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8 yr old with frequent angry outbursts diagnosed with several disorders
We have an 8 yr old boy who has been fully evaluated 2yrs ago. The results were 99th perceptible for iQ, adhd and possible ODD. We have since taken him to a number of drs and therapists. His first grade year went pretty smooth a few hiccups but mostly good. At home we didn't see to many. His dad deployed this past july 2014 and he same day his first major angry outburst. They started increasing over the summer and now in the 2nd grade it's almost a daily occurrence. He just had one a few minutes ago at a kids gymnastics he started running around screaming without any regard for who was watching. He was taking 50 mg of Zoloft he is now being weaned off to 25 mg. he takes 25 mg straterra in the am and 2.5 mg of abilify in the evening with the 25 mg of Zoloft. Please if anyone has any thoughts, info, techniques, that could help us please let me know. I'm feeling overwhelmed and scared for him.
COMMUNITY LEADER
He has been off strattera for about a week. How has he been at home? Does he have more energy? More meltdowns? Did you notice a difference.
Curious, before you said she when talking about the nurse practitioner. And now you just said He added strattera back on. typing error or different doctors? And I would start with a low dose of strattera. How much did the doc say to go on?
I completely agree with your therapist. The school does not appear to be helping him. Because he does not want to do his writing is no reason to send him to the principal. But I don't know all that went on in the classroom. But as I said earlier, they need to learn his triggers and avoid them. If one of my teachers (when I was a principal) had sent me a child because he didn't do his writing - I would have been upset with the teacher not the child. But here again - I don't know what went on in the classroom.
There is a small amount of validity to having Alex there only two hours a day (very small, by the way). That should only happen if it is for a short time and if they have a written IEP for him. And that is the big deal. They cannot limit him to two hours a day.
Am I correct in that they do not have a IEP or 504 plan for him? If they don't. Nothing happens until they do. Get your therapist to help you on this.
So, important questions are:
How has he been at home since going off the strattera? Oh, and you also tapered off the zoloft too? So notice differences during the day. In other words was he better or worse at certain times of the day.
Is the this same prescribing doc - he or she question above.
Does he have an IEP or a 504 plan in place?
By the way, share Dr.Parkers thoughts on a strattera buildup with your therapist.
Curious, before you said she when talking about the nurse practitioner. And now you just said He added strattera back on. typing error or different doctors? And I would start with a low dose of strattera. How much did the doc say to go on?
I completely agree with your therapist. The school does not appear to be helping him. Because he does not want to do his writing is no reason to send him to the principal. But I don't know all that went on in the classroom. But as I said earlier, they need to learn his triggers and avoid them. If one of my teachers (when I was a principal) had sent me a child because he didn't do his writing - I would have been upset with the teacher not the child. But here again - I don't know what went on in the classroom.
There is a small amount of validity to having Alex there only two hours a day (very small, by the way). That should only happen if it is for a short time and if they have a written IEP for him. And that is the big deal. They cannot limit him to two hours a day.
Am I correct in that they do not have a IEP or 504 plan for him? If they don't. Nothing happens until they do. Get your therapist to help you on this.
So, important questions are:
How has he been at home since going off the strattera? Oh, and you also tapered off the zoloft too? So notice differences during the day. In other words was he better or worse at certain times of the day.
Is the this same prescribing doc - he or she question above.
Does he have an IEP or a 504 plan in place?
By the way, share Dr.Parkers thoughts on a strattera buildup with your therapist.
We've had a run of very bad days. It was his birthday on thurs. He got in a bit of trouble. Then on Friday he refused to do his writing and got sent to principals office. He didn't calm down there he wanted to go with the counselor (b/c he didn't talk to Alex just let him sit in a chair while he did work) next thing you know he tried to leave and he said he was going to hit the principal (this is not the real alex at all) something has seriously changed in him:-(. So the principal informed me he only wants alex there 2 hrs a day. We have a meeting tomorrow morning. Our private therapist is meeting us to help advocate for him. She feels that this isn't acceptable and that he had a bad day/week and they need to help accomidate him esp with the writing issues.
Mean time I contated his dr abt meds and they said to go back to 50 mg zoloft. Then I made a appt on friday and he added strattera back as well so we are back on all 3 meds.
I think I am going to need anxiety meds of my own pretty soon...
Mean time I contated his dr abt meds and they said to go back to 50 mg zoloft. Then I made a appt on friday and he added strattera back as well so we are back on all 3 meds.
I think I am going to need anxiety meds of my own pretty soon...
