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{ 84 comments… read them below or add one }
Hi Dr. Parker….wanted to get your valuable opinion on a situation. I had my son on Intuniv for 8 months…loved the focus yet he had gotten very irritable on it. We decided to take him off and put him on Trileptal. Since on this med for a month…he has developed a tremor. Have you seen this before and would it cause you to be concerned? I am tempted to put him back on the Intuniv now that we have the mood leveled off. Any thoughts would be grateful.
Hope your summer is going well.
Shana
Shana,
Each of these questions, without your meaning to, is quite loaded, and response platitudes, as you know from these postings, are just not my cup of tea. Some general thots worthy of further investigation:
1. Could be that the Intuniv was not dosed correctly and the irritability is a side effect of dosage.
2. Possible that metabolic challenges, particularly immune system dysregulations often seen with associated bowel symptoms, pumped the glutamate, thereby making him somewhat glutamate toxic.
3. Trileptal doesn’t usually bring tremor – that finding encourages the possibility that he suffers with bulletproof liver [from 2007], downstream from metabolic challenges.
4. Bulletproof liver can reside downstream from many possible contributory factors.
5. Have you tried a stimulant in low dose?
cp
DR. PARKER!!!!!!!! ITS JUANITA KERNER!!! I saw you recently and I have some BIG! stuff to share with you. I truly AM an enigma!! I am a new type of ADHD! It’s very mind boggling, extraordinarily interesting, and will help advance the science (and thus treatments) in this field. But firstly, you need to know THIS: Caffeine can remain in body’s system for up to 20 hours. I will give you contact info for the doctor who discovered this when I get it. I will be calling your office soon today and perhaps you will have gotten this message by then. Otherwise, I will wait to review all of this at my next apt with you. God Bless!!!…. Juanita
Hi Dr. Parker,
I hope you are having a great summer! Have a quick question concerning Intuniv. My son who is 9 has been on this med for a good 6 months. During this time he has shown a lot of anxiety…..bad dreams…..sleep issues. We want to take him off the med for the summer just to see if in fact this is what is causing these issues. Have you seen children develop anxiety with this med? Also, when taking a child off Intuniv….how slow do you need to wean them down? He is currently on 2 mg.
Thanks for your wisdom!
Shana
Shana,
Weaning: just give him 1 mg for a couple of days, a long taper not necessary.
Yes, Intuniv can bring about some anxiety, usually on the front end of the start up, and if the increase goes up too rapidly.
cp
Dr. Parker , Our child is on Vyanse along with supplements, which has been great for focus and impovement in school. The problem we are seeing anger and frustration . What would you suggest ?
Kim,
Always watch for the fact that psych meds can become toxic with the supplements as the search for neurotransmitters is not so difficult, and with more on board they collect at the synapse more easily. Toxicity with Vyvanse: longer than 12 hr DOE, appetite down, sleep down, agitation and anger, over focused not under focused.
cp
Hi Dr Parker,
I’ve read your blog for months– it helped our psychiatrist understand why my 10 year old son couldn’t take prozac along with intuniv- thanks!
Currently his meds are:1500 mg keppra BID, 3mgs intuniv at bedtime, 100 mgs amantadine TID, 5mgs melatonin at bedtime
His current diagnosis: bp, pdd nos and “mood disorder nos due to medical condition of cerebral dysrythmia” This was his discharge diagnosis after a 2 month stay at a residential program, Meridell, in Texas.
He has had all kinds of other dxes, including, OCD, ADHD, Aspergers, NVLD, Anxiety, ODD… His VIQ is 99%tile, with a processing speed of less than 2%tile.
Currently he is as stable as he has been since the early fall when we tried him on strattera– which seemed to have changed him forever. He became suicidal and homicidal. He is very difficult to medicate- became psychotic on antipsychotics, had auditory hallucinations from valium, gets crazed from stimulants…
He is still raging– but maybe just once a week now. He has a very low frustration tolerance and tends to get overwhelmed easily, easily distracted. He basically has his good days which we yearn for, and his bad days, which are really really bad.
We are dealing with school refusal issues, even though he has been placed in a therapeutic day school.
He had a QEEG done at residential which revealed abberant activity on the parietal(?) lobe and the right and left hemispheres (Im writing this from memory, so I might have the terminology wrong.)
Curious if there is anything else we should be doing to help him or have we exausted all avenues? Could it be that this is as good as it gets?
Thank you,
Lucy in NJ
Lucy,
The process so far, having been down that road so many times, is one of point and shoot with the best information available. I have seen kids like your guy do very well with a new med, such as amantadine, for some time, often used quite effectively by that program. Only thing I can suggest is a serious look for more information, more evidence on a variety of issues from immunity to neurotransmitters. Take a look at this NeuroScience page to consider some of these options.
cp
Dr. Parker,
I am reading the book by Dr. Bock as you recommended – aaack, scary stuff. He mentions PANDAS several times and I looked through your website for mention of it, but I didn’t find any. What is your take on PANDAS? My son had strep 5 times last year, including scarlet fever 1 time. He doesn’t exactly fit the PANDAS profile – no tics and I can’t say there was a sudden onset, but there was a worsening of sypmtoms already present (oppositional, aggressive, etc.). Is it worth pursuing further work-up?
I am so interested in the whole immune system link to biobehavioral issues. My son has “cryptic” tonsils (lots of grooves to catch stuff) and they are somewhat enlarged, the ENT did recommend removing them since he had so many bouts of strep. We have been holding off, though, since it requires so much time out of school and actually he has not had a case since Nov. In the back of my mind I have been questioning sleep apnea as a contributor to problems because he rarely wakes up on his own, has to be dragged out of bed most mornings even though he goes to bed fairly early, and then of course has his ADHD issues of inattentiveness, etc. Another confirmation of the tonsil problem came from the orthodontist the other day who said that he must be a mouth breather and is developing an open bite with vertical growth – not good. But will getting leaky gut issues under control make the tonsils shrink or do we need to get them removed? Is a sleep study warranted? Do you have experience with these kinds of problems?
We are going to begin a trial on Intuniv, fingers crossed for no adverse reactions.
Thanks as always for your insight and compassion,
Kelly
Kelly,
Thanks for your kind remarks – yes Bock has a very good handle on matters, – but reading and listening to Bock is actually, for me, quite reassuring, because he pulls in so many relevant angles that I see every day in the office.
PANDAS is a definite possibility, and deserves our clinical attention – even tho his is not a typical presentation. Sleep apnea can be a significant problem, and will clearly have downstream consequences if you note breathing of ‘apneic’ quality.
Leaky gut issues can significantly underlie all of these matters, but the leaky gut itself is downstream from the immune dysfunction that we hope to chase down. As noted elsewhere here, even the trusty Intuniv can be unpredictable with these biomedical confounding factors. Intuniv itself relies on specific neurotransmitters, specifically glutamate, that, if already unbalanced, will create counterproductive consequences.
Not to worry though… we won’t be actually hitting any rocks on this coastal journey, but rather will be finding the channel markers as they light up in the foggy night.
cp
Dr. Parker,
It looks as though your prediction about Intuniv and glutamate may have come true – Friday was day #14 at 1 mg. and things had been going very well up until then, the teacher reported increased attentiveness and we were pleased that it seemed to be “smoothing out” some of the emotionality we see at home. But I got a call Friday morning that he was not well, he became very emotional during class and began to cry during a timed math test and told the teacher he was “overwhelmed”. He also displayed what she described as tic-like or seizure-like behavior consisting of very exaggerated yawns. In the school clinic he seemed disoriented, cried intermittently, and was scratching his legs obsessively as well as beating his chest (he later told me that he was beating his chest to help himself calm down). While waiting for me to come get him they gave him something to eat and that seemed to help bring him around so that by the time I got there he seemed OK, but I took him straight to the pedicatrician anyway. Since the only thing new/different in the routine is the Intuniv, his dr. said that is the likely cause and advised discontinuing it, as well as considering if he might have hypoglycemia as well. I tried to talk about the excessive glutamate that we know he already has (NT testing had him at 100) but the dr. looked at his NT test results and called them, in his words, “baloney”. He could not believe that anyone could possibly have the excessivly high levels that Nathaniel has on every NT but one and still be walking around. He gives no credence to the testing methods or results, although he does concede that there could be underlying food allergy issues contributing to Nathaniel’s problems. Did not have the time or the energy to refute his claim, just wanted to make sure my child was OK.
