Expert: Joyce A. Anthony - 11/26/2010

Question
QUESTION: In reading your answers to another parent in the same situation I hear you loud and clear about stablizing the mood first. My son has had 2 long term PTRF stays and we are on our third. His ADHD is severe. His IQ is average but he tests in the 95th percentile nationally in Reading, Math and Social Studies on Standardized tests and gets all A's and B''s. He has no IEP or 504. I am concerned that once we stabilize his mood which seem to going down the road of sedative medications that it is going to impact his cognitive level of functioning. If we do not add the stimulant back in to his  treatment. I am scared for my child. He has so many education opportunities open to him that his behavior and impulsivity will close the door on him if we can not get to a functioning balance. Please help.

ANSWER: Hi Elizabeth!

I can fully understand your concern, but hopefully I can help ease some of your worry.  I rarely use my own son as an example, but your son sounds so much like him I think it is perfect.

My son was tested at a higher IQ and was an A student before we started homeschooling.  He is now way beyond where he should be without the school limits.  Like your son, he had a hard time concentrating because of the ADD and bipolar disorder.  Following my own advice, we concentrated on the bipolar disorder.  After many trials, a combination of Lamictal and Seroquel was tried.

These were new at the time, but have quickly shown such promise they are becoming the combination of choice for kids who have had little success with other treatments. There are few side effects of either drug and for some reason the combination also takes care of ADD traits, making it unnecessary in approximately eighty percent to add a stimulant.  Both the bipolar and ADD are regulated.

Not only did this combination allow my son to have a mind that was settled enough to learn, it helped him excel.  In addition, he is on his way to art school in Pittsburgh next fall as he graduates in the spring.

You will see that once your son is stabilized, so much of his energy can be used toward things like learning.  His focus will improve greatly, yet he should not feel drugged.  In fact, any drug that does not allow him to function like a normal human is either the incorrect medication or too high a dose.The correct medication allows a child to function to the point that a stranger would never guess he/she was on any--yet the behavior is under control and the child can enjoy being a child again.

I do hope this has helped.  I wish you and your son the best of luck!
         Joyce A. Anthony

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

QUESTION: Currently my son is on Lamictal 25mg at 8 am
         Risperdal 1mg at am
         Tenex 1mg at 8 am
He then gets          Risperdal 1mg at 2 pm
He then gets          Tenex     1mg at 3 pm
He then gets          Lamictal  25mg at 7pm
         Loratadine 10 mg at7pm
         Risperdal  1mg at 7 pm
         Celexa     10 mg at 7pm
He made it off red level for the first time today in 3 months. I know that we are headed in the right direction. I also know in my gut that my son needs his Concerta 27 to balance out this other regimen. At this current time he cannot stay awake past 6pm. He said he feels out of it all day and cannot complete homework. But yeah we have no agitation or aggressive outbursts.Can't we add his Concerta back in and work with adjusting his risperdal if the aggression and agitation return? An 11 year old boy needs to be awake and alert enough to stay awake until atleast 8pm. Please help.




ANSWER: Elizabeth:

I can understand exactly why your son is so tired. Risperdal, Tenex, and Celexa all cause drowsiness.  Loratadine, which is an allergy medication, is known to cause excessive drowsiness on its own and mixed with the others it is worse.  

Your son needs one of two things right now--for you to step in and demand to know exactly why each of these medications is being prescribed --or find another doctor.  Your son is being over-medicated.  

With bipolar disorder, any medication that is overdone can cause the mood to go way down.  With children, depression very often comes out as rage, irritability, etc...

Risperdal has a history of causing depression in children.  That is the first medication I would ask to have removed.  At this point, adding Concerta to the mix would only create more problems for your son.

I will stand by my original suggestion--especially since your son seems to react as he does.  I would ask the doctors to taper off and eliminate all but the Lamictal and then add Seroquel.  The two together will eliminate agitation and mania, but won't bring his mood down to the point of depression.  He will not spend his days tired but will also be able to focus.
         Joyce A. Anthony

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

QUESTION: I did put my foot down and discontinued the tenex.

His other issue besides mental distractions is hyper motor activity. Can't sit still, fidgeting, interrupting, rapid speech, hyperactivity, can not play by him self, attention demanding. He is hyper active times 10 kids.

Also very chemical sensitive has to have his meds every 4 to 4.5 hours for a good overlap to decrease ups and downs.

So his risperdal is now dosed at 8am, noon, and 8pm I am waiting to see if he is still wetting the bed an issue that I am trying to get to the bottom of. If bed wetting continues I will move 8pm dose to 4:30pm.

They did do ua to check for UTI waiting for results, I want to know if he is spilling sugar in his urine as well.

I did not know that risperdal can increase risk for depression.

With the Lamictal what signs to look for that were theraputic before adding the seoquel if I go to make the change?

Then how best to address the hyperactivity if it is still present after adding the seroquel?


You have been so helpful, it is so hard to find someone to understand symptomology and terminology and to care about my child as much as I do. Thank you.

Answer
Elizabeth:

Once the Lamictal is at a good dosage, you will see less mood swings, less hyperactivity and fewer outbursts.  Your son will be able to deal with stressful situations much easier.  He'll be able to enjoy an activity without getting extremely upset or over-excited.  He will still experience normal moods--crying when something sad occurs or laughing when he's happy.  If all emotions become dulled, the dosage is way too high.

The hyper-activity could very well be mania.  Often childhood onset bipolar disorder comes out as mania.  The child can stay on the go for hours on end, will need very little sleep and seems to never tire.  

I am very confident that a combination of Lamictal and Seroquel will make any other medication unnecessary.  However, if there is still a need after six months, it would be best to discuss what has been tried and what your other options are.  Your son's medical history will determine what medication to add if necessary.  That is something I can't determine.  

As for the bedwetting--has this always been a problem or is it a new one?

         Joyce A. Anthony