COMMUNITY LEADER
So almost 3 weeks. By now the teacher should have an idea what is going on. Its really important for her to realize what is going on with him and looks at ways to minimize stress and then have signals for him to give when getting stressed and then a place to go to unwind.
Lots of ideas here that might be useful - http://www.additudemag.com/adhd/article/10820.html
Sorry to hear about the wait with Tricare, but I am familiar with the system.
Your school psychologist, school counselor, and therapist should also be trying to help out the teacher as much as possible. Oh, and bring her lots of apples and cookies :)
Do let me know how backing off the strattera works. From what Dr. Parker has said, it should give him his energy back which I think will actually be a good thing.
Lots of ideas here that might be useful - http://www.additudemag.com/adhd/article/10820.html
Sorry to hear about the wait with Tricare, but I am familiar with the system.
Your school psychologist, school counselor, and therapist should also be trying to help out the teacher as much as possible. Oh, and bring her lots of apples and cookies :)
Do let me know how backing off the strattera works. From what Dr. Parker has said, it should give him his energy back which I think will actually be a good thing.
He started July 31st. I am waiting on the primary care dr to get approval from our ins (Military tricare prime) then I believe within the next week the OT will call and/or mail me paperwork to fill out. So, longer than i would prefer but thats the way it is with tricare (referrals)
COMMUNITY LEADER
Tell me again how long he has been in school this year! A week, two weeks? Cause a lot of these frustrations can be prevented or lessened. And I hear you about the not knowing. Tapering down is good.
When is he seeing the OT?
When is he seeing the OT?
Yes I would definitely try to taper them down for sure. I think most of his triggers are the writing he always gets frustrated and distracted and says he needs a lot more time than what they give. Him. I sent her an email Monday morning because I knew what the weekend looks like so I anticipated that Monday would look much the same. That's when she sent me that email back letting me know about the cabinet in multiple outbursts. He also had a really bad sore throat yesterday and then overnight tonight I had a earache and fever, so I'm curious if that might've played into the behaviors we've seen. This whole process is very hard on mama. Just seems like with the physical ailment you go to the doctor they prescribe exactly what you need they can pinpoint what's wrong but with this whole mental health is just so grayt I just seems like one guess after the next
COMMUNITY LEADER
Oh, and do make sure his teacher knows what is going on and is doing things to lessen the stress. lots of classroom techniques for that. When did school start for him this year?
And, I would talk to teacher and see if she knows why or what stressed him out to jump off the cabinet. Learning his triggers is really important.
And, I would talk to teacher and see if she knows why or what stressed him out to jump off the cabinet. Learning his triggers is really important.
COMMUNITY LEADER
Be careful, some of those meds have to be tapered down. Bad side affects otherwise. Dropping the strattera is a good idea. It might take a couple of days to get completely out of his system. So give it a couple of days.
Sorry Monday and back to school for everybody haven't had much time to respond back. I'm so grateful for you taking time to help us out and to contact Dr. Parker that means so much!! He had another rough day at school today lots of frustrations and stress. I called and left a message for the nurse practitioner and she recommended stopping the Strattera for the next few days and see how that works. I'd he stays same or worsens add back 50 mg of Zoloft. apparently he jumped off of the cabinet in the classroom. Didn't want to have testing folders around desk. Long story short a bad day. I'm telling you he is normal polite and a decent kid. But when h le gets stressed it's like Jekyll and Hyde! And it happens in a few seconds. So his suggestion would be to prob get rid of abilify. I'm almost tempted to pull the plug on all meds for awhile and see what happens. I am so curious of how he behaves. If it's obvious he needs meds or if the meds are what's to blame.
COMMUNITY LEADER
Oh, Dr. Parker also added that, Abilify could add to soporific problems if either not indicated, or metabolized too slowly."
COMMUNITY LEADER
Just got another reply back from Dr. Parker. He said,
"Another early morning reply! Yes, genetic testing is showing the strong likelihood of med accumulation that will create side effects. One of the main side effects of Strattera, a 2D6 substrate, is that it clearly will create tiredness. I had one adolescent girl fall asleep on the tile floor in the bathroom in HS and they searched all over thinking she had run from school. No interaction w Zoloft tho.
Read more: http://www.corepsych.com/2009/11/intuniv-for-adhd-dosing-details/#ixzz3Al30T3FO
It really sounds like the strattera is building up.
