ADHD: The Science of Mind Evolves
Good Morning! – to a new ADHD world with more treatment options coming this fall. I just replied to a previous comment regarding the use of Tenex, guanfacine, [previously identified as helpful for tic disorder], and will send out this brief note with an interesting reference worth reading.
Short note, new vocabulary, take a moment sometime this week to chase down these links – they will likely soon become part of your everyday thinking in ADHD treatment.
Let’s make this simple, – er, let’s try to make the basic pharmacology a bit more understandable. Best to start with the basics, and this article in Science Daily breaks down an interview with a neurophysiologist at Yale, Amy Arnsten PhD, who has been looking at alpha 2 adrenoreceptors for several years now.
I’ve heard Amy present this interesting material, and know it needs translation, so I will simplify this brief note for you -
The real value to this new formulation:
- New brain information takes us beyond simply thinking about the synapse – into brain networks, systems and our new friend: ion channels
- This medication is not a stimulant
- More interesting information about brain function arises from evidence – and appears to offer significant possibilities for ADHD treatment.
New Post
Heads up readers: Posted an even more precise post on Intuniv for ADHD: Dosing Details – Do pop over there if you find this topic of interest.
cp
Related articles by Zemanta
- Pump Your Brain–And Other Stories from MIND (scientificamerican.com)
- ADHD Medications: Neurotransmitters to the Rescue (corepsychblog.com)
- A non-controlled substance drug for ADHD: Intuniv (guanfacine) ER (medicineandtechnology.com)
- INTUNIV demonstrated symptom reduction on oppositional subscale Conners’ ADHD rating scale (scienceblog.com)
Make sure you take a look at these pages!
ADHD Medication Rules Purchase
“Rules” Affiliate Link
Neuroscience Details
Link to this page
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Hi Dr. Parker. My son who is 5 yrs old, was recently diagnosed with ADHD. His dr started him on Clonidine 1/4 mg once at night, then moved to once in the am, and once before bed, and then finally once in the am, once in the middle of the day, and once at bedtime. He was doing somewhat better on the Clonidine, however, was overly droswy, and his anxiety was still very present. His dr switched him to Intuniv, 1 mg in the am, and 1/4 Clonidine at bedtime, approx 2 wks ago. We have definitely noticed a difference in him, without the excessive sleepiness. His anxiety has improved some, and his ability to actually sit and play with one set of toys, or hold interest in one activity for more than a few mins is great. However, he absolutely will not swallow the med. I basically have to hold him down and get it down his throat. It takes us sometimes as much as an hr in the am to get him to take the med. He is also showing some signs of increased impulsivity within the last few days, likely his dose needs to be increased. We returned to his dr today and I explained the problem with the med. His dr wrote rx for reg Tenex, 1 mg, to start out with am use only and then move up to another 1 mg in the afternoon. He remains on the 1/4 Clonidine at bedtime. My question is, will he have such good results with the reg Tenex that he was having on the Intuniv? If the Tenex does not work like we hope, will my son be able to return to the same results from the Intuniv as he is now, if we decide to try to give that again?
Thank you,
Kristin
Kristin,
If he could take tenex, is he breaking it up or crushing it? Know that you can break Intuniv x1 = 1/2 and still have pretty good delivery if the tab size is an issue. If he has to have it crushed, then you really don’t have a choice. Tenex is helpful but doesn’t last like Intuniv and requires more frequent dosing.
Some parents have had good success with practicing with small tasty items before going to the meds. And, yes, an hour is too much from a psych point of view… not worth the trauma on everyone.
cp
Hi Dr. Parker, thank you for getting back with me. We began giving the guanfacine on Friday, and as I had feared, he is not having the same results as he was having on the Intuniv. He is chewing the guanfacine in the am when we give it to him. He is having quite a few near meltdowns during the day, and has been taking at least a 2 hr nap, if not longer, and that is not typical of him. I am contemplating giving him the Intuniv tomorrow in the am, but wanted to know from you if you thought maybe these are side effects that may improve, or if this is not a typical reaction? I personally think he needs to try a low dose of Adderall, but he does have a lot of anxiety, especially in social situations, so we have been reluctant to do this. Is there any other medication that comes to mind with you that may be worth trying for my son?
