Still confused | ADHD Information

Hi SmallMom,

Yes, these kids can hold it together in school and out in public. But what
the case manager was saying is that they haven't noticed any changes in
his mood over the past 8 weeks. They haven't seen increased irritability
or any elevated mood.

What you said about Risperdal is interesting. The first week he was on
Risperdal, he was very agreeable and compliant. Then by the third week
the irritablity reared its ugly head again. I think I will ask about trying a
different med now that I hear that Risperdal is not typically used as a
standalone mood stabilizer.

When he took Strattera and Prozac he had a very bad reaction. When we
told the prescribing physician about it, he told us to stop the meds, which
we did. He did not tell us to taper off, as we later learned we should have
done. We also learned after the fact that Strattera and Prozac should not
be prescribed together.   Needless to say, we never returned to that pdoc.
momoftwoboyz,

Our son was put in the hospital program because the doctor felt he would
receive a complete evaluation there. His grades were falling in school, he
was becoming defiant and had rages almost nightly, which lasted about a
minute, but were often destructive.

The consensus of all concerned (both hosptial team and school IEP team) is
that he cannot function in a large, stimulating environment, so we are on the
quest for a new school. Ugh.

He could be co-morbid. His symptoms are pretty much what bipolar is. It's sort of splitting hairs to say ADHD/ODD/Disruptive Behavior DIsorder (what's that?). I predict and hope I'm wrong that his behavior will continue to be a big problem until/unless he is taken off stims and tried on mood stabilizers instead. JMHO. Guess we'll have to see, but I'd be questioning so many diagnoses. If he just had ADHD, imo, he wouldn't need partial hospitalization. Again, however, I could be wrong. We'll see. Risperdal is a short term solution to anger, aggression. By itself, especially with stims or antidepressants, it is less effective, BUT could work for a few weeks to a month. It is rarely good for the long term unless it is used in conjuction with a mood stabilizer. Risperdal is an antipsychotic that is often used off-label.

OlderMom38794.5278935185OlderMom, Frankly, I don't know what "disruptive beavior disorder"
means either The first time I saw it was on a letter the doctor gave us to
use in our IEP meting to bolster our request for non-public schooling.
Maybe it is not a diagnosis at all, but something he thought would set off
the appropriate alarm with the IEP team. I plan to ask him about it.

We were told that Risperdal is an antipsychotic and that it is used off-
label and was being prescribed to reduce his edginess, and his raging.
When we mentioned to the case manager that he raged one evening in
spite of the Risperdal, she said it could also be a power struggle and/or
learned behavior.

Who knows?



I agree with what smallmom said. I would not put all my faith in what the hospital says. My son has been hosptailized for a week and a half before and the hospital missed his diagnosis by a mile. My son has an amazing ability to hold it all togheter when he feels he needs to. My son has been given the bipolar diagnosis, and for him stimulants DO work. Like you said with your son, it helps him focus in school, but don't touch the angry outbursts. My son did have a bad reaction to one stimulant, but he has been on adderall now for 8 months now and hasn't had any major issues. I do plan on pulling him off of it now though because we are going to be starting a mood stabilizer monday and the treatment guidelines for bipolar say that you are supposed to treat the bipolar first since the ADHD symptoms could disappear once you get the bipolar under control. I agree that in all likelihood your son wouldn't be in the program he is in if he was jsut ADHD/ODD, it sure sounds like it goes beyond that. I wish you the best, I hope that you are able to find what works for your son.

Hi Keelime, nice to see you.  Honestly, it is so hard to figure out what's going on with these kids who have a little of this and a little of that.  Throw in puberty, and all bets are off.

I will tell you that my son's first dx 3 years ago (by a neuropsychologist) was ADHD and anxiety.  The oppositional behaviors began in 6th grade when the expectations that go along with middle school increased.  When we tried to medicate his anxiety both last spring and fall with SSRIs, he had manic reactions that led to his new dx of bipolar disorder.  The mood stabilizer Depakote has controlled his rages, but he is now depressed and unmotivated to do anything.  We recently took him off all stimulants because there was a feeling that they were increasing anxiety.  And honestly, while he has a bad case of executive dysfunction, we are questioning whether he truly has ADHD.  Three years of stims, by the way, did not make his behavior worse.  But it was when the mood issues became too great that it appeared the stimulants were no longer working (just our case -- may not be yours).  Our pdoc, by the way, told us this week that kids with BP almost always get a dx of ADHD first.   

Last week we learned that how our son handles life is inextricably tied to his moods. We know this because he was on Effexor last week, his mood lifted from depression and his behavior was amazing -- he got up early, got himself ready for school, got to school on time, didn't find school boring, did all of his homework. But Effexor went too far and spilled over into mania, so we had to stop the med trial. Even though the Effexor trial failed, our pdoc was optimistic -- he told us he believes the right combo of meds (still undetermined) will make all the difference in the world for our son.