Besides Specialmoms excellent ideas on dealing with angry outbursts, you also might look into buying "Don't Rave and Rant on Wednesdays". You can find it here - http://www.amazon.com/Dont-Rant-Rave-Wednesdays-Anger-Control/dp/0933849540/
the same author also has an excellent anti-stress book called, "don't pop your cork on Mondays" which you can find below the review on the site I listed. These books are meant for 9 year olds and up. There is another set of books for the 4 to 8 crowd. A good one is "Cool down and work through Anger" found here - http://www.amazon.com/Cool-Through-Anger-Learning-Along%C2%AE/dp/1575423464/ref=pd_sim_b_2?ie=UTF8&refRID=03YVNRTXF6Q0K4VQ7M8W
Let me know how the OT meeting goes. Good Luck!
"Another early morning reply! Yes, genetic testing is showing the strong likelihood of med accumulation that will create side effects. One of the main side effects of Strattera, a 2D6 substrate, is that it clearly will create tiredness. I had one adolescent girl fall asleep on the tile floor in the bathroom in HS and they searched all over thinking she had run from school. No interaction w Zoloft tho.
Read more: http://www.corepsych.com/2009/11/intuniv-for-adhd-dosing-details/#ixzz3Al30T3FO
It really sounds like the strattera is building up.
Besides Specialmoms excellent ideas on dealing with angry outbursts, you also might look into buying "Don't Rave and Rant on Wednesdays". You can find it here - http://www.amazon.com/Dont-Rant-Rave-Wednesdays-Anger-Control/dp/0933849540/
the same author also has an excellent anti-stress book called, "don't pop your cork on Mondays" which you can find below the review on the site I listed. These books are meant for 9 year olds and up. There is another set of books for the 4 to 8 crowd. A good one is "Cool down and work through Anger" found here - http://www.amazon.com/Cool-Through-Anger-Learning-Along%C2%AE/dp/1575423464/ref=pd_sim_b_2?ie=UTF8&refRID=03YVNRTXF6Q0K4VQ7M8W
Let me know how the OT meeting goes. Good Luck!
COMMUNITY LEADER
Just found this regarding metabolism:
Problem #2: Neglecting the Evidence of Metabolic Rate:
! Don’t worry; this *metabolic rate* thing will be easy. Think burn rate: fast or slow
burn. Fast burn rates require much more medication to correct the symptom picture,
and slow burn rates require much less medication. Slow burn rates can create
unpredictable toxicity, even with “average” doses. Think about it: Fast burn is like pine
wood on a fire, slow burns like an oak Yule log. Fast needs more meds, slow rates need
lower doses. Many are simply not paying attention to the way medications burn, or the
body biologic factors that effect the actual, biologically-based burn rate of ADHD meds.
! Age, weight, body size, gender, do not consistently effect the burn rate. Autism,
brain injury,10 Asperger’s, and a wide variety of metabolic variables often do effect the
burn rate, and become far more indicative of sensitivity to medications than those
previous markers – often creating a very slow burn rate. Remember that slow burn rate
will almost always show a relative toxicity, resulting in unwanted side effects, even at
Predictable Solutions For ADHD Medications
New ADHD Medication Rules - © Dr Charles Parker! 8
9 Context and changing reality matter: Brief Video On ADHD Context
10 CorePsych Article: Brain Injury and ADHD - Often Overlooked
even low doses. ADHD meds will become far too stimulating, and just won’t work
right.
! Knowing burn rate, understanding the underlying metabolic challenges, will
make medication adjustments far more predictable
Problem #2: Neglecting the Evidence of Metabolic Rate:
! Don’t worry; this *metabolic rate* thing will be easy. Think burn rate: fast or slow
burn. Fast burn rates require much more medication to correct the symptom picture,
and slow burn rates require much less medication. Slow burn rates can create
unpredictable toxicity, even with “average” doses. Think about it: Fast burn is like pine
wood on a fire, slow burns like an oak Yule log. Fast needs more meds, slow rates need
lower doses. Many are simply not paying attention to the way medications burn, or the
body biologic factors that effect the actual, biologically-based burn rate of ADHD meds.
! Age, weight, body size, gender, do not consistently effect the burn rate. Autism,
brain injury,10 Asperger’s, and a wide variety of metabolic variables often do effect the
burn rate, and become far more indicative of sensitivity to medications than those
previous markers – often creating a very slow burn rate. Remember that slow burn rate
will almost always show a relative toxicity, resulting in unwanted side effects, even at
Predictable Solutions For ADHD Medications
New ADHD Medication Rules - © Dr Charles Parker! 8
9 Context and changing reality matter: Brief Video On ADHD Context
10 CorePsych Article: Brain Injury and ADHD - Often Overlooked
even low doses. ADHD meds will become far too stimulating, and just won’t work
right.