Thank you,
Kristin
Kristin,
Adderall or Vyvanse might be very helpful for anxiety, – more often than not it helps. But if the guy is having problems with meds in general, none of these might prove right. Only time will tell and some care. As I have regularly posted: the best solution to the conundrum of not-working-meds is a better appreciation of the neurotransmitters and the metabolic background noise in the first place.
cp
Hi Dr. Parker. What are your thoughts on Wellbutrin for ADHD treatment in children (5 yrs old to be specific)? Child does exhibit some anxiety and nervousness as well. Guanfacine did not work so well, my son exhibited increased studdering, social withdrawal, lack of motivation and extreme sedation while on this. Any thoughts are appreciated. Our dr has recently put him on Celex to address the anxiety and nervousness. Since he’s been off the guanfacine, he’s extremely happy again which is great, but his hyperactivity, impulsivity, not listening, not following directions, etc. are thru the roof. This is everywhere, home, school, etc. I know the Celex will take some time to work but he needs an ADHD med. Just looking for the best route. I’m pretty sure he needs a stimulant, but he did try a few days of Ritalin approx 8 mths ago and it did produce some tics with his hands, pulling at his ear, etc. They did seem to get better each day, however, his anxiety was so extreme that I could not continue the Ritalin. It could have just been to high of a dosage, or just not the right med, not really sure. He was not seeing a psych dr yet at this point so I did not cont until we were actually seen appropriately. I myself take Adderall for adult ADHD. This works fairly well for me. I think my son may benefit from a low dose of Adderall XR (I need to be able to break this up as he will not swallow a pill). But, I have read some positive findings with Wellbutrin for tx of ADHD and wanted to get your opinion on it?
Thank you in advance!!
Kristin
Kristin,
Wellbutrin is not on the top of my list, in fact It is quite low, even tho some reports have suggested it might be helpful. I quite agree with you on the AMP side of things, and yes, Adderall could be helpful, but so could a very low dose of Vyvanse.
My best advice on these young folks: look at immune system dysfunction every time. Stomach and bowel, then skin and respiratory – IgE testing done by most allergists doesn’t cut the mustard. I’ll be writing a post soon on the immunity details.
cp
Just piping in to say LISTEN TO DR. PARKER!
“Meds roulette” is sometimes part of the necessary challenge in treating complex cases of ADHD, but without a methodology and without identifying any underlying issues GI-immune conditions, as Dr. Parker points out, kids and adults with ADHD can feel more like a “pin the tail on the donkey” than a patient who is receiving care driven by careful protocols.
Also, lest we forget, the wrong medication can create side effects that linger even after that medication is stopped. Then that side effect is treated as a symptom, treated with another med, and on and on the mystery continues.
Please read Dr. Parker’s book, consider the NeuroScience Inc testing through Dr. Parker, and establish a strong basis of data from which to decide upon treatment strategies. It’s so very important!!
Tiffany-
Talk to your doc, but two issues might be at play:
1. Give it in the AM
2. Keep the dose down until she is more adjusted to the med in the first place.
cp
Dr. Parker,
I have an 8 year old son with a 22q13.3 deletion(Phalen/McDermid Syndrome) and arachnoid cyst in the left temporal lobe. His Nuero has him on lamicatal 125mg twice a day and behavior doc on Intuniv-2mg a day. There has been good results for his behavior but still not interest in school work. Should other testing be done or need more time on meds? He has been on for a few months for lamictal and 6 weeks for Intuniv.
I welcome any advice you have.
Thank You,
Caren Ferrari
Caren
See if your doc will approve a very small dose of Vyvanse with the Intuniv [1/2-1/4 of a 20 mg to start].
cp
Dr. Parker, Our son has been on Vyvanse and supplements for months now. He just told us he feels that he has become angry , non trusting of people and we have seen some tics . Could this be related to the medication ?
Kimberly,
Tics can occur downstream of any stimulants, and have seen them occasionally downstream from Intuniv, although the guanfacine molecule has been indicated to treat tic disorder for years.
cp
Dr. Parker,
My 11 year old son takes Focalin and Intuniv for ADHD and Aspergers and it works incredibly well for him. But I am getting mixed messages on whether we can split the Intuniv in half or if that will mess up the extended release. The reason I ask is we are going up in dose and we have a bunch of old ones I’d rather split and combine, and save the money before we fill the new prescription. What do you think? And I love your blog, BTW, thank you!
