, it would be quite risky to treat the condition with thyroid hormone. The side effects of thryoid hormone supplement can be quite serious, sometimes even life threatening in and of themselves. For example, excessive thyroid hormone therapy has been known to produce symptoms of tachycardia (rapid heart rate), high blood pressure, stroke, arrhythmias (irregular heart rate), hyperexcitability, hyperactivity, and even mania and psychosis. So it is highly doubtful that you would find a pediatrician or pediatric endocrinologist who would treat your son for hypothyroidism without hard data.
In addition, given that your son has been diagnosed with ADHD, (attention deficit disorder with hyperactivity) and not ADD (attention deficit disorder without hyperactivity), it is unlikely that a low thyroid hormone level is the cause. In hypothyroidism, people are sluggish, not hyperactive, and have attentional issues due to slowed brain function rather than due to distractability from external stimuli.
In terms of the relative risks of thyroid hormone supplement vs standard ADHD medication, it can be far less risky to offer him a trial of a short acting ADD medicine such as Ritalin or Adderall. First, these medications are out of the system within hours. They work quickly. As soon as 20 to 30 minutes after taking them, a person can experience a noticeable improvement in their ADHD symptoms. With thyroid hormone supplement, a person often does not experience the results of the trial for several weeks, and it takes up to 3 months of daily dosing to stabilize on any particular dose, and sometimes even longer to achieve observable results.
When I see a child with an ADHD diagnosis, I often recommend starting with a low dose of one of these medicines. I look at it as a test dose, to see whether the medication will be helpful, and also to minimize the possible side effects. The goal is to achieve the minimum optimal dose which will relieve the child’s symptoms so that he can function as well as possible without interference from side effects. Typical side effects are appetite decrease and difficulty sleeping (if the medicine is taken after 4PM). However, since these medicines primarily help children to focus at school, they are seldom needed beyond school or homework hours. Therefore, they are out of the system by bedtime.
In addition, thyroid hormone has to be administered every day, whereas ADHD medicines can be given only on days they are needed, like school days. Often, children do not take the ADHD medicines on weekends, holidays, summer vacation, etc. unless they need them for other symptoms associated with ADHD, such as reckless behaviors, oppositional behavior, defiance, or aggression, all of which can be symptoms of ADHD related impulse control issues.
In regard to your treatments that do not involve mediation trials, there are other programs that have been used with some success to “re-train” the ADHD brain. Two software products that come to mind are “Cog-med” and “Fast-Forward”. Suggested reading includes Doidge’s book called “The Brain that Changes Itself”.
All in all, the most effective, efficient, and reliable treatment for ADHD to date, in my opinion, remains Ritalin, Adderall, and their time released forms which offer up to about 10 hours rather than 3-4 hours of benefit per dose. That is not to say that medication and non-medication treatments are mutually exclusive. I see many patients who employ a number of modalities simultaneously, depending on the nature of the condition, age, and other factors. The school your son attends should also be involved in offering whatever academic modifications may be most helpful.
What is a “medication cocktail”?
Posted by admin in Depression, Medication, Treatment on May 21st, 2009
Question: I have been on the same four medications for years. I am happy to say that I have been doing well and am back to work. I hardly even think about my symptoms unless it’s time to see my psychiatrist once every 6 months, or go and get a refill.
My girlfriend and I are getting pretty serious. I felt I had to tell her about my meds and why I take them. I am on two antidepressants and two medicines for anxiety. She was OK with it. She called it a “medication cocktail.” I’ve heard that before, and I figured it just means a combination of medicines that works well together. But then I started wondering why I have two of the same kind of medicine? Wouldn’t one of each be enough?
Anne Fenton, MD: My patients often ask me this question, and it is an excellent one. There are several reasons that people are given more than one medication for the same condition.
Sometimes, people respond only partially to one medication and need to enhance it with another of the same kind. Sometimes, they might have a partial response to a certain medication at a certain dose but can’t tolerate the side effects of a higher dose. Adding a different medicine helps achieve a better response without added side effects.
We often try after a while to streamline the “cocktail” by eliminating apparent duplications. However, this is easier said than done. One reason is that, even though more than one medication, (like your antidepressants), treat the same condition, it does not mean that they treat it in exactly the same way. And even medications which are in the same “family” have differences in chemical structure which offer different benefits.
