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
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- 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)
—>Tweet this post below! For ADHD Medications: Download complimentary white paper Precise Solutions now, – and get ready for the complete version of ‘The Patient’s Guide’ details to follow. Get Neurotransmitter Details Here
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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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