Audrey,
Off label: but at a recent national conference one of the primary researchers slipped and said that he broke Intuniv in 1/2 whilst titrating upward.
My office experience: 1/2 is no problem with the delivery of effective doses, crushing it up is absolutely not recommended.
cp
Thank you for your input. He metabolizes the stuff so fast, we’ve changed dose three times in seven months! I don’t know how long we can keep this up, but for now, Intuniv (and Tenex when we were using it) is a wonderful addition for him.
Audrey,
He should find a plateau, if not you are missing something and treating only the symptoms will be insufficient to correct the underlying biological challenge. Tachyphylaxis with these meds almost always means metabolic disarray.
cp
Me again here. We are now up to 6 mg Intuniv (too much according to the manufacturer) and its obvious to me that his metabolism is messed up if he keeps going up as quickly as he has. What can we do about this? The Intuniv has made him so much happier and more social, not to mention a much better sleeper…. and we don’t want to give it up (he’s ADHD and probably a bit Aspergers).
FYI on the sleep thing, we use Melatonin when needed, but he works up a tolerance to that too (more slowly) so we don’t like to use it too often. The Intuniv has been a God-send for his sleep….
Audrey
Audrey,
As you have recognized, metabolic issues prevail and absolutely need further evaluation and attention. See this neuroscience page for multiple recommendations for further inquiry. We provide consults and lab evaluations long distance, but if you are anywhere within travel distance to our Va Beach office I could be more specific with an interview and with med follow up.
cp
My son is 16 and has been on about 10 different medications for ADHD over the years. They work for a while than nothing. He was on 70mg of Adderal xr which was working well and our Dr put him on Intuniv because he thought it would give even better results. We started at 1mg and worked our way up to 4 mg over a month. I have to say he is sleeping at night (which he hasn’t done EVER and when I say EVER I mean that) since birth he has had insomnia. However through the day he is so hyper that its hard to deal with. And on top of that he has gained 50lbs since Nov 2009 and since its May 2010 thats crazy. He is about 5 11 and 190 lbs. He has always been thin so it was nice to see him gain a little but this is nuts. And with all that like I said he is HYPER all day. I have been looking into him taking GABA 750mg and Omega 3 daily and we are hoping for success.
Melissa,
Your guy is more complicated than a simple note on a blog. Sounds like he may have some metabolic challenges? Did you stop the Adderall? Have you tried Vyvanse? The combinations work and no drug interactions occur with other stimulants based on metabolic pathways.
More info is needed there – a more careful review. And you can get very specific answers on the GABA question by looking at the Neuroscience page here.
cp
my son Elijah is 5yrs and started guanfacine 1mg b.i.d he seemed fine at first but now hes always crying and pale. Is this a normal side affect? Should I keep him on this medication or switch or just stop altogether? He was so hyper before and his doc said he was adhd, but now its like he isn’t the same kid. I need an opinion. Thanks
Sarah,
Do get him back to your doc and look at trying a different med, perhaps a stimulant, and no – that is not a typical reaction.
cp
Dear Dr. Parker,
How would I go about getting the NT testing done? The doctor we use doesn’t believe in the value of this testing and doesn’t know much about it. How can the tests be ordered? I gave my son the Zoloft at bedtime last night before reading your response and he seemed to sleep fine, but woke up a bit earlier than usual for him. At least there were no headaches or other complaints…he seems fine this morning. I’m hoping that the combination of Zoloft and Intuniv will tackle the anger and frustration issue, but I would be curious at the findings of the NT testing.
Thanks again,
Gail K.
Gail,
The NT testing is easy to do, only a urine on a Sat AM, after the first one is flushed, and nothing by mouth – details in the kit. We can do this testing long distance, details coming offline.
cp
Hi Dr. Parker can you send me the same details about my son getting NT testing done ? Thanks, Ricky.
Ricky,
Just call Sarah over on Services on the nav bar of CorePsych Blog. Look forward to chatting.
cp
When my son was 2 he was diagnosed with as hypersensitive. He would not touch grass, sand, playdough, rubber, etc. At age 4 1/2 he was diagnosed with ADHD and some tics. With stimulants came verbal tics (humming & throat clearing) and physical tics (straightens his eyelashes ((not pulls)), picking at bellybutton and lip, facial stretching, head roll, eyesquinting) and some OCD. I noticed anxiety before and after the stimulants. We have tried vyvanse, short & LA ritalin, focalin, & concerta. He could not do the Daytrana as he had a reaction to the adhesive and he was always picking at it until he pulled it off.
