Expert: Joyce A. Anthony - 3/15/2010

Question
QUESTION: My son will be 8 this summer and he has recently been diagnosed with a co-morbid presence of ADHD and Bipolar.  He has been taking 20mg of Risperidone medication for almost 2 years.  Which helped some with his mood.  He was being sent home almost daily for his aggression.  After he was put on Risperidone, his mood was more manageable.  However, he still experienced a lot of mood swings.  He is very argumentative, irritable, and aggressive, so recently his psychiatrist also put him on 5mg of Prozac, which I noticed a change almost immediately.  He was less bothered by things and more easy-going and calm.  However, he has extreme hyperactivity, distractable, impulsive and can not focus in class. His ADHD symptoms have become a huge issue in class. We have tried Adderall, Ritalin and Focalin.  All of which made his aggression worse.  I am at a loss of what to try.  Even on the Prozac and Risperidone, he still has a great deal of mood swings.  Should I try a different medication for his Bipolar or try to get his ADHD under control.  His psychiatrist says we will have to go back and forth.  Now that we've noticed a good outcome from the Prozac, she now wants to address the ADHD, but nothing seems to work for that.  Any advice you can provide will be greatly appreciated.

ANSWER: Darcy:

Very often, a child will have both bipolar disorder and ADHD.  The thing is...the bipolar disorder needs to be stabilized first.  Medications designed to treat ADHD make the bipolar disorder worse in almost all cases.  I would talk to your son's doctor about trying a new medication for the bipolar disorder (maybe Lamictal, Seroquel, or a combination of the two) and seeing how that works.  After the bipolar is stabilized, you may not even need medication for the ADHD as symptoms seem to lessen with controlled bipolar.  If needed, however, treatment can begin after the bipolar stabilizes.

         Joyce A. Anthony

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

QUESTION: Thank you for your quick response.  I have another question.  How do you know when the bipolar disorder is "stabilized"?  Will he no longer have mood swings?  How do you know when it is as good as it gets?  Also, after the bipolar is stabilized, what type of medication would you recommend to treat the ADHD.  Like I said, we've tried various Stimulant medications.  Should I try a non-stimulant?  What about Tenex or Intuniv?

Answer
Darcy:

So often, the bipolar medication takes care of the ADHD, so no other medication is necessary.  Should it be, try to get a non-stimulant.

The best way to tell when a person is stabilized is to see how they react in situations that would formerly cause an outburst.  Once stabilized, a child will still experience the normal happy and sad behavior we all face, but the moods will all be from the circumstance and won't happen out of nowhere or frequently.  

When you can go through a period of say two months or more without a major outburst, you will know he's on his way.  The best way to explain it is this:  When unstable, we often say, wow, he only had one major outburst today.  Once he becomes stable, you'll realize it's been so long since he had a major outburst that you can't recall exactly how many days.  It is difficult to explain, but what happens is you stop thinking in terms of good day/bad day in regards to outbursts.  Does that make sense?

         Joyce A. Anthony