! Knowing burn rate, understanding the underlying metabolic challenges, will
make medication adjustments far more predictable
COMMUNITY LEADER
Thanks for all the new info. Wondering he had the low energy problems before the straterra was bumped up to 25 mgs or even before he started the straterra. Have you discussed his tiring out quickly with his doc. How is his weight. does he get a good breakfast?
Dr. Parker got back to me. Can't believe it - he replied at 6am on a Sunday morning! I quote him below. Oh, I also just emailed him again with the new info you gave me on the meds and the metabolism info. I missed that the first time. That really might be part of the problem. I will explain after his quote.
"Sandman,
Strattera is also a 2D6 substrate, but Zoloft is not a significant 2D6 blocker. More likely is the problem of elemental neurotransmitter imbalances living downstream from immunity issues. Norepinephrine is the neurotransmitter collected by Strattera, and if it is elevated already by immunity issues Strattera will cause problems, just as in the case of Intuniv with backup glutamate secondary to immunity issues.
I would welcome the opportunity to work with you to help you assess these matters w your clients. Take a look at the tests at this link: http://corepsych.com/tests14 – For cost effectiveness the IgG Great Plains and the TMA. Neurotransmitters are interesting, have seen hundreds, but IgG and TMA drive more to underlying core issues. If issues don’t correct with those two then we dig deeper w OATS and NT to cover other contributory possibilities. Links on the PDF will give you even more instructions.
Read more: http://www.corepsych.com/2009/11/intuniv-for-adhd-dosing-details/#ixzz3AgmPI1ho
Basically immunity issues are food issues that effect how the meds work. things like gluten, milk, etc. this link explains the whole idea thrugh a series of short videos by Dr. Parker.
http://www.corepsych.com/2013/03/adhd-insights-8-videos-immunity-gut-meds/.
and here is a link to a search of "immunity" on his site.
http://www.corepsych.com/?s=immunity+issues
Its possible that the immunity issues allow the straterra to build up and cause the outbreaks. Anyway, we'll see if Dr. Parker will get back to me.
This is all info that you may want to share with your doc.
Hope this does not get to confusing, but its possible that some things are coming together.
Dr. Parker got back to me. Can't believe it - he replied at 6am on a Sunday morning! I quote him below. Oh, I also just emailed him again with the new info you gave me on the meds and the metabolism info. I missed that the first time. That really might be part of the problem. I will explain after his quote.
"Sandman,
Strattera is also a 2D6 substrate, but Zoloft is not a significant 2D6 blocker. More likely is the problem of elemental neurotransmitter imbalances living downstream from immunity issues. Norepinephrine is the neurotransmitter collected by Strattera, and if it is elevated already by immunity issues Strattera will cause problems, just as in the case of Intuniv with backup glutamate secondary to immunity issues.
I would welcome the opportunity to work with you to help you assess these matters w your clients. Take a look at the tests at this link: http://corepsych.com/tests14 – For cost effectiveness the IgG Great Plains and the TMA. Neurotransmitters are interesting, have seen hundreds, but IgG and TMA drive more to underlying core issues. If issues don’t correct with those two then we dig deeper w OATS and NT to cover other contributory possibilities. Links on the PDF will give you even more instructions.
Read more: http://www.corepsych.com/2009/11/intuniv-for-adhd-dosing-details/#ixzz3AgmPI1ho
Basically immunity issues are food issues that effect how the meds work. things like gluten, milk, etc. this link explains the whole idea thrugh a series of short videos by Dr. Parker.
http://www.corepsych.com/2013/03/adhd-insights-8-videos-immunity-gut-meds/.
and here is a link to a search of "immunity" on his site.
http://www.corepsych.com/?s=immunity+issues
Its possible that the immunity issues allow the straterra to build up and cause the outbreaks. Anyway, we'll see if Dr. Parker will get back to me.
This is all info that you may want to share with your doc.
Hope this does not get to confusing, but its possible that some things are coming together.
Sorry, miss still digging through the archives...sometimes drs seem to think that this could have caused slit of this. When he was born he got stuck in the birth canal. They used a vacuum but it wasn't working so they used forceps. He had.a pretty good sized hematoma on his head. To this day his head is misshapen (the opposite side of the hematoma bulges out more). We've had ct scan (I thinks that's what it's called) twice and nothing was shown to prove any damage.
Also forgot to mention (just remembering as I'm thinking about all this) he officially hasn't been diagnosed with anxiety however the 2nd psychiatrist after I listed his lengthy symptoms is the one that made the determination that anxiety was at play along with the adhd (mainly impulsiveness) she said that anxiety is tricky to treat with adhd, generally that stims may have a neg effect I think she called it I think comorbid?