The hypersensitivity & OCD seemed to go away as the ADHD & anxiety worsened.
We just started Intuniv about 2 months ago. The tics are gone! My son is 8 years old. He is extremely smart (A+ student due to his OCD). He is starting to make real friendships on this new med. He has no weight issues (60% on the weight chart and 100? on height) as before Intuniv we typically used a dose of short acting ritalin in AM and another after lunch. He is a healthy eater, but did have mysterious diarrehea for most ages 1 through 3 for which we put him on soy at that time.
We also started him on probiotics about 4 wks ago. He has been taking fish oil and flax seed pills at the same time as the Intuniv (IS THAT OK?)
Our issue: my son is complaining that everything hurts him. Literally a feather fell on his head and he said “ouch.” Any bump is major to him. He spits out some food because he said it has hard parts in it. Warm liquids hurt his throat. He says the sun on a 70 deg days too hot. You get the idea. My husband thinks he may be looking for attention since the Intuniv has been so wonderful that he does not get the CONSTANT negative attention he used to get. I think that he anxiety has been controlled through Intuniv and now the sensitivity that he showed around ages 2-3 is back. My theory is that it was always there but was masked by the ADHD. I am concerned that he says his chest hurts, but it is typically after eating acidic foods. He is having minor headaches (lasting a few minutes a few times a week). He has told me a few times in the last 4 weeks that he was light headed when standing. He is also complaining of a minor stomach ache at times. I don’t want to minimize this issues as I know they could be very important after reviewing possible side effects, but he complains at the slightest touch and does not say that the chest/stomach/dizziness pain is bad at all. He says “my stomach hurts.” I ask how bad and he says not bad at all and then he walks off and does not complain about it again. It is also before he needs to poop. I am planning on calling his Dr. in the morning to get her input. I figure she will check his blood pressure. I am thinking about reducing the dosage to 2 mg but we went up to 3 mg in the first place because 2 mg only worked about 5 days and then did not help. He is his sweet self on 3 mg.
Is sensitivity to touch a side effect of Intuniv? I have search the 2 yr studies and saw nothing about it. Is 3 mg too much? He is sleepy but not too bad (mainly at 7pm his is ready for bed if he had sports that night.)
Sorry for the rambling, but as a parent who is also ADHD, when will Intuniv be available for adults?
Kerri,
Intuniv does not cause sensitivity you describe – unless it for some reason has to do with already high glutamate levels. Intuniv does increase glutamate, if you read the literature closely, and those with already high glutamate, such as is often seen on Neurotransmitter Testing of those with pre-existing immune dysregulation and metabolic issues. Said more succinctly: Intuniv could possibly show some aggravation of pre-existing sensitivity downstream from the immune dysfunction – I haven’t seen it, nor have I heard about it in numerous conversations with the research folks who did the original investigations.
I will leave the dosage specifics to you and your doc, but, as mentioned, don’t think the sensitivity issues are directly Intuniv. I am suggesting that the stomach pains are primary, not secondary, and significantly contributory to the challenges you describe… perhaps secondary to casein or gluten sensitivity. Testing for IgG would be in order just from what you have said here.
Intuniv can be used with adults, but the FDA has not yet approved an adult ADHD indication, so it would be off label. Tenex, the parent compound has been used with adults for many years for hypertension, and only recently received, after specific research demonstrated, an indication for ADHD in children and adolescents.
cp
I am a 44 yo woman with ADD. I also have long standing anxiety problems. I have managed my ADD symptoms fairly well with nutrition and excercise. I take Klonipine 1 mg at night. The thought of taking a stimulant for my ADD is scary given my history of anxiety attacks. Recently, my MD prescribed Intuniv. It seems the onset of perimenopause has worsened my ADD symptoms. Because of the expected fatigue, and the fact that I teach high school math, I will start this over Spring Break. I have had a recent heart work up and am in good shape. I do have low BP and once, after a marathon, I fainted from dehydration and was told by the EMT I had first degree heart block. No evidence of this has ever been noted on subsequent EKG’s, so I assume it was temporary. My questions are: Is there any anctedotal evidence that this drug works for adult ADD?Should I worry about very low BP? Will I become so fatigued and stoic that I come off as a complete dullard to my students? And finally, could this drug cause the AV block to reappear? Thank you.