Does it seem likely that Intuniv would have caused the problem especially given his already high glutamate level? I am confused about the tic-like behaviors since I thought Tenex was prescribed to treat tics. Some of the other behaviors do seem to resemble a hypoglycemic episode and he did have a very small breakfast that day due to very complicated circumstances. I am just so disappointed that we seem to have lost out on another treatment option since the stimulants were already a disaster and I am reluctant to try Straterra or the atypical antipsychotics. Have you seen anyone else have this kind of reaction to Intuniv? Also, could you clarify for me – does immune system dysfunction precede the leaky gut or does leaky gut cause the immune system dysfunction?
Thanks as always for your feedback,
Kelly
PS And if you can point me to the appropriate info. to use with my pediatrician I would be very grateful!
Kelly,
I am not ignoring you, it’s just that this excellent set of questions takes me down a whole post, with many provocative angles. I hope to have time to draft a full answer via a CorePsych Blog posting this weekend – stay tuned, want to get some links to get this all straight for you and other with similar problems – glutamate excitoxicity is a big deal, often under recognized, treated relentlessly with mood stabilizers, and quite correctable with a specific, targeted, glutamate intervention plan.
cp
Dr. Parker,
As the young people like to say, “OMG”. Read the wiki link, as well as some other things, e.g., http://www.msgtruth.org and http://dogtorj.tripod.com/id16.html
Starting on the low glutamate diet right now, not sure what will be left for the poor child to eat but we will make it through. I am seriously ready to go back for another Ph.D. in psychoneuroimmunology and/or food science.
Anxiously anticipating your blog post!
Kelly
Kelly,
Thanks, – very interesting links on the glutamate/glutathione connections.
cp
Hi Dr. Parker:
I am wondering if you have noticed a side effect of bloating w/ the Intuniv? My son has been on it for 5 months now and seems to be very heavy and bloated in the gut region. We were at 3mg and I have gradually gotten him down to 1mg just to see if the Intuniv is causing this effect.
Also, in an earlier post, I had mentioned that we had started Trileptal to see if his irritability would settle a little. He has been on the Trileptal for 5 weeks and I do see a difference. I tried to increase from 150 mg to 150mg twice a day. Seemed to be too much too fast….the motor tics got worse. Part of me thinks maybe we should try Lamictal. In your experience, does the Lamictal have a tendency to make the Intuniv run through fast as the Trileptal does?
Grateful for all your thoughts!
Shana
Shana,
Sorry to be so brief, but the significant GI symptoms, the refractory response to meds and the tics all lead me down a deeper path: the Neurotransmitter Testing Way… Strongly recommended look at his neurotransmitter levels and the answers will be there. Drop us a line if we can be of help.
Remember to back off the Trileptal slowly as he will likely become quite overdosed on the Intuniv going off the Trileptal. Lamictal not likely to do the job on the tics, but not involved with drug interactions thru CYP450, Phase I metabolism – a good thing!
cp
Hi Dr Parker,
I recieved an email from a collegue concerning “digital drugs”. supposedly the kids download “idose” off of U Tube and can become hallucegenic, drunk, orgasms, etc etc because of the sound waves to the brain waves. Have you heard of this and if not I will send you the email. The warning was out of Mustang High School administration in Oklahoma.
thanks for your input. I am an addiction specialist and this is very scarey!
thanks
Hattie Stein
Hattie,
Please do send along the email – will look at it this weekend, haven’t heard of it.
Thanks,
cp
thanks so much.
Hattie
Dr Parker, LOVE your blog, I have learned so much from it. I have an 8 yr. old son with ADHD and ODD qualities (he doesn’t meet clinical criteria for it because he mostly shows it only at home). He can be very explosive and defiant but seems to be able to exert enough self-control at school so that he doesn’t blow up there, but by the end of the day I think self-control reserve is gone and so he falls apart at home. Anyway, he failed trials on stimulants last year – Focalin made him weepy, Adderall made him angry and aggressive to the point that he was assaulting me almost daily. We dropped all meds for a while as school seemed to be going well and we can manage other problems at home, but recently issues of inattention and disorganization have caused more difficulties – he has no academic concerns, just behavioral. I talked to his dr. about other options, he was willing to try Intuniv after I said no to Straterra (based on your writings about it). We have not started it though because I found an ND who uses Neuroscience testing for neurotransmitter levels and we just got the results back from the Attention Issues profile. He is WAY out of range on everything except glycine: dopamine = 440, GABA = 20.2, norephinephrine = 75.4, epinenephrine = 22.5, serotonin = 571.8, glutamate – 100, PEA = 200, and glycine = 115.2. The ND is thinking that he has leaky gut and attributes the crazy NT profile to that – does that sound plausible to you? I don’t disagree that there are some GI issues going on but I don’t think that is the whole story. She has him on a program to address the leaky gut and started him on Calm PRT for now. Neuroscience made additional recommendations in their report: Kavinace, EndoTrex, & NorLox. Are these going to be enough to manage the symptoms or do we need to try pharm. like Intuniv? I would love your thoughts on this and I think we are going to end up doing a phone consultation with you. Thanks in advance for all of your wisdom and insight – I appreciate it so much, partly because I am ABD in Dev. Psych. but even moreso since I am a parent of one of these challenging and interesting kids!
Kelly,
Thanks so much, and best wishes on finishing the ‘d’ on abd! Stay tuned here because I will be offering affiliate status to professional folks who would like to add a few bucks to their bottom line encouraging others on the forthcoming book! Take a look at the White Paper – it’s an outline for the book, at this moment titled: ADHD Medication Rules: What to do when nothing is working..
I confess, having looked at so many NT results I can tell you with considerable certainty that your ND is right, – and was reading the numbers looking for the histamine level! With the high DA and all the rest your guy is very likely dealing with an immune disorder of the food sensitivity variety – as as for me, I want the evidence if I can get it – for the specific offenders causing the immune dysregulation and the leaky gut. You can use Neuroscience Food Sensitivity Testing, and if you want to run it through your insurance LabCorp # is 680230 for 96 foods, IgG, IgG4 is what you want, and Metametrix has a panel as well. Once you get those results you will have to work on healing the gut, and watch for the possibility – often seen in our work – of withdrawal. And BTW, the most frequent antigenic offender in my office is milk products not gluten – thus the reason to dig in hard on that next step.
Having said all of that: Remember that the Intuniv is great in these cases… except for when it isn’t! – And ‘isn’t’ can often be predicted by increased Glutamate levels…. as glutamate is the stealth neurotransmitter with Intuniv – discussed in this Intuniv post. One of the first failures on low dose Intuniv happened to come into my office right after his NS testing… he blew out the top of the Window… based, in retrospect, on his significantly elevated glutamate and his immune dysfunction. Now I watch that one like a hawk, – if you don’t look, you can’t see!
As for me, I would try the Intuniv, get the IgG back ASAP, and don’t give up on it if he has a prob.. when the glutamate comes down after proper treatment/elimination on the diet, then we are back in business with any of the ADHD meds – especially if he remains sensitive to the AMP products. Don’t forget, some folks simply can’t take AMP anyway due to polymorphic changes in CYP 2D6 noted here.
