Developed Tolerance to Stimulant, Now What?

[gcvmom]

Just registered here and am hoping your experiences can help me understand better what's going on with my 10yo.

Brief history: Dx'd ADHD age 5. Responded well initially to stimulant meds. At age 7, started having problems with mood -- rages on the playground when frustrated. Tried Zoloft in combo with Adderall, but caused manic behavior. Stopped Zoloft, switched to Concerta and added Risperdal, which seemed to do the trick for a couple of years.

Jump to December '06 and his dosage for Concerta has crept up and is now beginning to act like water (even at 162mg). ADHD symptoms not in check, emotionally labile and prone to outbursts of rage. Switched to Focalin XR -- started at 20mg but had to increase to 80mg to see best results. Swapped Abilify (7.5mg) for Risperdal. Pdoc lowered Focalin XR to 60mg and increased Abilify to 10mg because ADHD symptoms and rages coming back by lunchtime instead of maintaining usual symptom control until at least late afternoon.

Jump to today -- he's still at 60mg Focalin XR, still at 10mg Abilify. ADHD symptoms are mostly in check for about six hours (barely) compared to the eight or nine solid hours I saw before all this started falling apart. When the meds are spent, he's increasingly argumentative, easily frustrated, gets "stuck" on things, easily angered, etc. Lots of fighting now between other siblings because of his annoying behaviors, lots of frustration on my part. It's been a very slow couple of months in trying to find some solution. He's very bright, but very much a PITA right now.

Is this just ADHD out of control? What other med options do we have to manage this? Pdoc does NOT want his Focalin dosage increased I think for fear of having him develop tolerance to it as well.

Thanks in advance for the advice!

[pepperidge]

Hi,

Welcome to the board. All I can say is that it sounds like where my youngest son (the almost ten year old) is at right now (on Abilfy , now trialing Focalin), you have described him to a T.

Also somewhat where my oldest one was before we got on mood stabilizers. He started off pretty well on just Adderall (had more inattentive type of ADHD), but it seemed to lead to very angry episodes, particularly on the rebound. He was irritable/depressed all the time. We added in Prozac, but then he became very impulsive. We needed more stimulants just to deal with the side effects of the Prozac. Needless to say, we ditched the Prozac pretty quickly. It wasn't until we got to the combination of the stimulants with Lamictal and Risperdal that we have achieved some stability.

Have you seen the thread on severe mood dysregulation of about a week or so ago? That seems to describe my kids pretty well, much better than bipolar, since they don't seem to cycle at all.

Is there anything that would make one think of more classic childhood bipolar (Have you read The Bipolar child?)

Have you discussed trialing a mood stabilizer with you pdoc?

One thing I don't understand very well is the interaction between Abilify (which acts on dopamine) and stimulants (which also act on dopamine.) I wonder if the abilify dampens the impact of the stimulants. But haven't found a pdoc yet who could give me a satisfactory answer to that question.

We haven't had good luck with yet with my youngest. While the Focalin seems to be helping a bit with the frustration intolerance, I am not sure it is the total answer. Abilify worked great for a few months, but then pooped out on the mood front, though I think it helps the impulsiveness a bit. So we too are wondering where to go. We trialed Lamictal for him, but didn't seem much of a difference it seemed (though maybe a little more than we thought).

All this to say that it sure is complicated. I would look at reducing the Focalin (maybe some of the anger and frustration are due to that) and maybe think about a mood stabilizer of some sort.

Don't know if this helps. I guess I would research more bipolar/severe mood dysregulation and familiarize yourself with mood stablizer drugs if you are not already familiar. Is your Pdoc sympathetic to the notion that it might be a mood disorder?

And many of us think that the Explosive Child is very useful, too, if you haven't read it already.

welcome and hope you can get things straigtened out.

[house of cards]

Hi, and welcome, this is really an incredible site. Don't have any answers for you but I am in a similar place with my GFG. I am very interested in the answers you get and will be learning along with you.

[Wiped Out]

Welcome! This sounds a lot like my gfg. He started at age 4 on Ritalin which worked for awhile and quickly progressed through other stimulants and other dosages. The argumentativeness, easily angered, etc.. all sound like my gfg. For us it turned out our gfg had ADHD and Bipolar disorder but that was our son and all kids are different.

I'm glad you found us but sorry you had too. It can be slow here on weekends but others will be around to welcome you. You will find much support here! Hugs.

[jodyice]

Hi and welcome to the board. I don't have any advice, but know you found a wonderful place to come and get some insight and lots of knowledge from those that have been doing this for awhile. I hope you get some answers and your gfg gets back to a place he was before the moods got out of control.
Welcome once again.