Susan,
1. No problems with concerns about AV block in the context of your presentation, – just work with your doc on these details and be watchful, – it is medicine, and everyone is different so no absolutes. A problem is highly unlikely. Sounds like fluids were the culprit there.
2. No studies in on use with adults, but in my office we have had some good results used alone for those wishing to not use stimulants.
3. Don’t worry about stimulants if it doesn’t work, only go low and slower than usual. Most of the time Vyvanse will knock out the cognitive anxiety without adding to it. if you do have anxiety increased with Vyvanse you have a neurotransmitter imbalance that would very likely be correctable with targeted amino acid interventions following specific testing. In fact you may wish to start there with your other concerns.
cp
Hello Dr. Parker,
In reading Denise’s questions about the frustration level on Intuniv, I have the same concern. My son is now on 3mg of Intuniv for the past 2 1/2 weeks, and his frustration and explosive behavior is quite frequent. He is still very tired on the medicine, especially from after-school hours through bedtime, yet sometimes wakes up a few times at night. He’s pale and seems to have his eyelids half-shut at times. The good part is that his teacher says she sees marked improvement on his fidgeting in class and focusing on the work. She says he’s happy all day at school, but I get a different child when I get him home. He is resistant to doing his homework and complains in a nasty way through the whole thing, making it very trying every afternoon. Could this nastiness and explosiveness be related to fighting the tired feelings throughout the day? HIs doctor feels he needs to stay at 3mg given at the same time each day for the next three weeks to see the results. I’m trying to stay with it, but I’m getting tired of the anger and nasty behavior. It rules the house each afternoon and effects us all.
Thank you for any advice you have to offer,
Gail K.
Gail K,
As you can see, something is not right. And your doc has a point, – it can improve over time. My own approach in a situation like this is to do something to answer the mother’s concern and the child’s frustration. But what-to-do is again too complex with just this brief note on Intuniv alone. Several thoughts come to mind for review with your doc:
1. Does he have a comorbid depression that hasn’t been addressed?
2. Does he have a comorbid metabolic problem – breakfast, #2, picky eater, little protein, too many sweets, etc.
3. If the Intuniv proves inadequate for PM concentration there is the old standby: Vyvanse… has he been tired on that? It does work with Intuniv.
4. Is he getting enough exercise?
- Might be some answers in one of these inquiries,
cp
Dear Dr. Parker,
I am going to look into the possibility of depression since my daughter, 13, has also been diagnosed with ADHD and seems to be responding well to Zoloft alone. As for the metabolic issue, yes, he is a picky eater and I try to push the protein. He does eat breakfast but not always what I would like him to have. I have tried to make my own pancakes with cottage cheese and eggs and more protein than carbs to make it interesting for him. He refuses vegetables, except for carrots, so I encourage eating apples and strawberries, which he loves. However, he probably does not get enough of the fruits and vegetables no matter what. I try to bake the sweets he has so I can monitor the sugar and use whole wheat flour and sneak in protein wherever possible. How can you make a young child eat what he needs to eat? Sigh! As for Vyvanse, I am wary of stimulants because Tourette’s Syndrome runs in my family (his uncle has it and it has been very severe and life-changing). My son had a few ticks last summer and I’m concerned for starting those up again and possibly leading to Tourette’s. What are your thoughts on this? I will consult my doctor on the rest of these questions as well. So far, she has agreed that we should stay away from stimulants.
Thanks again for your response,
Gail K.