This should cover your next steps, thanks again for your kind remarks,
cp
Dr. Parker, thanks so much for your response! We are going to pursue the food sensitivity testing ASAP, in the meantime will keep him dairy-free. The ND suggested a 4 day rotation diet, don’t eat a food except once every 4 days which I am trying to follow but will eliminate all dairy period. What do you mean by “withdrawal”? What would that look like?
I don’t suppose you would be surprised to learn that we have had bowel/bladder issues for years. At age 4 we went to bowel mgmt. clinic at our children’s hosp. because he was still stooling in his pants, seemed to have problems recognizing when he needed to go, etc. They found nothing “physically wrong” at the time so we were left with a behavioral explanation, worked with a psychologist for a while and had some improvement, 6 months later we went back through clinic again due to regression and still no explanation except it’s behavioral. He did seem to get the BM issue mostly under control (still gets some BM in pants occasionally) but we had continued problems with daytime urinary incontinence. He seemed to have periods in which he could stay dry but over time accidents became more and more frequent. In Mar. 09 he had an abdominal x-ray which GI said was fine and regretably over the next 9 months as he had less & less bladder control we became more & more frustrated/angry with him, thinking he was just being lazy about going and attributing it to ADHD – unable to shift focus, too distracted, etc. Started with another psychologist to use behavioral plan to address the wetting with very little success, started OT to work on SI issues, still very little improvement, and agreed to try AMP to see if that helped with the wetting – that was disastrous. It’s no fun to be afraid of your own kid because he is unpredictably violent! Finally saw urology in Dec., they looked at the same x-ray and said he was too full of BM, colon pushing on the bladder was causing accidents. Urodynamics study in Jan. confirmed overactive bladder, started ditropan and miralax to clean out the colon. Repeat abdominal x-ray 2 weeks ago was once again OK by GI standards (no blockage and he is not “constipated”) but by urology standards it is still problematic, they said he is full to his ribs. They say clean out the colon and the bladder problem will subside. Meanwhile, traditional allergy testing only showed reaction to dog dander, foods were not a problem and the allergist seemed dismissive of other types of allergy testing. To think we might have solved this problem years ago with proper diagnoses and testing… oooooh, so frustrating! How awesome it would be to solve 2 problems with 1 treatment – a simple change in diet. What a concept.
As for the “d”, I still need 60 participants for my study to reach proper N for power, it is going too slowly for me and I have been at this way too long but somehow someway I will finish! I told my husband I am going back for another degree in psychoneuroimmunology
I live near Ohio State Univ., is anyone there working on interesting stuff that you know of?
Thanks so much for the information and support!! I will definitely spread the word about your white paper, you seem to be light years ahead of others. How long will it take the rest of the world to catch up??? That research-to-practice gap has bothered me for years! Be blessed!
P.S. The Neuroscience Attention Basic panel does not test for histamine, too bad because it would be interesting (maybe scary) to know where he is.
Kelly,
Gotcha – I don’t use that the Attention Panel because I am seeing so many with multiple issues.
cp
Kelly -
Thanks again for your notes and kind remarks – so often it happens that a mom [or dad] with a boy like yours can make a significant contribution by reporting what happened and staying with your studies on the subject. So many just write these problems off as psychological, as all we have known for years is the fact that symptoms appear to come from the brain. So few appreciate the brain and body connections, including some of the notable pioneers in brain studies – they just don’t take those other steps to understand the interface between the various communication networks in the body from neurotransmitters, to hormones, to this guy with the immune system dysregulation. The bowels and urine can speak to us just like the brain if we could only listen and get away from Paleolithic psychoanalytic concepts that deify the mind alone. And the psych labels do absolutely no justice to these matters – DSM 4&5 just throw cold water on other inquiries as they are stuck with descriptions alone.
You will have great fun at the next Defeat Autism Now [DAN] meeting in the fall – I am in Baltimore now for the Spring conf. I can tell you these guys have received some heat in the past, but they are so smart, so experienced – and one guy I would encourage you to check out is Ken Bock MD who has great information on the immune system – and has written 2 [?] books, on the immunity issues which are improving with the new science everyday. T
he real future of mind medicine is the interplay between these communication networks, and the most difficult to understand is the Immune system. SPECT Brain scans are interesting, but so macro, and using them: you should not cookie cut treatments based on those scans – just cost prohibitive for what you get. Been there. They are an improvement, as the evidence with SPECT is better than no evidence – making it a clear step ahead of guessing in the office. But if you do SPECT for awhile you soon see what it doesn’t tell you, and they one has to dig deeper into the measurable neurophysiology and body chemistry – period.
Regarding withdrawal, take a look at this gluten/casein withdrawal post with some links there, and look for an article about my comments on withdrawal from gluten this summer in Living Without a magazine for the gluten sensitive – the author said probably a June pub date.
Thanks again, glad you are on the path,
cp
Baltimore! I hope you had a great time and ate some crab cakes. My doctoral program is actually in Baltimore, at Univ. of Maryland, Baltimore County. I started there many years ago, moved to central OH when my husband was promoted and have been trying to finish long distance ever since then (with a few maternity leaves thrown in there too). In March I got to go back for a few days when I did a poster of my diss. research at a conference. I love Baltimore!
My ND uses ALCAT labs for food allergy testing, are you familiar with them? Are they a quality lab? In the end we might just go with your Neuroscience panel as we think we can get it covered by insurance. For now we are staying dairy-free and he is handling it better than I might have expected given his difficulties with flexibility and frustration tolerance.
We are nervous about starting Intuniv with his already elevated glutamate, should we wait a little longer to allow diet changes to make an impact? Having had such a bad experience with meds last fall we are very leary of having another bad time of it.
Thanks so much Dr. Parker, hope you had a great trip to Charm City.
Kelly,
Very familiar with ALCAT labs, and recommend them for precision and excellent reports. One of the best. Don’t forget that LabCorp has a 96 panel Food Sensitivities test #680230 if drawn at LabCorp, and if your insurance covers LabCorp Testing! We have some in Hampton Roads that are completely Paleolithic, driving only the business to their own labs, some of whom just don’t get IgG testing.
I do agree with your concerns about the glutamate levels contributing to possible reactions – have to watch those, but permit me to quickly reassure you… glutamate levels don’t absolutely forbid a trial of Intuniv… don’t know why, am keeping my ears to the wall, but have seen it go both ways.
cp
Dr. Parker,
I have posted recently in reference to my 8yr old son being on Intuniv 3 mg. We recently added Trileptal for some mood issues. We chose Trileptal over Neurontin because we were concerned about the possible side effect of weight gain. Since being on the Trileptal he is experiencing motor tics. I hate to take him off the Trileptal because I think his mood has evened out a bit. In your opinion, do you think the Trileptal could be aggrevating these tics?
Thanks for your never ending support!
I read your books loyally and feel your advice is the best.
Shana,
Do take a look at this post on Intuniv, as it is one that brings up the Trileptal and Intuniv issues. Actually Trileptal will cause the Intuniv to not work as well [burns it up more quickly with induction thru Cyp3A4], – and you have to be careful going off Trileptal because if he is still on Intuniv he will likely be overdosed and too sedated based on the 3mg.
Having said all of that, I doubt that Trileptal is aggravating his tics, and have no idea why Intuniv would be, but have found some who do have ‘tic aggravation’ downstream from Intuniv… I am watching and listening to colleagues on this one – and don’t have enough experience to say definitively that the Intuniv is causing the problem.
cp
My son is 14 years old, and has been on various medications since age 5 for ADHD (emphasis on the “hyper”). He started with Ritalin, and moved to Concerta, Adderall, then Vyvanse. He also tried Strattera for about 6 months. The stimulants worked, to an extent, in that they helped him focus. They didn’t work for his oppositional behavior or impulsiveness, in fact some of them seemed to exacerbate his ODD. Strattera didn’t work at all. This school year, I actually took him off all meds for awhile, since there didn’t seem to be enough positive effects to outweigh the negative.