We tend to “lump together” a variety of symptoms into one word that describes the overall condition, like “depression”. We forget that behind the general condition may be several different mechanisms that are going on in the brain. You can see how one medication alone may not always provide the best treatment for a condition that represents more than one symptom, or is caused by more than one change in the brain’s chemistry.
In many cases, the balance created by a combination of medications in the system seems to provide a benefit beyond that of any individual medication. This may be akin to the adage that “the sum is greater than its parts”. If we tamper with that balance, we often find that symptoms recur. It appears that the balance itself is an important factor not only for achieving, but also maintaining emotional stability.
When should I stop taking my medication…
Posted by admin in Depression, Medication, Treatment on May 21st, 2009
Question: I have been seeing a psychopharmacologist. He prescribed some medicine for me a few months ago. It helped a lot, and now I feel fine. I would like to stop taking my medication. I think I’m ready. But whenever I bring it up with him, he talks me out of it, or changes the subject. I’d like to do it the right way. Can you help?
Anne Fenton, MD: People often ask why they should be on a medication once they are feeling better.
You are right to bring this up with your prescriber. Part of his job is to explain how, when,and whether you should go off your medication. Part of your job is to communicate your thoughts about it, as well as your interest in his guiding you safely through the process.
Generally speaking, the protocol for discontinuing medication varies with the particular type of medication, the response of the individual, the onset and duration of the original symptoms, the persistence or recurrence of symptoms over the period of treatment, and many other factors.
There are also standard treatment guidelines for suggested length of treatment based on research studies. Researchers study the treatment outcomes of thousands of patients who have been on a particular medication. They continue to monitor these patients for symptom recurrence after they have discontinued their medicine. Researchers may review the results for groups of patients who were treated, say, for 6 months, a year, a year and a half, and two years. Then the patients are monitored after discontinuing their medications for 6 months, a year, a year and a half, and two. The recommended optimal length of treatment is based on which group had the lowest rate of recurrence over the longest period of time after discontinuing treatment.
Not everyone is able to discontinue medications indefinitely without recurrent symptoms. There are many people whose symptoms simply require continued, lifelong treatment. This is similar to any chronic medical condition.
Sometimes, people go off their medications and feel fine for a little while, but start to experience symptoms after a few months. It can often take that long before the effect of the medicine wears off, even though it is out of the system within a few days after discontinuing.
It is thought that the initial and rapid positive response a person may experience within the first few weeks of treatment represents positive changes in brain chemistry mediated by the medication. The longer, more stable positive changes result from physiological and anatomical changes in the brain that occur later as the brain recovers and returns to normal.
As you can see, your question does not have a simple answer.
When you and your prescriber feel the time is right to discontinue medication, it should be done carefully. You and your prescriber should work together closely to observe for any symptoms of withdrawal from the medication, or any recurrence of your original condition. The best and safest way to ensure your successful “medicine taper” is to do it slowly and carefully. Regular follow up even after discontinuation is recommended to monitor the possibility of recurrence and resume treatment if indicated.
It is also important to follow up with your prescriber at specified intervals over the two years following discontinuation. If you do have recurrent symptoms, you will be in a good position to get help before your symptoms take hold.
When do you tell your “significant other” that you see a therapist or take medication?
Question: When do you tell someone you are getting close to that you see a therapist and take medication?
Anne Fenton, MD: The simple answer is: when you are confident about yourself and your treatment. Consider a person who has a family, a social life, and a job teaching in a university. He also happens to have asthma. Obviously, he is much more than simply an “asthmatic”. He has to treat his symptoms so that they won’t interfere in his daily life, but nothing more than that.
Similarly, even though psychiatric symptoms affect emotions and behavior rather than physical areas of the body, they are no more than symptoms of a condition that can be treated in order to carry on with normal life. A person who has bouts of depression is not “a depressant” nor is a person with panic attacks “an anxiety disorder”.
Clearly there are complexities to relationships and personalities. A lot depends on trust, history, and approach.
Your question also touches on a larger issue: when, how, and whether to tell schools, employers, peers, managers, etc. There are many variations on this theme that space does not permit a more complete and inclusive answer. However, I will be happy to respond to questions on specific situations as they come in.
Without a doubt, stigma continues to play a role in such situations.
All things considered, it would be useful to talk it over with your therapist, or anyone who knows you well and/or has been in a similar situation.