Gail,
If Tourette’s becomes a problem we always look at the NT values, as exceedingly high excitatory NTs downstream from immune dysfunction – most especially milk – can all be measured and often significantly corrected with neurotransmitter precursors. Myself, I wouldn’t stay away from stimulant simply because of family hx of Tourette’s, as I believe I have other intervention options if we do discover that difficulty. As always my policy: slow and low.
cp
Dear Dr. Parker,
Thanks you for your continued insight into my son’s condition. After 5 1/2 weeks on 3mg of Intuniv, his tired side-effects diminished markedly, but his temper flareups were still there, especially after school and when he was told “no” for something. I asked the psychiatrist what she would suggest and she decided to try Zoloft along with the Intuniv since his teacher said he was doing better at concentrating at school on the Intuniv. We have now given him two doses of the Zoloft (25mg). The first day it was given to him at 6pm, and he seemed to sleep lightly all night, eyes opening at various times throughout, and finally rising for the day at a crazy 5AM. I gave him the second day of Zoloft along with his Intuniv at 5PM. His behavior was fine all day, not even seeming tired, until we went out for a late dinner. He then complained of a terrible headache, which he has never had before. I had to take him out of the restaurant and wait for the rest of the family in the car so he could have quiet in the car until I could get him home. I gave him some Tylenol and put him to bed. He seemed to sleep soundly all night, from about 10:30PM, but woke early at 7AM. So far, he seems fine today…
What do you think about combining Zoloft with the Intuniv? Do you think that the headaches will diminish over time? We have had such a good experience with my daughter improving significantly on Zoloft that I would like to hope that it will help Max’s mood issues as well. Finally, should I split up the two drugs and give one in the morning and one later in the day? If the Zoloft is contributing to his sleeping lighter when I give it to him at dinner-time, I don’t know if giving it right before bed would be better or in the morning would be better. Quite frankly, I feel this trial-and-error stuff with the meds to be maddening. I just want a happy, well-adjusted little boy.
Thank you once again for your input!
Gail K.
Gail,
After checking with your doc I suggest trying the Zoloft in the AM with the Intuniv – I personally give it at night only if the recipient has a problem with over sedation. The more complications you have, the more likely more specific testing is indicated from several points of view. More information needed to accurately suggest specific actions.
cp
Dear Dr. Parker,
My son has been taking 3mg of Intuniv and 25mg of Zoloft (started Zoloft 2 weeks ago). He has become happier in many ways, but is now hyper most of the time and is having trouble falling asleep and staying asleep. Any suggestions?
Thanks again for your help,
Gail K.
Dear Dr. Parker,
So Tristan is on day 6 of 2 mgs. of Intuniv. He is complaining more frequently of feeling “depressed.” His pediatric neurologist said that depression is not a side-effect of Intuniv, but I believe I have read otherwise. To make matters worse, his non-custodial father is brainwashing Tristan, grilling him, telling him the meds will turn him into a zombie (he does not know Tristan is being medicated, I went over his head in my desperate attempt to help our son be well). His father is depressed himself and will not admit medication may help him. It’s not right that a ten-year old has to be treated in this way; put in the position of lying to his father in order facilitate my atempt in pursing a medical answer to his problem. It’s breaking my heart and making Tristan feel worse. I have an appointment with a psyciatrist to discuss other options. If I decide to take him off Intuniv, even temporarily to try something else, how would this be done? Gradually? All at once? Please advise, and thank you for all your helpful advice.
Janis
Janis,
Problems like this one need intervention from a lawyer or a divorce mediator… With the conflicts between you and your ex regarding his meds he is obviously caught in the middle. My best recommendation is to find a mediator person, as most lawyers do what they can to keep the adversarial work going. With a good mediator you can discuss these issues, come up with a plan and sign off on it. Visitation itself may need renegotiation with your docs input.
In the meantime: Intuniv does not cause depression. Tristan may feel a bit sedated, – and for that one you do want to watch for the Top of the Window as described in this CorePsych Blog post on dosing. And, yes, he may be suffering with a comorbid depression with all of the pressures. The standard for Intuniv for discontinuation is gradual: slow, but only over a few days, and you can break it in 1/2 for that purpose.
And don’t forget, as mentioned elsewhere, there are many ADHD combos and other medical, neurotransmitter options. If Dad doesn’t want meds, consider neurotransmitter measurement and intervention with only amino acid precursors = supplements.
cp
If I may pipe in here from a non-medical angle….
I’ve heard many stories like this over the years of leading support groups for the partners of adults with ADHD — conflicts with co-parents, especially in shared-custody arrangements, over the very idea of ADHD, much less medical treatment for it.
I think I would feel “depressed,” too if I was a child given medication by one parent and told by the other than it’s bad. Especially, I hate to say it, by a parent who might say anything to win the child’s favor. (Keep in mind the genetic factor; if your child has ADHD, it might be that his father is not only “depressed” but he might have ADHD as well.)