In January, his psychiatrist prescribed Intuniv. He ramped up to 4mg over the span of a month. 1mg and 2mg had minimal benefits. 3mg seemed to help his demeanor, but not his focus. For the last month, he’s been quite simply a different child. He is happy, responsive to us, engaged with the world. He told me he thinks things through before he reacts. At school, the teachers feel he has better focus, is beginning to take responsibility, and is not as impulsive. They say he seems to be gaining a little maturity. I say it’s the Intuniv.
The effect this medicine has had on our family is profound. Reducing his oppositional behavior and impulsivity has felt like a huge weight being lifted from our family’s shoulders. He is still incredibly disorganized, and forgets homework and turning in assignments. But he seems to be trying harder to do the right thing. He seems to CARE more.
By the way, I have a younger son who’s ADHD. For him, Concerta works just fine.
Mary,
Thanks for your positive remarks, – and on a guy with some clear refractory challenges. Your observations parallel what we often see in our offices, some dramatic turn-arounds in clinical situation which ordinarily seem completely out of the range of regular meds… and often lead to atypicals as the previous *first line intervention* just to get the day done at school. Your remarks typify why I have written so much about Intuniv here – it works quite often for the ODD subset when previously the treatment options were so limited.
cp
Dr. Parker thanks for all the terrifc info on Intuniv. I have not noticed much posting on the BP meds. I saw at one point you had mentioned that Trileptal burns fast with Intuniv. My son (who is 8 yrs) has been on Intuniv 2mg for 5 months. Love the focus….hate the moodiness. He has been thru tons of MRI’S and allergy tests for various concerns. We are now at the point to see if adding a BP med will help ease some of the mania like behavior. Do you have any feelings towards these meds mixed with Intuniv? We are considering Trileptal since my daughter is on it and seems to do well with it….no side effects to mention.
Shana
Shana,
Just to be perfectly clear on the Trileptal and Intuniv combo: Trileptal is an antiepileptic, not exactly indicated for BP [but useful there]. It encourages the Intuniv to actually run through faster, and would require careful watching with Intuniv dosing [needing more to get the job done because it burns so fast] – that’s why I write about it and why to not use it first line. I would start with Neurontin, also off label for moods, but clean on 3A4 induction – meaning won’t mess with the Intuniv dosing strategy.
Allergy testing needed: IgG for foods with LabCorp, often not done at the allergists office: #680230 at LabCorp – that tests for enteric antigens, different than respiratory or skin reactions.
cp
Thank you for your quick response. He just had blood work done thru Lab Corp for the enteric antigens this week. All seemed to be fine. Therefore, we want to try an additional med. Are you familiar if the Neurontin has any tendency to increase motor tics? That is the main reason we are sticking with the Intuniv…no issues with tics. I am always fearful to add a med with the possibility of aggrevating the motor tics.
So grateful for all your help!!!
Shana,
Neurontin doesn’t create motor tics, and in some cases can help.
cp
Hello Dr. Parker,
I am a 47 year old female who was told I had ADHD several years ago in grief counseling but never really got an official diagnosis and never sought treated because I was breastfeeding and went on to have 2 more babies and breastfed them. Now at 47 with the additional stresses of peri-menopause I am finding my ADHD unmanageable as of late. I finally got to see a psychiatrist which was a nightmare. He wouldn’t listen to anything I said, he told me three times in the brief 15 minute initial visit that he didn’t have time to listen to my research or what I knew about the disorder. My husband witnessed this. I tried to tell him my symptoms I mentioned I was on edge or tense most of time and irritable. Again, he didn’t hear me, he asked me very few questions, one was what was today’s date and the other was what as 22 minus 9. Seriously, that is all he did then he did then he said, yes you have ADHD and started writing a prescription for Focalin XR.15 mg. because I told him in the past my doctor would give me some Ritalin to help when I wasn’t breastfeeding. He asked how that worked and I told him it helped but it was too short lived and it frustrated me and made me irritable when it wore off. I was not happy because he really wasn’t interested in hearing anything I had to add but I did what he told me. I took the medicine and the first day I felt minimal effect. But a couple hours after taking the medicine I was agitated until it wore off – which was about two hours later. I never felt the second release. Twelve hours later I took the medicine again because I had something that needed my full attention at night and again, same symptoms. I did not cause me to lose any sleep. The next morning I took a higher dose…stupid I know…it again, minimal effect but extreme agitation two hours later. I had to go to bed and wait until it wore off. The next day I took the 15mg he prescribed and I felt no effect except agitation. I read on the leaflet that Focalin is contraindicated with patients with marked anxiety/tension and agitation. I told him I had this mental status yet he still prescribed it. I am going back tomorrow am, I would like to try Adderall as that is what my brother is on, what if he makes me take more Focalin for longer? How do I respond? How do I insist on trying the other family of stimulants? I hope you get this before tomorrow AM. You can e-mail me directly if you wish.
Thank you
kristina
Kristina,
15 min is an insufficient evaluation, – confirmed on that one! I find it hard to give any advice with an already adversarial situation, a doc who is clearly not building feedback loops in the first place. To suggest something in that context sets us both up for challenges.
Having said that: You would do very well to have a more careful review of your several apparent issues – from hormonal [sounds quite contributory], to depression, which appears to linger in the background.
If you have metabolic background noise it is highly unlikely that any of the meds will work predictably. I can see your frustration, but be careful with the meds, and stay within recommended guidelines or you will likely add to some of your problematic reactions. Looks like you are paying attention to DOE, but something clearly is wrong with dosage and your reactions – just too difficult to tell what might be going on without more specific information.
cp
Dr. Parker,
What are your thoughts on Strattera 36mg. + Intuniv? 6 y.o. daughter starting this tomorrow, as Vyvanse + Strattera resulted in angry outbursts, lack of improvement in ADHD:Inattentive symtpoms.
Is it safe? Effective?
Medication trail since 3/09: Focalin, Focalin XR, Vyvanse, Strattera, Strattera + Focalin, Strattera + Vyvanse, Strattera, Strattera + Intuniv (starting tomorrow). She initially has success on new drugs, then after about 5 weeks, the good effects taper off. Social Worker thinking she is metabolizing meds too fast?
Just diagnosed Celiac Disease.
Would love your thoughts!
Thank you!!
Dana
Dana,
Your girl is another example of my regular theme here: Metabolic challenges always create medication problems, and with celiac you can rest assured that all meds will work unpredictably.
Also: Strattera is a 2D6 substrate, has no interaction with Intuniv, but both could be out of adjustment based upon underlying neurotransmitter imbalances that are measurable and correctable once your girl has the underlying problems identified. My past history: I scored many effective points by intuitively going lower and slower than most with complicated cases. My current approach: I regularly provide more predictable answers and strategies based upon the available evidence… and complicated presentations can have even more specific interventions.
cp
Dr. Parker,
Thank you for your comments.
We have an appointment with a gastroenterologist, but cannot get in until June 2010. In the meantime, I have her on a gluten-free diet.
Do you recommend that we see a Neuropsych.?
Thank you!