Hopefully one day we will progress to such a point that stigma is no longer an issue.
Daughter with Depression
Posted by admin in Depression on May 14th, 2009
Question: I have a daughter who has a diagnosis of depression. She was in bed practically the whole summer. Once she started treatment, around the middle of July, she started getting better. But she is still having a hard time concentrating. A friend of mine is a child advocate, and told me I should get the school involved, and put her on an ed plan. But I’m not sure I even want the school to know. And even if her guidance office knows, I’d rather the teachers not know. I don’t want her to be pigion-holed in any way..
Name Brand vs. Generic
Posted by admin in Medication on May 14th, 2009
Question: Do you think there is a difference between generic and brand name medications? I’ve been on the same medication for a long time. All of a sudden, my doctor prescribed a generic version. It did not work, and I started getting very depressed and anxious, and I had my first panic attack in years. What do you think? My pharmacist says the generic is exactly the same as the brand name. My primary care said it’s all in my head.
Anne Fenton, MD: First, it is important to realize that your doctor did not prescribe the generic version of your medication. Your doctor filled out the same prescription as you have always had. However, as soon as the patent on a brand name medication expires, a generic version is produced, and pharmacies are automatically mandated by insurance companies to dispense only the generic unless the doctor specifies “dispense brand name only” This is because the generic is less expensive for the insurance company to pay for than the brand name drug.
Often, we prescribers do not even know that a generic has been released to the market until patients come in telling us of experiences like yours. We are not informed by either the product manufacturer or the insurance companies of these developments.
There can in fact be significant variability between the generic and brand name for many medications. I have been told that the FDA allows for up to a 20% variability in active ingredient, which may explain why equivalent doses of the generic medication are not as effective as the brand name dose. In addition, fillers and additives can vary among generics and brand names and may account for allergic reactions to some generics but not to others nor to the brand name medication.
I am aware that a great deal of marketing effort and dollars go into letters sent by insurance companies to patients advising them to ask their doctor about the generic, or about prescribing an alternative medication used for the same diagnosis. When doctors do request that the brand name medication be dispensed, we receive countless letters and faxes from insurance companies requesting us change the prescriptions to generic. Regardless of how we respond, or how we explain that the patient requires brand name, we are still bombarded with these letters and faxes. Letters like these are very misleading, since not all antidepressants are alike, and not all patients with depression or other “like” diagnoses respond the same way to the same medications. In fact, even antidepressants or anti anxiety agents in the same family (SSRI’s, or benzodiazapenes,) for example, have significantly dissimilar chemical compositions to justify customizing treatment.
So it is simply not true that all generic medications are exactly the same as the brand name medications. To be fair, they are generally similar enough that most people do not have a problem switching. Nevertheless, a significant percentage of people do notice a difference in benefit or side effects, and this difference should be taken seriously. A case in point is that of a young adult who is mentally retarded and emotionally unstable. His symptoms include self mutilating behavior. For years, these symptoms were well controlled with a certain medication. According to U.S. patent law, pharmaceutical companies are allowed to produce generic versions of brand name medications after a specified number of years after the brand name medication has been patented. When the generic version becomes available, the patient generally receives the generic version from the pharmacy instead of the brand name version. In this case, his mother was initially happy, since she is not a rich woman and was grateful for the decreased cost of her co-pay. However, after years of stability, the young man began to have severe rage attacks, and was mutilating himself to the point of bleeding, all because of the decreased efficacy of the generic. After battling the insurance company by having to send numerous and repeated requests to authorize payment for the brand name, the company finally consented authorized the pharmacy to dispense the brand name medication. Within two weeks, the patient was stabilized, with no further incidents of violent or self mutilating behavior. Clearly, this mentally retarded patient’s dramatically different responses to generic vs. brand name medication were not attributable to being “all in his head,” since he is cognitively incapable of understanding, knowing, or expecting that there was any change in the medication prescribed.
This is not to suggest that patients should in all cases request only brand name medications. For economic reasons, the generic may be worth a try. If you do notice a difference, though, talk to your prescriber about requesting an override from your insurance company to pay for the brand name. This process, though not trivial, is worth the effort to provide better treatment or fewer side effects when indicated.
Primary care or Psychiatrist? Who should treat?