Another possibility: When some people start medication for ADHD, their worldview changes, understandably. They slow down, start to notice more things (such as their feelings and the feelings of others). This can actually come as a shock to some. Imagine if you had poor eyesight and had navigated the world with it for a few years. Then someone gave you eyeglasses — it would take some getting used to this new world. And it might require some help.
Children need “psycho-education” when taking medication just as adults do. In other words, they need some help in understanding why they take the medication and how it helps them.
good luck,
Gina
Gina,
Thanks for your insightful and sensitive remarks.
Just to add one observed phenomenon frequently witnessed on the topic of ‘world view change’ – even with children. So often it appears that those suffering with ADHD, and living withing the envelope of shame associated with under performance and embarrassment, often have two distinct phases in their recovery once on meds and corrected.
1. The Maybe Stage: The first 3 mos of successful medical intervention they wait for the other shoe to fall, waiting to become a relative failure or problem again. Trust is gone and it takes significant time to rebuild in almost every interpersonal relationship. Self mastery builds bridges over the chasms of self esteem deterioration.
2. The Crystallization Stage: The next 3 mos, after seeing that they can remain in this new cognitive context without worrying about failure, they set out to change their lives, and often this happens with work and marriages. Said another way: I can be this other imaginative, follow through person, am actually more autonomous, and just don’t need that troubling cognitive dependence associated with seeking someone else’s prefrontal cortex for decision making. Bridges are built, now I’m going somewhere.
cp
Wonderful way to describe those phases, Dr. Parker.
I would add #3 for some people: Forgetting that the Medication Helped Me Get Here.
I always advise adults with ADHD to keep a journal — write down the challenges they’re experiencing in life and the things they’ve already tried. Then keep a log of rating scales, to show their gradual improvement over time.
The format and depth of detail can vary. What’s important is that they have a concrete reminder that medication (or physician-advised amino acids, anti-allergen diet, etc.) made a difference and to not discount its importance later. When they mistakenly assume it’s simply that new calendar that’s made all the difference.
Gina
Gina,
Love your #3, thanks! Have often thought of a video interview locked down at the first visit, for review later ‘as needed!’
cp
Wow…thank you for this. I will chew on this for awhile. It helps me to understand what my son is going through. My heart just goes out to him. What a thing to live with.
Dr. Parker,
My husband just watched all of your videos here on this site and he said he is so glad that he did. He now has a much better understanding of our child’s disorder and his words exactly were “Wow, what a passionate doctor, I wish we could take our son to him”!!!!
Thank you for your thoughts and advice!! Your site is part of my life now. Every time I get nervous about doing something for my son or even second guessing an issue regarding his ADHD I turn here. And let me say, it has really SAVED me
I wanted to update you and ask a few more questions. We have decided to stick with the Intuniv a little longer. We started the 2 mg dose this morning and are going to watch the side effects for a few more days (mainly the emotional roller coaster issue)!! If this doesn’t work out in the next week, we are switching to the Vyvanse and using your titration guide to start Blayne on a lowered dose. We have been given the 20 mg and told to break it into 10 mg, however, should I go another notch lower to 5 mg since he seems to have longer lasting and more persistent side effects (and tics possibly with a stim) or would that not give him enough DOE since he starts the day at 7 am, homework at 6 pm, and bedtime at 8 pm?? I know it is trial and error, and some patients are at a good DOE even with 5 mg but I just wanted to ask an opinion first. Hopefully we will see the 2 mg Intuniv make some more marked improvement!!! Guess it’s just one step at a time
Thanks in advance for your time, have a wonderful weekend!!!
~Robin
Robin,
Glad the info here is working for you and your family. I quite agree that your problem with Blayne is more than simple ADHD, as based upon the metabolic challenges. I agree with the suggestion of working with your doc there to go even more low and slow than expected based upon that history – and a 5mg start with Vyvanse could be tried with or without Intuniv. A clean trial with only one drug would give you a clearer picture, but again, don’t be disappointed if Vyvanse doesn’t work… I do strongly believe he has more fundamental issues that must be corrected first.
“Trial and error” become more “Trial and adjustment of dosage.”