I'm guessing bc the daytrana patch (lowest dose) on day one of wearing it gave him tics and he was way more emotional. Then they tried adderal not sure amt I'm sure it was a low dose too and same thing minus the tics no visible signs if it helping only more intense emotions.
Yes, I'm sure the physical activity is good for him, he doesn't get enough. Usually he isn't motivated to get outside too much, he seems to tire pretty quick. I'm pretty sure his meltdowns aren't connected to that bc many times he will still get just as upset after a day walking the zoo (which had splash park and sev playgrounds). Of course he does a good amt of having his moments bouncing around our furniture and such when his waves of energy come But I'm sure extra activity regardless is good for him, hard though being a temp single mom of 3 guys esp with school back in.
We started the Zoloft spring of 2013 and the straterra in Sep or October of 2013.
Yes, I'm sure the physical activity is good for him, he doesn't get enough. Usually he isn't motivated to get outside too much, he seems to tire pretty quick. I'm pretty sure his meltdowns aren't connected to that bc many times he will still get just as upset after a day walking the zoo (which had splash park and sev playgrounds). Of course he does a good amt of having his moments bouncing around our furniture and such when his waves of energy come But I'm sure extra activity regardless is good for him, hard though being a temp single mom of 3 guys esp with school back in.
We started the Zoloft spring of 2013 and the straterra in Sep or October of 2013.
COMMUNITY LEADER
She does appear to be listening to you and adjusting the meds accordingly. Any idea why she choose not to go the stim med route?
By the way, I emailed Dr. Parker at CorePsyc and asked about the possibility of an interaction between the strattera and the zoloft. Doubt that he answers emails over the weekend, but we will see if he gets back to me.
Does your little guy do better if he has lots of physical activity. Many times that can be very helpful. And by that I mean to run him as much as possible.
Oh, do let the OT know what meds he is now on as that might effect things.
Sounds like you started the zoloft in 2013, When did you start the straterra (month and year)?
By the way, I emailed Dr. Parker at CorePsyc and asked about the possibility of an interaction between the strattera and the zoloft. Doubt that he answers emails over the weekend, but we will see if he gets back to me.
Does your little guy do better if he has lots of physical activity. Many times that can be very helpful. And by that I mean to run him as much as possible.
Oh, do let the OT know what meds he is now on as that might effect things.
Sounds like you started the zoloft in 2013, When did you start the straterra (month and year)?
I truly appreciate you taking time to give us advice and to help us figure out the course we need to take. The psychiatric nurse practitioner mentioned seeking a occupational therapist but I mentioned the writing part of it but not for anything else. This lady gets pretty good reviews online. Our current therapist recommended her. Yes the kindergarten where the police were called we never went back to that school system we actually moved to a different school district where there a five-star school. So far the school has been more than accommodating and helpful there's never any blaming me or him for his behavior. I'm very anxious to meet with an occupational therapist and see what the results are of the screening. My prayer would be that he could begin therapy and we can get rid of the medicines. It's just always been so beg women I think it's just a discipline problem the next minute I think it's autism. Then I sometimes think there's just nothing wrong with them then of course he has an outburst a day later:-/
COMMUNITY LEADER
Oh, and if he does have sensory issues - you may be able to stop a lot of the meds. I would certainly ask your doc if he/she is aware of SPD.
COMMUNITY LEADER
If the outbursts have gotten worse, I am thinking it is the interaction between the zoloft and the straterra (but have to research that some more.)
And yes, for ADHD, straterra is only 50% (maybe less) as effective as a stim med. How experienced is this psychiatric nurse practitioner?
glad to see the school is wising up to the fact that your son is not some delinquent, but has a problem that he can not control. And, I have got to say that as a retired elementary school principal, I can't believe that a principal would call in the police to scare a child. Hopefully, he no longer around.
And yes, for ADHD, straterra is only 50% (maybe less) as effective as a stim med. How experienced is this psychiatric nurse practitioner?
glad to see the school is wising up to the fact that your son is not some delinquent, but has a problem that he can not control. And, I have got to say that as a retired elementary school principal, I can't believe that a principal would call in the police to scare a child. Hopefully, he no longer around.
She is a Child and adolescent psychiatric nurse practitioner. We just had a talk with the school on Friday and they are not going to take away recess anymore. They are putting together a behavioral modification plan for him. I would love to see him off all the meds. We are in Indiana. Right now his outbursts seem so bad. I'm guessing bc of the lesser mgs of Zoloft? I'm curious how he will do in 2-3 weeks when he goes to none. Do you believe the straterra is non effective and that a low dose of a stim would work better? And of course stop the abilify too.
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