Expert: Dr Billy Levin - 5/30/2009

Question
QUESTION: Doctor--

I have an 8 year son that has all the symptoms of inattentitve adhd.  We tried several things but ended up with a light dosage focalex med for the past week.  

The first day was GREAT.  And every day has been good until the drug wears off around 5 pm at night and he has become super irritable and angry.  we went out tonight for dinner and he would not even sit with us he was so angry.  It was a horrible dinner and when we got back to the hotel room (on vacation) I told him that the consequences of doing this EVER again would be losing guitar lessons.  He lost his mond and stared crying like crazy.  We checked on line and found that this drug does have an anger side effect but I never want to give it to him again with these types of side effects.  He has never ruined a dinner like that but it is so difficult because he has performed soooo much better at school with the drugs. He loves the drug too and always asks for it! Any advice?  Should we increase to 10mg to carry him throughout the day?  Also, the next question is how direct should we be about all the medication stuff.  I do not ever want him to feel that he is not a good kid with tons of potential.. thoughts????

Bottom line is his moodiness has made us all crazy.  Help!!  Thx Mike

ANSWER: There are so many things I would like to comment on that I would have to write a book to answer all your questions. Nevertheless, if I am to be of some help I would need your express permission to call a spade a spade without offending anybody. However what I would have to say might not be to your or your doctors liking. If you are strong enough I would certainly be willing to help. I would also need to know exactly what dose of the medication he is taking and at what times he takes it and especially what method is used to monitor the effect of his treatment and whether he is receiving any other therapy. What other "things" were tried?

---------- FOLLOW-UP ----------

QUESTION: Thank you Doctor... I can handle it!  My Doctor is not the greatest at this stuff and we are all ears trying to help our youngster. We give 5mg each morning fro the past 2 weeks of Focalin.  We had his teachers monitor him and they gave us a full report that the first day as the drug kicked in really helped him yet later and the week no change.  Passing grades but easily distracted.  We have tried a family psychologist to see if it is depression based as that stuff can run in our family.  She is still observing but sees a little bit of depression. We have heard that nutrition plays a big role too.  Our next plan is to work on the meds to see what works best.  Probably increase to 10 mg per doctors orders or they also advised just taking him off the meds for the summer!  Give me your thoughts and you will not hurt our feelings!  thx--

Answer
It concerned me you stated having already tried many different products. An expert doctor starts you on the ideal treatment and usually within 10 days some improvement can be seen. Did you as parents instigate the changes or were you directed by the doctor to make the changes?
You mentioned a small dose of Facalex? Did you mean  Focalin?
Out of interest, there is only one dose that works and that is the so called  optimal dose. Too much or too little does not work. This dose is based on response and not age or weight. Rating scales are the only real way to evaluate an optimal dose, yet they are not even mention.
For a treatment to be successful the parents need to be fully informed by the treating doctor about side effects and how to deal with them. It was obvious to me the parents were groping in the dark.  When he reacted in the evening with a typical rebound reaction when medication had faded instead of recognizing it and knowing how to handle it he was threatened with punishment. Hardly a way to success! Rebound is real and difficult for both parent and child unless the parents are prepared for it and can manage it for the sake of the child. “Add on” medication is occasionally need as well besides the stimulants..
 Do not ask you son to listen or co operate until he is teachable. He will only be teachable when his dose is optimal.  Safe and correct medication used in the correct way to cover the whole day will be the first step on the long ladder to success.
ADD often needs remedial therapy as well.
Have a friendly talk with  the treating doctor. I sincerely  hope he will be able to help you. Medication is every day including week ends and holidays. ADHD is NOT a part time condition. There is so much more but this to start  with.