Dana
Dana,
Yes, an adjustment of meds might help in the short run, and your psychiatrist may help with those adjustments.
cp
Hi Dr. Parker:
I have read many of your posts regarding Intuniv and am so thankful for the information. Since this med is so new….I can’t seem to find much support. I have a son who is 8 yrs old that takes 2mg of the Intuniv for ADHD. I did start out giving it to him in the evenings but he was too tired during the day… so I switched to the am dosing. He has been on the med for about 3 months. He has never had an issue with sleep until he started this med. It seems to have heighten his anxiety level were he is afraid to be alone…day or night. Why would the Intuniv enhance anxiety if it is not considered a stimulant? I do like this med. It has helped his focus as well as calmed some of his moodiness. At this point, I am considering adding an anti-depressant. I see were you like the Effexor with the Intuniv…..any thoughts on Buspar? Is this med considered clean?
Thanks for all your help….your site has been a blessing to me and others!
Shana,
Effexor is remarkably clean and my first choice depending on the age of the child. If he is less than 12 or so I start with 1/2 of 25 mg of Zoloft if indicated. See what your doc thinks about that.
cp
Thanks Dr. Parker for the quick response. I have tried the zoloft with him and he tends to be more moody on it….even at the real small dose. Not sure if the doc will go with Effexor for your reasoning….he is only eight. What is your feeling with the BuSpar and Intuniv? Is BuSpar a clean drug?
Shana,
Don’t have time to check it this AM, just Google it and look for 3A4 interactions, – Intuniv is a 3A4 substrate.
cp
Dr. Parker,
I don’t know a lot about Vyvanse and our G.P. has not ever heard of it. My 11 year old son has been on Concerta 27mg for about 20 months. It has definitely made a big difference in his focus, school work, and mood swings.
However, he has lots of trouble with appetite (even before the Concerta) and sleep problems and anxiety. So the doc added Strattera about 6 months ago and while this has taken the edge off his moods a bit, he’s still got the sleep, eat and anxiety issues.
Would it make sense to ask for a trial of Vyvanse? Something that I read led me to think it might have less of the amped up feeling he has now that seems to add to his anxiety.
In your experience, do you think there’s a chance he’d do better and fewer bad side effects on the Vyvanse?
Also, if we do the trial, should we taper off the Concerta & Strattera slowly?
Bonnie
Bonnie,
The value in Vyvanse is the DOE, search Vyvanse for many posts for details. No need to taper, can drop one and start the other same day, just need to be careful with the first dose, then taper up as noted in the many posts here.
cp
Dr. Parker, My 16 year old was recently diagnosed with “mild” inattentive ADD. He is a very smart guy, and over the years had done well in school based up his intellect. Now, with the sheer workload of his 3 Honors, 1 AP and 1 College Prep curriculum, he hit the wall. Grades are tumbling, and he is becoming unhappy at school as a result. He has been completely opposed to medication…he doesn’t use caffeine, drink sodas, eat chocolate…etc. He is a healthy eater, 6′5″ and 172 pounds….plays basketball.
Things finally got so bad, he agreed to try medications. The doctor put him on 30 mg of Vyvanse. He commented that during some math tutoring, he felt more relaxed and could power through the toughest material. Also I noticed he was very chatty until the evening. We gave him his dose at 9:30 am, and he did not go to sleep until after 5 am. So one hour of sleep before a very tough day at school He says this experiment “ruined his life” and that he will never try medication again. Before I convince him to try again, I just wondered if you think that the 20 mg dosage and giving the medication earlier….say 6:30 am, might do the trick. Thank you so much….I am at a loss…and it is very sad to watch him going through this.
Denise,
This unhappy outcome is why I am such a sleuth about the metabolic background – should be carefully reviewed before any meds are started. Especially with a big guy, as those guys are so often overdosed based simply on size. See this Big Guy Post from almost 3 yrs ago.
With his situation I would suggest to your doc going down to 1/2 of 20 for about 4 days, then go up to 20 and carefully assess the DOE, rather willing to under dose than create another problem. See the specific titration strategies on this CorePsych Blog post.
cp
Dr. Parker,
I enjoy your blog and have learned so much. You also personally answered a question for me last fall after the ADHD Online Conference and pointed me toward an alternative anti-depressant (I chose Effexor) to replace the Prozac that included a risk when combined with Concerta.
I’m not sure if this is the place to ask a new question, but I’ve never seen this issue addressed anywhere. I’ve been on Concerta extended release since last May–have titrated up to what my P.A. says is maximum dose–72 mg. It definitely makes a difference in my life, although sometimes I wonder if it could be making even MORE of a difference. I have nothing to compare it to.
My son is also on Concerta. He’s 11 and has had very little appetite since birth–always underweight. Can’t actually say the Concerta has made that worse, although he says it makes him “not hungry.”
For myself, I’ve struggled with weight issues, especially since his birth 11 years ago. I’ve been 25-35 lb. overweight for the past 11 years. When I read that stimulants depress appetite, I thought it might be a nice perk for someone like me who struggles with weight.
Well, have you ever heard of someone GAINING weight while on a stimulant? I’m 47, have always had a healthy appetite, am not a binger but possibly some emotional eating. Anyway, Concerta has not noticeably affected my appetite either way and to my surprise, I’ve actually gained 15 lb. since going on it.
Just interested in your thoughts and whether you’ve heard of this before. Or am I just “lucky” to be an exception?
Bonnie
Bonnie,
Your ‘exception’ exemplifies the frequent complexity of the many ADHD comorbidity issues. The new brain science does help us understand many symptoms we previously simply overlooked as insignificant. There are many questions, that could be asked in a different format than these posts, which would include details about your periods and female issues such as breasts, hair, ovulation etc. If the meds don’t have the expected effect [insufficient DOE] and you are paradoxically gaining weight I would look more carefully at other body systems, and set aside the ADHD as the culprit. Think about the possibility of Estrogen Dominance [Female ED!] – Sounds a bit like a postpartum rebound on an already likely ED landscape.
Concerta, as you likely know from these many posts, is acceptable, but not the best for the PM coverage, as it rarely can be trusted to work past 8 hr without hitting the Top of the Window the rest of the day. My favorite is Vyvanse, with a 12 hr DOE.
Your ‘exception’ is likely somewhat connected with the ADHD, but remotely, and not likely to be corrected with stimulant meds of any kind.
cp
Dr. Parker,
Thanks for the reply. Sorry about the confusion, I am just new to all of this information, so it gets a bit confusing to me.
You suggested that I start off with NT testing, and to start off with the least expensive one. What is the least expensive test called? Where can I find those tests and their pricing? And how can I get my insurance to cover the cost? Is this also called metabolic testing?
Do you suggest that I seek out a psychopharmacologist at this time?
What are your thoughts about Biofeedback, Neurofeedback, and Qeeg/Brainwave testing?
I talked to someone over at Lifebridge about the SPECT. It seems like they can measure damage done to your brain by drugs. However, they don’t seem to be able to offer a solution to the core issue besides antidepressants. Does that seem correct to you?
You also wrote this in a post to me… “Remember, they may no assertion, nor do I, that these are diagnostic per se – you can’t pop over with a DSM-4 diagnosis – but you can draw biomarker implications that very frequently prove useful clinically. With this interesting information we are turning many around that appeared refractory even though all parties were on board and fully cooperating with all treatment parameters.” I am not clear what you mean. Can you please explain it to me?
Thank you for your help!
Joey
Joey –
First download the Biomarker paper on the Neuroscience page and read that carefully. The test costs are at the website there, we don’t charge for the testing, we give you the test kit. You can call Neuroscience to see if your insurance pays for the testing, most do. Read the other articles I have put up there and you will better grasp your next steps.
Right about LifeBridge, they are a great group, focused on SPECT evidence, not neurotransmitter measurement.
Search about Neurofeedback here, several posts – positive on Neurofeedback.
cp
Hello, I was diagnosed with ADHD and Depression three months ago and I am coming out of the first three month period into the ‘acceptance phase’? Help I am lost again in cognitive thought and have been referring to it as Holiday Hangover or maybe this is the end of the seasonal depression? My question after I have purchased two full-priced books at borders and have three over due from the Central Libary, is can I expect to have a blissful next three month + period??? Is this where I accept that I will need to be on treatment forever?
