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My 8 year old son is diagnosed with ADHD combined type for

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which he has taken metadate...
My 8 year old son is diagnosed with ADHD combined type for which he has taken metadate for 3 years (50mg). While on the metadate each day, his behavior is calm, he does well in school, his vocal volume is normal. However when he starts to come off the medication each day, his emotions are rollercoaster like, he is incredibly angry, seemingly about things that dont exist and his anger is way out of porportion to the situation. He sees a therapist at this time who has witnessed some of these episodes. She believes he is demonstrating psychotic behavior during this time. Two months ago, his psychiatrist started him on .25 miligrams of risperdahl and has increased the dosage to .50 miligrams. There has been some improvement but he is still having a great deal of difficulty during that time period. This period lasts for about 2 hours each day and he is imposible to reason with at that time. His therapist thinks that I should ask for another increase in Risperdahl and she is very concerned about him. He is crying one minute and then yelling, then crying again. He absolutely cannot sit or stand still during this time period and he is very clumsy. He is also ravenous at that time and the spells last until he has eaten a substantial amount. Would an increase in risperdahl be the right way to go?
Submitted: 5 years ago.Category: Mental Health
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6/12/2012
Mental Health Professional: Dr_Anderson, Doctor replied 5 years ago
Dr_Anderson
Dr_Anderson, Doctor
Category: Mental Health
Satisfied Customers: 335
Experience: Psychiatrist
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Dr_Anderson : Greetings, and thank you for your question. I'm sorry your son is going through all of this! There are two ways to go here, as I see it. One would be to increase the Risperdal a bit more to see if it helps control these huge mood swings that he has. But another option would be to consider that his Metadate might be the culprit. In many of my kids with ADHD, their medication stops working as they get older since they are bigger, their metabolism changes, etc. You mentioned he's been on it for several years, so that would be a high possibility in my book. An increase of the dose to 60 mg might alleviate these issues. Another method I'll use is to try a short-acting one, like Ritalin, when the long acting one is wearing off and see if it controls the symptoms. A final option I'll try if those don't work is to see if perhaps the medication itself is no longer a good fit, so I look at other long-term options. A lot of info here, and I'm sure you have some follow-on questions, so please let me know when you are online and I'll be happy to assist.
Dr_Anderson : Regards,
Dr_Anderson : Dr. Anderson
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Customer reply replied 5 years ago

On days in which he wakes up to late for his metadate, he is impossible to deal with. He is angry all day and literally climbing, running, destroying, crying, knocking things down, and nonresponsive to directions or even his name being called. On those days, he is unable to stick at any of his favorite activities. The Metadate makes a huge difference for the period of the day in which it is active. The only negative thing about the Metadate is the impact on his appetite. It is very difficult to get him to eat. Sometimes I am even wondering if the tendency not to eat is generating some type of hypoglycemia because he does not snap out of the bad mood until after he has eaten. The difficult thing is that this ravenous appetite comes on all of a sudden and occurs during the mood swing. We have tried a short acting small dose of Focalin during the wearing off period but it did not have a viable effect. His doctor's current thinking is that he has difficulty going from the medicated state to the nonmedicated state. That is why he started the risperdahl. We have not however tried the increase in Metadate that you suggest. That might be worth a try.

Mental Health Professional: Dr_Anderson, Doctor replied 5 years ago
Another option to consider is switching stimulant classes. He has been on Focalin and Metadate, which are both in the methylphenidate class of stimulant. It sounds like the amphetamine class has not been tried. It may be an option. Ones in this class include Dexedrine, Adderall, and Vyvanse. Vyvanse has the added benefit of being the longest lasting stimulant of all stimulants (12-14 hours at max).
With the mood swings and emotional dysregulation he has, it may be necessary to have something like Risperdal (Depakote is another one I'll use in those cases) until he learns to regulate his emotions and moods better. But, if a simple adjustment of his current regimen works, that would mean less pills for him to take.
Regards,
Dr. Anderson
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Customer reply replied 5 years ago
He was on Vyvanse prior to taking Metadate. He complained of continual headaches. I am beginning to wonder if he is experiencing bipolar disorder as opposed to ADHD. It is my understanding that the two are very simular.
Mental Health Professional: Dr_Anderson, Doctor replied 5 years ago
Indeed they are. I have gone down the ADHD road before only to find it was bipolar, and vice versa. The two can co-exist as well, making treatment even more challenging.
I think in your son's case, the best way to proceed is to make gradual and definitive changes, so you know what is leading to what. For example, if the Metadate has a calming effect and helps him as you described above, then it is unlikely to be bipolar alone. Why? Stimulants tend to exacerbate bipolar symptoms rather than help them. But, with the presence of the morning moodiness and mood swings without the Metadate, while it can argue in favor of untreated ADHD with a lack of emotional regulation skills for your son, this kind of picture lends itself towards bipolar thinking. Medications like Risperdal may help in ADHD, but only by sedating, not by helping with focus or organizational skills.
Confusing? Yes! So, moving up by 10 mg on the Metadate is a conservative change, with a low threshold for going up on the Risperdal as needed.
Dr_Anderson
Dr_Anderson, Doctor
Category: Mental Health
Satisfied Customers: 335
Experience: Psychiatrist
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Customer reply replied 5 years ago
Thank you very much. I am going to discuss your suggestions with his doctor. I agree with making a conservative change. It hurts to watch him struggle so much. I will accept your answer on Wednesday.
Mental Health Professional: Dr_Anderson, Doctor replied 5 years ago
My pleasure to help! It is very tough to see your little one go through so much turmoil. I am optimistic, though, that a good solution and fit can be found for him. Conservative is always a good approach in the pediatric population. Please let me know if I may be of further service, even if to let me know how he is doing!
Regards,
Dr. Anderson
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