[oceans]

Since he does not do well on AD's, I am wondering if he might need a mood stabilizer, and then the stimulant would work better. Your situation sounds somewhat similar to my gfg when he was younger. I am still trying to get the pdoc to bring a mood stabilizer on board to see if it would help. We have wasted a lot of years with stimulants and AD's with nothing helping in the long run, and with worsening of the problems if anything.

[gcvmom]

Wow -- I am so grateful for all the replies. Thank you!

I do have "Driven to Distraction" and "The Bipolar Child" -- bought the former when my oldest got his ADHD dx and the latter a few years ago when the middle boy was first put on Risperdal because pdoc thought it was possible we were dealing with early bipolar...

Pdoc has since changed his mind, as there does not appear to be any cycling going on and the rages are comparatively short outbursts that blow over and are forgotten by him. I don't think it's an explosive disorder, but that's not to say, though, that I haven't been afraid that he'll actually hurt someone during one of these tantrums.

Pdoc thinks this is just an extension of the ADHD or a variation. If I remember right from our last appointment, I think he did mention mood stabilizer, so that may be the next step. I'll have to leave an update for him tomorrow.

Not that it matters much, but I made a typ-o on the Abilify dosage -- he's actually at 20mg right now. Is this typical for an 85-90 pound kid?

We had a family gathering today and I increased his Focalin XR to 80mg for the day (vs. the 60 I've been directed to give) just because I didn't think things would go very well if I didn't. The hyperactivity, focus and attention were improved, but it still didn't last as long as it should have and he was still "stuck" on certain activities [img]/forums/images/%%GRAEMLIN_URL%%/frown.gif[/img]

Thanks again!

[smallworld]

Hi and welcome. I was talking with my son's neuropsychologist recently, and he indicated that doctors are finding Focalin XR is actually lasting only about 6 hours. So what you're seeing with your son may atually be "normal" with that med. You could ask your doc for a "booster" dose of regular Focalin for the afternoon.

Having said that, I really don't think what your son is experiencing is out of control ADHD. I'm really wondering if your son has ADHD with a mood overlay. That's my son's dx. He has ADHD, but it's not his biggest problem. He really has huge mood issues that have been much more difficult to get under control than the ADHD. My son's history is similar to yours: He was dxed with inattentive ADHD and anxiety at age 9 and did well on Concerta for about a year and a half. When he went to middle school, his anxiety increased, and we took him off Concerta and tried Zoloft. After 3 weeks on Zoloft, he had a prolonged intense manic reaction that we could not get under control until his pdoc put him on a mood stabilizer. He is now doing much better (although not perfect by any stretch of the imagination). With the mood stabilizer in place, my son is now able to tolerate a low dose of Focalin XR (10 mg) and a low dose of an antidepressant (2.5 mg Lexapro) to target symptoms the mood stabilizer doesn't cover.

The atypical antipsychotics (Risperdal, Abilify) help with anger and aggression, but they do not have long-term mood-stabilizing properties like mood stabilizers, and they tend to poop out over the long haul. Furthermore, stimulants like Concerta and Focalin XR can fuel anxiety and mood lability, which Risperdal and Abilify cannot offset.

You might want to consider an evaluation by a neuropsychologist (found at university or children's hospitals) to figure out what is what. My son has had two neuropsych evals (one at age 9, one at age 13). Both times we gleaned invaluable information about how to guide both meds and therapeutic interventions.

This is not an easy road to travel. Best of luck to you.

[gcvmom]

Thank you, smallworld. I do have the short-acting Focalin and have used that after school to get him through homework (20mg).

It's just so much different from the Concerta where he could manage well until almost dinnertime. I'm okay with the booster, just as long as I know that this is what's typical with this med.

I'll be leaving an update for the psychiatrist today. His spedcialty is peds/adolescents, and he's actually been quite good at managing things for us for the past seven years (unlike the pediatricians we've had who are just way out of their league). I know that gfg2's latest developments have been a bit more puzzling for him. I think he has mentioned mood stabilizers in our last meeting (things get blurry... KWIM?). We go back on the 20th.

When your gfg had the neuropsych eval, was he medicated during the exam? Just curious if that helps with the assessment or if they can see what's happening despite the meds.

[smallworld]

Concerta is supposed to last 10 to 12 hours (it's the equivalent of 3 short-acting Ritalins). Focalin XR is supposed to last 6 to 8 hours (it's the equivalent of 2 short-acting Focalins). Focalin is refined Ritalin.

For his neuropsych eval, my son took all of his regular meds, except for Focalin XR. The neuropsych gave him his Focalin halfway through the testing. It was our way of testing the effectiveness of stimulant medication for ADHD symptoms.