It has been a month, a job change, and family holiday time since I’ve seen the therapist you recommended me and now that I feel I’ve fallen and floating, I am very much looking forward to that appointment! I’m currently taking 18mg of Concerta, 20mg of Citalopram and 100mg of trazodone for sleep…Am I going about this in the right way? I can’t tell whether there is a difference or not, I can only say that for a time everything felt in order and now I am east bound and out again. Any light would be great! Thank you, Emily
Emily,
Sounds like the meds are not right period. You should be feeling much better, on the positive side, – not so much on the ‘forever’ side. If you are taking Concerta, are likely under dosed at 18mg. Do call today and come in early with any one on the medical team – it’s too long not feeling well.
cp
Thank you, I agree, I can not get in soon enough. Is a therapist appointment the right way to go? Or should I see someone for the meds, or both? It’s like I’m back at square one where everything was fuzzy and I kept finding myself in unsatisfying work and feeling hopeless with what to do next. My goal is be able to write when I have something to say like ‘Ronald Sorenson’ who commented from July. I can relate to a time where I seemdd to get it, but now I have low energy and have not had much of an apetite for a few days..
Emily –
Your work situation needs review with a therapist. Your meds need review by anyone on the Medical Team ASAP both can occur almost simultaneously.
cp
Dr. Parker,
I have some more questions, and I am still confused as to where to navigate on your site to find the information you mentioned in my other post. Is it possible to call you or email you directly? I have also found a doctor in Orlando that does a series of brain scans, and I wanted to ask your advice/opinion about those. I think yo have my email address. [Took off his email and phone #]
Thank you,
Joey Gomez
Joey,
I have consulted and presented several times with the SPECT imaging center LifeBridge Diagnostics in Melbourne, FL, and often review scans from them – they provide excellent service, high quality scan information and have state of the art software.
I will send you a note offline to chase down that other info for you.
cp
To Dr. Parker,
I have a bit of a unique situation regarding depression. I am wondering if you might be able to help me or possibly point me in the right direction to seek out help. Thank you for taking your time to read through this.
I have suffered from depression for the past 12 years, which has mostly been controlled by antidepressants. However, in the past year I have hit a severe low depression. I have tried several different medications within the year, that don’t seem to work. Currently, I am on week #3 of Lexapro and Wellbutrin. Also, within the past year I have been in therapy and under a psychiatrist care. Unfortunately, I don’t think anything is working. My current psychiatrist is about to give up on me. He says he doesn’t know what else to prescribe for me. He recommended I go see a “psychopharmacologist”. I tried to research them, and could not find any local ones.
For about 5 years in my past, I was a heavy recreational drug user. (Mostly ecstasy, ketamine, and acid.) I have stopped using drugs for the past 5 years, or so. Since I am having such a difficult time with depression, I am wondering if I might have damaged part of my brain from the past drug use. Or, I am wondering if my body does not naturally produce enough serotonin, dopamine, or norepinephrine. And if either one is the case, what can I do about it.
An online doctor told me, “Street drugs can cause brain damage. Ecstasy is going to be most problematic when it comes to fighting depression. With even a very few exposures, ecstasy can fry out the serotonin receptors (“exhaust”) them in the limbic system. Therefore the AMOUNT of serotonin, dopamine, and norepinepherine may not be the issue as much as is the receptor site issue. It would be like all of the wall plugs in your house getting fried out. You could have all the juice or electric cords in the world, but unless you have somewhere to plug them into, they just aren’t going to work. So I would urge you to contact an addiction medicine specialist. These are the physicians who will understand the nature of your recovery and the unique needs of a man who has been a past long term user of the drugs mentioned.”
I tried to research “addiction medicine specialist”, but could not find any either. Also, I was also doing some research on the internet to see if there was a serotonin test that you could take to measure the serotonin levels in your body. Or if there were any tests that you could take to help to see which antidepressants might work better, or to see how your brain is functioning. Below is what I have found through my research on the internet regarding tests:
• Serotonin Level Blood Test, or a 5-HT Level, or a 5-Hydroxytryptamine Level
• rEEG Test
• SPECT Brain Test
• Cytochrome P450 Blood Test
So I am wondering if you might know how I can get help, or point me in the right direction? I don’t know if I should see a psychiatrist, psychopharmacologist, addiction medicine specialist, or a neurologist? Also, are you familiar with any of the tests I mentioned above?
So my questions are:
1) Where do I find a local psychopharmacologist?
2) Can street drug usage damage your brain & body chemistry? If so, how can you fix it or test for it?
3) Are there any tests that can be done to measure the amount of serotonin, dopamine, or norepinephrine in your body?
4) Are there any tests that can be done to see what antidepressants work best for you body chemistry, or if you even need an antidepressant?
5) Would a rEEG, SPECT Brain, Cytochrome P450 blood test, or 5-HT level test help me? And if so, who does them?
6) Should I go see a neurologist?
7) Do antidepressants release more serotonin, dopamine, or norepinephrine into your body?
Again, I appreciate you taking the time to read through this! I should mention I am in the Orlando, Florida area.
Sincerely,
Joseph Gomez
Joey,
Very short response as I have to get out on the road today:
I don’t agree with the online doc that you are completely fried on your receptors – implying you won’t recover. With supplements and neurotransmitter [NT] replacements, you can recover, no doubt. Simple to measure the deficiencies and imbalances and get started there. Without measurement you will be only shooting geese at night.
Local Psychpharms are hooked up in the phone book or at your local medical school, and a simpler call to the office will tell you what they do.
Test for NT are discussed here on the NeuroScience page at CorePsych.
All those test could be helpful I am recommending that you start with the least costly – NT testing is paid for by many insurances.
No on the neurologist [most of them].
Antidepressants only modify what you have on board.
cp
Dr. Parker,
Thank you for your reply!
I have searched the “NeuroScience page at CorePsych.” page you mentioned, and I am not sure what NT tests you are talking about. Could you please tell me what NT tests you are talking about?
Thank you!
Joey
Joey,
The testing is for specific neurotransmitters, 12 of them, and each of the neurotransmitter test examples on that page [NeuroAdrenal and NeuroEndocrine Samples] show specifically the neurotransmitter biomarker results. Just go down the page past the Adrenal and Hormone results, and you will see examples of those specifically tested.
We can send you the test, and can review the results by phone for specific recommendations on the specific amino acids interventions in question. Take a look at those and get back if those sample results and the other downloads don’t answer your questions.- Looks like I need an FAQ page!
cp
To Dr. Parker,
Thank you for your reply. I think I am missing something though. I am still having trouble locating what you are talking about. Is it under this section on that page…
Administrative Details: Testing Options
Neurotransmitter Precursor Test: 12 Neurotransmitters – [Download PDF: Neurotransmitter Test Info]
Neuroendocrine Test: 12 Neurotransmitters, 4 cortisols, & 6 sex hormones – [Download PDF: Neuroendocrine Test Info]
Food Sensitivity Tests: AutoImmune Testing for up to 110 Food Sensitivities – [Download PDF: Food Sensitivity Testing]
NeuroScience Product List: Linked details at NeuroScience and Quick Reference Chart
Thanks,
Joey
Joey,
Sorry I thought you were on the Neuroscience page when you posted this comment. Most of the testing info is on the Neuroscience page linked for your review. The testing examples give outcomes if you look under the Neurotransmitter sections of the test beginning with Epinephrine and Norepinephrin.
Remember, they may no assertion, nor do I, that these are diagnostic per se – you can’t pop over with a DSM-4 diagnosis – but you can draw biomarker implications that very frequently prove useful clinically. With this interesting information we are turning many around that appeared refractory even though all parties were on board and fully cooperating with all treatment parameters.