This is all my long-winded way of saying that I would hazard a guess there is some mood component going on with your son.  It doesn't have to be full-blown bipolar disorder -- could be anxiety, depression, some kind of low-level mood disorder.  I don't buy the fact that there's nothing going on by virtue of the fact that no one has noticed symptoms in the partial-hospital program.  Two of my kids have BP, and believe me, they hold it together at school day after day.  Their teachers have told us they would never have guessed based on their own observations.  I also find it hard to believe that a child with ADHD alone would end up in a partial-hospital program (and IMHO, ODD is not a helpful diagnosis because it describes a set of behaviors that have no known cause; it is indicative of an underlying condition that causes oppositional behaviors). 

In terms of Risperdal, it is common for it to work right away and then the effects taper off.  It is used in BP as an as-needed med, not as a stand-alone mood stabilizer, or as an add-on to a first-line mood stabilizer to control irritability, aggression or emotional reactivity.  It is generally not used alone for mood disorder over the long haul.  So I'm not surprised you saw partial results.  Remind me -- what happened when your son took SSRIs and other meds?  That may give you some clues to what is going on with him.

Sorry for going on and on.  I hope this helps somewhat.  Your situation is not easy to figure out.

 

My 13YO son is in the partial-hospital program at a major university. It is
the consensus of the team that he has ADHD/ODD and a disruptive
behavior disorder, whatever that means. OlderMom and others have
commented that ADHD/ODD usually means early-onset bp. And we have
questioned whether he may be bp.   However, he has been on stimulants
for seven weeks and his turnaround at school has been remarkable. The
turnaround could also be attributed to the fact that he now is in a very
small, sturctured environment in the hosptial school, but he reports that
the stims really help him get his work done. But stims are supposed to
make bp symptoms worse. We asked his case manager if the team
considered bp. She said they discussed it, but in the eight weeks he has
been in their program no one has seen an indication of it and she believes
that even with rapid cycling, someone would have noticed symtoms when
he has been constantly under the microscope for seven hours a day. It is
all so confusing.

Although the stims helped his focus, they did not help him with the near
nightly outbursts. So Risperdal was added to the mix about three weeks
ago. However, he still has some explosions and gets irritable.

We learned that his bio-mom has lots of issues and took drugs during her
pregnancy. We wonder if the drugs are the cause of his problems.SmallMom, we've not seen more than one rage in an evening. Perhaps, if
he were home all day, he might erupt more often. I don't know. There
are entire days when he's just plain nasty/out of sorts morning and
evening. This irritability came with puberty. Prior to that he was chipper
most of the time, unless he got angry about something. He's had the
rages since the terrible twos. And they have always been of very short
duration. I am just reminded of one incident when he was about three.
He threw himself on the floor and began screaming, about what, I can't
remember. We ignored him by walking out of the room. He stopped
crying, picked himself up, walked into the room where we were and threw
himself on the floor and started all over again. We couldn't hold back the
laughter. Obviously, having a fit is not productive unless you have an
audience!

The case manager is a nurse practitioner with 25 years experience at NPI.   
Our son, like all the kids in the program, is evaluated and discussed
daily by the team which consists of the psychiatrist who oversees the
program, an educational psychologist, the program administrator who
leads group therapy, the recreational and occupational therapists, the
case manager, an assortment of aids and interns and the school teacher.

It would be pretty amazing and disappointing if after being under a
microscope for all these weeks and dissected by so many people that the
correct dx has still not been made.keelime38795.7231481482My own gut feeling? No, he can't help his raging. I personally think he's on the wrong meds, but, again, time will tell. My son was misdiagnosed so many times and by so many experts that, if the professional didn't help my son, I started to believe it was because they were barking up the wrong tree. In the end, I was right, at least about my boy. The truth was, most of them had no clue what they were looking at. In my son's case, it was high functioning autism (wrongly diagnosed as ADHD/ODD and early onset bipolar). Your son has more symptoms of bp than high functioning bipolar to me, but I'd take him for another opinion. I doubt there is a diagnosis called "Disruptive Behavior Disorder." It's amazing what some professionals come up with. That's one we didn't hear for my son...lol. Myabe the only one. He was on tons of meds he didn't need! I do wish you luck and hope you have your answer.

Hi again, I did a little googling and Disruptive Behavior Disorder is a catch-all term that includes ODD and CD.  And according to web sources, it frequently accompanies ADHD, anxiety and mood disorders.

I agree that the raging is not about power struggles and/or learned behaviors.  I assume the case manager is not a medical doctor . . .  You say the rages only last one minute, but do you ever have more than one rage over the course of an evening?  Do you ever have evenings of ongoing irritability without raging?

One more thought:  My daughter with BP typically does well all day, and when she has her "episodes," they typically begin in the late afternoon/early evening.  Her pdoc told us this is very consistent with a mood disorder.  If your son is following that pattern, the program docs might not be seeing mood instability.

I hope you find some answers soon.

    

But hardly impossible.