This Neuroscience webinar on the subject is a bit deep, but might help explain just how the targeted amino acid precursors work to stabilize neurotransmitter challenges. Suspect an immune dysregulation, as I indicated before. If you do want to set up a telephone consult, do call our Patient Care person here.
cp
Hello again Dr. Parker! I wanted to update you on a few changes since we spoke last and see what your thoughts are…….We went back to 1mg of Intuniv after 6 days on 2mg. The 1st day Blayne was really sleepy, the 2nd not emotional at all and just very blah, the 3rd and 4th way “over” emotional and anything would set him off and he would cry his eyes out!! After almost a month on Intuniv is seems we are now regressing. I see old behaviors rearing their ugly heads, and the teacher is seeing that hyperactivity is still a problem at times. We went back for a check up on the meds, and he suggested we either start the 2mg again and give it a few days to see if the “emotions” are still up and down, and if they are back down to 1mg for a few days – and then try to move on to Vyvanse using the 20mg but splitting it to 10 mg to start with.
At this point I’m really not sure what road to take
I’m wondering on one hand…..have we really given the Intuniv enough time? And on the other hand……..is this medication just not “right” for my child?
In the mean time we are waiting for our NT Testing kit. Should I stick with the Intuniv until after we finalize that or just call it a loss and move on to the Vyvanse. If I do and the tics rear their ugly heads then I’m going to have to back off that med too
We have also scheduled an appt to have a pediatric neurologist possibly take over our case since the tics may be a long term problem to deal with when medicating our son.
Any advice would be greatly appreciated…..we are just scared and lost at this point in the game
~Robin
Robin,
As you know it would not be appropriate without actually seeing your guy to tell you specifically what to do…not good medicine. Short and sweet, I do quite agree with your doc and am very pleased to hear your doc is suggesting the micro titration strategy on the Vyvanse as outlined more in this Vyvnase Water Titration Post at CorePsych Blog. On a reassuring note: one simply can’t predict exactly what will happen at this pont, and no harm will be done trying this suggested intervention.
Further, the NT testing will be helpful, with more specific info on the excitatory increases so often seen on NT with tic disorders. I think I did mention this before elsewhere: tic disorder for me at this point almost requires NT testing to see the actual NT landscape, rather than simply chasing down symptoms with med changes. Comprehensive strategies arise from more comprehensive evidence.
On the ped neurologist: I am always for second opinions with any of my valued medical colleagues. If another doc has an improved answer, all to the good – no matter who is seeing your son. If you were in my office, I would encourage that follow through, but not from a point of worry, but from a pont of confidence that more information most often provides better results.
cp
Hi Dr. Parker,
I’ve been checking in from time to time on this thread with our Intuniv progress. Thought I would again. We have been on 4 mg now for about 3 weeks. This is the only dosage that we have seen any change. His school work is night and day. The ability to focus on it and especially complete writing assignmnets is AMAZING! Also very nice and neat cursive.I have homeschooled him for the last 2 years, he is in 5th grade. Our goal was to bring him home and get him to where he can be mainstreamed again. I have just recently enrolled him in 2 outside classes, kind of a test to see if he would function in a classroom setting. The teacher’s feedback was that he was one of the best behaved kids in class…yeah for him! It’s only the first week, maybe a honeymoon period, we’ll see. The area where he still struggles is frustration level and outbursts. Granted they have gone down in frequency…is it just old habits die hard? That he has gotten used to dealing with things this way because of his ADHD? (he’s 11 and never been on meds)I also see windows of real comraderie with his sibilings, which was never there before. But I’m concerned, is Intuniv enough…should the outbursts be gone? Should he have a higher frustration tolerance level? etc… etc…
I am hoping to be ablt to have a phone consult with you in March (saving my pennies;)
Thanks Dr.Parker
Denise
Denise,
Super, and yippee!
All of these are natural maternal concerns… but my recommendation at this point: hang loose, find a good perch, and watch. Time will tell. All of your questions, regrettably, are quite unpredictable, except for the fact that he likely will maintain well and improve with age. More PFC neurons = better executive function over the years, and better executive function brings better self esteem, even more improved control.
The prognosis is good unless you guys missed something, and whatever you find down the road will be much more fixable in this new context of improvement.
Excellent news!
cp
Thank you Dr.Parker for your encouragement and support, and your passion for these kids!
Kind Regards,
Denise
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