Please let me know if this does cover it.
Best for the Holidays-
cp
Dr Parker,
I have seen dramatic improvement in my health since following your reccomendations for treatment of my taurine and neur-transmitter problems.
I was wondering if there is any research into treating MS using some of the supplements that Neuro-Science provides, the Partient that I know also obstains from eating any animal meat due to religous beliefs . This concerns me that she may be having symptoms that are related more to her diet choices than the disease. I ve seen several animal studies that had very bad outcomes with a Vegan diet in rodents and higher animals like cats.
I don’t know how a patient with MS can have normal amino-acids and dietary protein if their only source is Soy products and Vegan diet. Also many of the Meds she’s on have dramatic effects on health, example ATZ.
Doug
Doug,
I can tell you without reservation that the problem of diminished protein significantly effects neurotransmitter levels, and will, furthermore, encourage very weak outcomes if any psych meds are used. MS is clearly related to an immune dysfunction, and neuroimmune issues always cloud the outcome from both a physiologic and psychological perspective. If you Google MS and D3 you will see much has been written about that relationship.
Having said those general remarks it appears that MS, like autism, has many contributing factors, and it would be an oversight to look at only one aspect of comprehensive intervention strategies. David Perlmutter covers the MS subject well in his Better Brain Book.
Very pleased to hear you are coming along with the targeted amino acid intervention strategy!
cp
Hello Dr. Parker,
Well Dr. back on July third I wrote to you and you answerd on the fifth and the bliss just keeps getting clearer and calm this connection with life in geral and the only way to explain what is flowing from my brain to my heart the picture that keeps comming into view is how most people are programed and follow what I call the pied piper and now that i have separated myself from this way of life I find that everything is working with me even sleep I have never been able to sleep my whole life so about 10 months ago when I would write around 2 am i used to back to bed toss and turn till it was time to get up and all the doctors would put me on sleep meds and they never worked so now I just stay up and do little meditations once or twice a day for about 2 minutes and now I sleep about 1 and a half hours each night and feel better than ever and feel I am mentaly getting younger can you explain this and I the only one?
Thank You Dr.
peace
Ronald,
You and Edison may be one for the books. That level of sleep will most often leave you with significant impairments cognitively and affectively. The sleep experts all suggest 8.25 hrs for Total Ave Hr [TAH] of sleep to accomplish the brain desktop defrag. Without examining you, without more specific conversation, it does sound like your excitatory neurotransmitters are on the top side, and running your brain around a bit too much for a healthy nocturnal defrag – but then each to his own, if it’s not a problem, it’s not a problem.
cp
Dr. Parker–
I’ve become familiar with your work through the online ADHD conference earlier this month. I’ve learned a lot and continue to read your articles. Could I please just ask a quick question? You talk about the dangers of ADHD meds plus depression meds, but I know it’s really just certain meds. I’ve been reading and re-reading and am not sure I have a handle on the specifics.
So my simply question: what about daily Concerta (72 mg) and daily Prozac (40 mg)? If that’s not a good combo metabolically, what might you suggest a patient of yours try next?
Bonnie
Bonnie,
Prozac and Paxil often create long term interaction problems at the dosages you are on. Best antidepressants: Effexor XR, Pristiq, Lexapro and Celexa, all quite clean on 2D6 interactions. For most I prefer, as studies show, the AMP products, but some simply can’t take them – favorite there is Vyvanse with several articles here, just Search that term.
cp
Dr. Parker,
I am so appreciative that you took time to respond so quickly to my question. It’s been so difficult to find a professional in my area–I’m sure you hear that all the time. My son and I were both diagnosed with ADD (ADHD for my 10 year old) within the last 18 months. But I was diagnosed with depression 10 years ago.
Our family practitioner is wonderful and willing to prescribe, but she’s a generalist and relies on me to do research and bring it to her. That’s why I’ve been pursuing this Prozac/Concerta question.
I’m 47 and have discovered through trial and error that, though I’d rather not need any meds, I really do need both an antidepressant and an ADD stimulant med. My goal is to find a combination that’s effective for me, but also without any of the potential problem interactions that you discussed.
If I could please trouble you with one more question before I see her? If I had come to see you, having been taking Prozac 40 mg and Concerta 72 mg daily for a few months (and doing okay) but you were concerned about that combination, would you switch both of them at once? Or one at a time?
Grateful for your research,
Bonnie
Bonnie,
Smart move making the change early before the problems. Just get rid of the prozac and switch to a cleaner antidepressant [AD] as outlined previously. Concerta will be clean with the other meds, just not prozac and paxil. With prozac there is no discontinuation, and you can just, with your doc, stop it cold turkey, – but do get the other AD running simultaneously with the discontinuation… no taper needed on prozac, and that is the only one you don’t need to taper.
cp
Dr. Parker
I’m an adult who was diagnosed with ADHD in January of this year by my family doctor. I have been having a nightmarish time finding an Adult AHDH specialist in my area. I live near Barrie Ontario Canada (Toronto would be the closest major city) Although I have an amazing doctor with are struggling to find a medication to assist in the management of my ADHD symptoms. My hyperactivity, poor focus, easy distractability and lack of completion of tasks are my main areas of concern. I also am very sensitive to stimulus. I get very overwhelmed in Big box stores like Walmart because there are too many things that distract me. My brain almost boggles!
We have tried Strattera and have had no results. My Dr. suggested trying Seroquel (to assist especially with sleep) I had a horrible reaction to it and had to stop immediately. I am currently on Adderall XR we started slowly and I noticed that 25 seemed to be my optimal dose but I would crash in the afternoon. My dr tried Divoprotec (no results) she suggest we drop the Adderal to 20 in the morning at around 9am and add 10mg at 2pm. Nothing seems to be helping at this point.
I’m currently taking sleeping medication as well. My sleep issues occurred before beginning the ADHD meds. My brain just doesn’t slow down at night and I was waking up in the middle of the night going through my to do list or getting brilliant ideas about paint color etc for our reno project. I’m on 15 mg of Zopiclone and 15mg of Temazepam nightly for sleep.
If you can suggest a specialist that can assist in the medication department I would geatly appreciated it. I have began the process of educating myself and find that the more I continue the more frustrated that i’m getting.
Thanks
Coreena
Coreena-
Sorry to get back so late – simply don’t have an easy answer for the complicated situation. Only thing I tell my own patients: If you aren’t happy with what I am doing I will support and encourage you to find another opinion.
When I was a kid in Missouri and Indiana I had no idea what a psychiatrist was… they didn’t have any in the small towns, and I can appreciate the challenge. If you don’t find someone local do pack up and get over to the nearest med school up there with an appointment for a second opinion. You just don’t have to live that way, and deserve a better shot at turning it all around.
cp
Dr. Parker,
We are struggling with helping our 7 1/2 yr. old son who has a working diagnosis of ADHD- impulsive type, but he is not a textbook picture of it. He functions fairly well at school, excels academically so far. Our biggest presenting problem is daytime urinary incontinence – he just cannot seem to stay dry all day long. When we ask him why he has accidents he says “I just couldn’t stop having fun”. Using the bathroom has never been a priority for him, he has always viewed it as a nuisance or interference to his day. After hearing a psychologist talk about behavior regulation last spring we decided to have him evaluated for ADHD and reframe the issue as one of not being able to shift attention. He just did a trial of Focalin XR but when we moved up to a 15 mg dose he became too overly emotional (crying, etc.) so we discontinued it and have just started adderall 10 mg. He is also working with a psychologist on a behavioral toileting plan but this is the 3rd time we have sought professional help for this problem, we began when he was 4 and having both bowel and bladder incontinence, and frankly we are still not seeing too much progress using a behavioral approach. The bowel issue is mostly resolved although he still has times when it seems like he “waits too long” and ends up with some BM in his underpants. We are also pursuing OT evaluation for sensory processing issues as he seems so unaware when he has accidents much of the time and fails to recognize his body’s signals. Have you seen this problem before and do you have any suggestions of other ways to treat it? As of now it does not seem to affecting his peer relationships but the time will come when others will notice and frankly I am tired of having to deal with the messes (he cleans himself up to the extent he is able to).