Posted by AnneFentonMD in Treatment on March 31st, 2009
Question: I have a male primary care who is treating my depression. My husband, who sees a psychiatrist, thinks I should see one, too, since they know more about all the conditions and medications and all that. Is he right, or am I ok to keep seeing my primary care? I think I’m doing fine, but I guess my husband thinks I could do better.
Anne Fenton, MD: My guess is that you wonder if your husband may be right. If that is the case, there is no harm in consulting a mental health professional. I am sure your primary care would have no problem referring you to someone for a second opinion. Our job in the medical profession is to help people in the best way possible. We know this often includes referring our patients to people whose opinion and expertise may prove to be more helpful to our patients.
Anxious son…
Posted by AnneFentonMD in Anxiety on March 27th, 2009
Question: I wanted to take my son to be evaluated. I think he has some serious anxiety. My husband has a thing about seeing a psychiatrist. Maybe that is because his whole family is nuts. He won’t let me take my son, and even if I go behind his back, no one will see me without my husband agreeing.
Anne Fenton, MD: Unfortunately, your husband is not alone in his desire to avoid the stigma of mental health issues and seeking treatment. I have seen problems go on untreated for years before people are finally compelled to seek help. Of course by then, the consequences of long term symptoms are far more serious than real or imagined consequences of the stigma. Before you and your husband fall into this sort of paralysis, while your son continues to suffer anxiety and its side effects, you may consider starting with a “neutral” sounding consultation with a pediatric neurologist or developmental specialist. Talk to your pediatrician. He or she can refer you to a specialist whose title may be less subject to stigma. If at some point your child is referred to a mental health professional, you and your husband will have heard the recommendation from more than one specialist and the language will be more familiar.
Smart kid…but an underachiever
Posted by AnneFentonMD in Uncategorized on March 5th, 2009
Question: My son is a smart kid. His teacher got me really mad, though, when she said he is an underachiever. She says he spaces out in the classroom. He would get much better grades, but he doesn’t do his homework and he won’t study. Every year, his report card has comments about how his “organizational skills” need improving. I don’t know what to tell him because I was the same way. But I’d like him to do better. I think it is because he is bored in school. The teacher isn’t giving him interesting or hard enough work. When he is really interested in something, or likes the teacher, he does fine.
Anne Fenton, MD: Many children with good intelligence have the kinds of difficulty in school that you describe. They are smart, but have trouble focusing or concentrating. They often have trouble organizing their materials as well as their thoughts, especially when it comes to writing assignments. They need to be reminded over and over to do chores or tasks, they can be forgetful, and inconsistent in their academic performance. These problems become more obvious every year, peaking in middle school and high school, when academic requirements are more complex. These features are consistent with what is called attention deficit disorder. Many parents don’t think of this diagnosis, because their children, like your son, seem to be able to focus for hours on subjects or projects of interest. Parents figure that if the children can do that in one area, they should be able to do it in every area. However, like all of us, children with ADD can accomplish more and focus better on subjects they like. The contrast between “hyperfocus” and distractability on other topics is simply exaggerated. I would suggest you have your child evaluated for ADD. If that is his problem, it is a condition which is very treatable and widely treated.
high maintainence child
Posted by AnneFentonMD in Uncategorized on March 5th, 2009
Question: My child is really “high maintenance”. He has horrible tantrums and can be very aggressive. He is very intelligent, and does well in school, but at home he is a monster. Everyone tells us that it is our fault. They think we should discipline him better, but when we try to, he doesn’t respond. He doesn’t care if we punish him or take things away. And he lets us know.
We are at our wits’ end. It is especially hard because no one believes there is something wrong with him. They just think there is something wrong with us. His classroom teachers, our relatives, even his pediatrician look at us like we are the problem. We are afraid to take him to see someone who will tell us the same thing.
Anne Fenton, MD: There are children with significant symptoms which only show up at home, but not outside of the home, until much later on. We think that the structure of the school day or the public eye offers some buffer to help the child control the behaviors outside of the home, only to have a meltdown at home. It is parents of such children who have the hardest time getting help, just as you describe. Unfortunately, by the time others see the symptoms, it is too late for the early intervention so important for the child’s normal development.
Child psychiatrists are familiar with stories like yours. We understand that you know your child, and that you have already tried all the standard parenting approaches, read the self help books, and looked for answers wherever you could. A child psychiatrist will take your concerns seriously, and offer the help your child needs.