He is also very defiant at times and difficult to manage because he ALWAYS want to do things his way – the classic “marching to the beat of his own drummer”. Thankfully so far he has not challenged authority at school or elsewhere, only at home. He also physically assaults me at times when he gets too frustrated – that has to stop as he takes karate and is becoming too strong. In short, he is exhausting to parent. Any insights or suggestions you can offer would be most welcome. Thank you and God bless.
Kelly,
Recommend several things [yes have seen this many times]:
1. do the neurotransmitter testing mentioned on my site to cover the fact that he appears refractory to meds – Probably too high on glutamate or PEA – excitatory neurotransmitters.
2. consider neurofeedback, – often helps in this kind of situation
3. crash likely associated with some depression – which often shows as not caring… don’t know on this without eval.
4. but still think that a very careful titration of Vyvanse may help a bit as he has some improvement.
Hope these remarks help -
cp
Dr. Parker, My daughter was diagnosed with ADHD – Inattentive type – at the end of her freshman year of high school. She wasn’t remembering information given in class and constantly forgetting to turn things in even if she remembered to do them. She was originally on Focalin XR and did well, except for appetite suppression. We switched her to Vyvanse ( 50mg.) her junior year and things really clicked well educationally, though she didn’t like taking the meds – often hid them so she wouldn’t have to take them. She said she sometimes felt weird on it and it really affected her appetite and she wanted to be able to eat during the day. We have so many more conflicts with her when she is off her meds, and it becomes difficult to communicate with her. She is a sophomore theatre major in college, starting back in two weeks. Her daily schedule is erratic. Some days she has a class at 9:15, others not until afternoon, and many nights is at rehearsals until 10p.m. On the days she does not have to be up until afternoon, she sleeps in in the morning. Questions: 1) Is dosage simply about duration of effectiveness, or is it also about ability to focus. In other words, if she switched from 50mg to 40mg, would it simply last fewer hours, or would it also not give her the degree of focus that 50mg would. 2) Could she take a lower dose on those days she sleeps in and only needs to be medicated from noon til 8p.m. (8 hours) than if she needed to be medicated for 12 -14? She doesn’t like taking her Vyvanse in the afternoon because it will keep her up too late, but is concerned that a lower dose won’t be as effective cognitively, even if for a fewer number of hours. 3) If she functions cognitively on more than one dose, is there any reason she couldn’t simply take the dose needed for the shorter number of functioning hours? Compliance has always been an issue – a friend of hers once told her she was more “fun” off her meds, so I think she developed the idea that, as a theatre student, she may be more creative off her meds (her professor has told us that that is a myth and that he find ADHD kids off their meds are often less reliable and that focus is needed for creative expression, not impulsiveness). After watching one of your YOUTUBE segments, I’m wondering if 50mg is too high a dose for her since compliance has been such an issue. When she first started on it, they only had 30mg as a lower dose and she said she didn’t get the same focus that she did on 50mg. Maybe 40mg. would be just right? Any insights or suggestions would be greatly appreciated!! Thank you!!
Kathy,
Your girl needs some more information for the best adjustment with her medical team. With someone who has such an erratic schedule the specifics of DOE matter even more. I strongly suggest she sit down and keep a journal, noting exactly when she took it, and when the cognitive drive drifts away each day regardless of the time she takes it – to record and consider the specifics. The good thing about Vyvanse: it is so predictable when you actually know what the medication is doing. She will notice that closer to 12 noon will often take her past midnight if the dose is accurately adjusted for a 12 hr DOE – don’t know why – but that will give her specifics on the latest dosage time.
Honestly, she needs some good coaching on the entire matter once she has the clear information. I always do my best to twist the college folks into some routine, a grid that works for their variables on those specific days, and a grid for other, earlier days. Naturally it would be best to simply get up every morning and be done with the stress of ineffective structure. Yes, she might need two different doses, but that would be, from my own experience the rare exception [I never do it] because:
1. Two different scripts will confuse the pharmacist and the insurance company as it is a controlled substances,
2. She is likely away at school, and that will create office refill problems for any of her docs.
3. She could remain confused if she doesn’t just get it organized – more choices = more over thinking.
A solution that works for many of my college folk that builds a bit of flexibility:
go for either [in this specific situation for example]
1. Vyvanse 20, 2 in the AM [=40] or, one in the AM and one a bit later to cover those late rehearsals. [one script]
2. Vyvanse 10 5/day as indicated by DOE [one script] If the 10 runs for 4-5 hrs then you will know when to take it, and you still have the advantage of the prodrug release.
Dosage can influence not only DOE, but efficacy and focus thru the day, most often both. If someone is out at 3pm from a 7am dose, the dose will not work as well and the DOE is too short for that specific dose. It’s ineffective all around.
Time for a good sit down, structure chalk talk with parents and doc before heading out to school.
cp
Hello, I was diagnosed about two years ago with adhd ocd I think all the d’s I had never in my life read a book or never did home work and taled my way through school. I have only worked for myself my whole life and have masterd my work and since being diagnosed at age 48 now at 51 I am like a computer my knowledge is like google I have no idea were it comes from, I am now writing poetry and am winning all kinds of competitions as well as being offerd scholerships from big schools such as Rutgers Stanford and many more. I can also feel my blood going thru my body I can hear my heat beating and am in touch with the function of my body, I just do not understand what is happining to me and sometimes feel as if im going crazy in a good way though and I want to help people with this, children with this cling to me. Also I have as a young child had many bad ear problems and I had a twin brother who passed as a baby and this past year found his grave site with no directions and went excatlt to the site almost IMPOSSIBLE, I am searching for tecnologicl help.
Thank You.
Ron Sorenson
Ronald,
Interesting phenomenon; coming out of the cognitive fog and into the reality of life change and increased perceptions. Many with ADHD have very little recall of their childhoods, sometimes because they ‘had problems,’ and most often simply because their head was always full of stuff, living in the clouds of unmanageable cognitive abundance. It may look like OCD, but rarely is only OCD – as OCD and ADHD are really spectrum disorders with many reality contributions beneath the surface.
Stimulants for ADHD that correct the ‘foggy’ often create a surprising 3 mo period of time at the onset of meds, when the person worries they will loose the new perception and the new skills – I see it so often I call it the Acceptance Phase of treatment. The next phase, often about another 3 mos, but often lasting longer, is the Crystallization Phase. – Who they are consolidates and crystallizes with the self observation that “I can be this new person for the rest of my life.” They accept this new awareness process and can then develop it further, for their own development, and often with improved awareness of how they contribute appropriately to the lives of others. It’s more than a self esteem, self mastery process, but with an ability to sort reality, they see how they can make the contribution they always wished to make and set off on that process.
I have seen many folks over the years who have surprising connections with the ‘Mystic’ – the connection with people and situations outside of science, outside of our measurable awareness. Connections with the Mystic provide significant big picture awareness that can be completely unpredictable. My short take on your gift: walk with it, develop it and don’t question it. Some very intuitive people are significantly connected to the other side,
Best on the path,
Congratulations on finding that part of you,
cp
I can’t find where to get biofeedback in the jacksonville area. Please avise.
William,
Provider links are on the handout for the Neurofeedback Program #17 downloadable at CorePsych Radio Their providers are top notch.
cp