Which comes first?

Discussion in 'General Parenting' started by smallworld, Jul 1, 2008.

  1. smallworld

    smallworld Moderator

    This is one of those chicken-or-egg questions.

    My younger daughter M just underwent neuropsychological testing. She was diagnosed with executive function disorder. The neuropsychologist is recommending to M's psychiatrist that M start on a stimulant. M's psychiatrist is reluctant to trial a stimulant until M's mood is more stable.

    By way of background, M has always been an anxious child. She had separation anxiety as an infant and toddler and selective mutism as a preschooler. At age 7, she developed a choking phobia that led to extreme weight loss, hospitalization and feeding via an NG tube for a month. Through medication and intensive behavioral therapy, she recovered and now eats almost normally.

    M has been on Zyprexa since just before her hospitalization. Prozac was then added to address residual anxiety, but she became giddy and disinhibited. Her medical team wanted M to trial a second SSRI, but we declined given that her siblings had experienced manic reactions to just about every other SSRI out there. She has done better on Remeron, but we're still seeing "emotional reactivity" -- low frustration tolerance that results in meltdowns.

    This spring M's teachers reported lots of distractibility, slow work production and trouble initiating multi-step projects. That's why we decided to go ahead with neuropsychologist testing at this point.

    The neuropsychologist is convinced that M's executive function disorder is responsible for her anxiety. He has also reported that she is "dysregulated" (which makes me think M needs a mood stabilizer instead of a stimulant). M's psychiatrist believes her primary diagnosis is anxiety, and executive function disorder is a result of that anxiety.

    Any insight on how to sort all of this out?
  2. Sara PA

    Sara PA New Member

    I am really beginning to believe that the biggest -- the underlying -- issue with a lot of our kids is anxiety. With a child with a history of anxiety, I would be very, very careful about starting a stimulant.

    So the thinking is that the excutive functioning is causing the anxiety and by adding the stimulant the executive functioning will improve and thus reduce the anxiety? Not that the anxiety is causing the executive functioning problems and that the stimulant will increase the anxiety? Or even that the stimulant will help the executive functioning -- as it does for most people -- but will, nevertheless, increase anxiety.

    What the neuropsychologist proposes seems counterintuitive to me.
  3. klmno

    klmno Active Member

    Sleep on it, talk to tdocs and psychiatrists and read and mull it over.

    Then do the one thing that is tried and true- use your Mommy gut. (It sounds like there is probably going to be a period of medication trials no matter what.)

    I kind of wonder if a neurologist might be able to give a good opinion on this. Not on the diagnosis, but on which medication to try first.
  4. klmno

    klmno Active Member

    Me Too, Sara!!!
  5. tiredmommy

    tiredmommy Site Moderator

    There's a lot of mood disorder in the family with bad reactions to stims. My thought is that the mood dysregulation is causing the anxiety. The executive functioning, I would think, should improve when her mood is stabilized.
  6. Sheila

    Sheila Moderator

  7. pepperidge

    pepperidge New Member

    /Smallworld, I

    I don't know how to sort it out but I will give you the benefit of my children's experience for the little it might be worth to you.

    First of all, on the stimulants, ask yourself what is the worst that would probably happen. My guess is that you would have a miserable child for one or two days, and then you would deep six it, especially if you started with a very low dose. This is what happened with child #2.

    My oldest son who is very anxious, mood disregulated, probably not bipolar truly but who knows what, was started initially in this whole long process on a stimulant. It turned a non cooperative child who had trouble focusing on work into an emphathetic far more cooperative child. This continues to this day. The neuropsychologist (whom you know) was not at all clear whether his learning issues were a result of his anxiety (a lot of separation anxiety) and whether if we got the anxiety under control the learning issues would improve. That was five years ago and we are still not clear ultimately about just about anything.

    We did have rebound effects that weren't too positive but the benefits from the 5 mg of Adderall are very definitely there so we haven't wanted to stop it. With a combination of Lamictal and Risperdal to help with the depression and anxiety and ability to tolerate no, Ihave a reasonably functioning kid. Still with anxiety, still with major school issues but generally cooperative around the house and not lying in bed all day.

    If there was a huge downside to the stimulant then I would be wary. I guess you have the appetite thing under control. but if you think there might be some benefit it might be worth the trial.

    I do think my child reasons more clearly and is more capable of taking the long term perspective and less likely to say no automatically when on a stimulant. I wouldn't say he is less anxious because of it other than maybe he fits in a little better at school and that must help his whoel social adjustment. So just thinking out loud here, would it help her be a better student at school? And how would that help her? But the logic of better executive functioning to less anxiety I have a hard time seeing, unless she is unable to make some needed cognitive connctions because of the exec functioning issue that keeps her anxious.

    You know, this all reminds me of how little they truly know and much is guesswork.

    good luck. do let us know what you decide and what goes on.
  8. flutterbee

    flutterbee Guest

    Here is my experience.

    difficult child's former therapist thought that difficult child's anxiety stemmed from her EFD and the NonVerbal Learning Disorder (NVLD) characteristics. I never agreed with that. I do think, however, that it does become a vicious cycle and they feed off each other. The anxiety causes the EFD which causes more anxiety, etc.

    My difficult child was born anxious. From the age of 3 weeks to 3 months I had to hold her all the time. No exaggeration. If I put her down for a minute, she would scream. And I don't mean she would cry herself to sleep. She would scream until she was hoarse and then she would scream some more. She would fall asleep on my shoulder and as soon as I laid her down, she'd wake up. About every 3rd day she slept all day, only waking up for feedings, because she was just so exhausted.

    She always had separation anxiety, but by the age of 4 I couldn't even leave the room without her falling apart. She always had this need that I can't even articulate.

    And I have noticed that when the anxiety is under control, the EFD isn't such a big issue. It's still there, but she can compensate much better. Since being homeschooled, she's gone from not being able to clean her room at all, to me sitting in her room and telling her what to do next, to doing it on her own. When her anxiety was sky high, she couldn't even begin to form the necessary planning to even get started.

    Think of a situation that causes you severe anxiety. Think of how you feel and how you perceive the world around you. For me, it's public speaking. My heart races, I feel like I can't catch my breath, there is a buzzing in my ears, my hands shake, I have trouble keeping my thoughts in any kind of an order or that are even relevant, even with cuecards I lose my place, I'll lose myself in time and space, I'll forget what the date is...I could go on and on. Imagine living like that every day of your life. Yeah, I think it would effect executive functions.

    We've had the professionals that wanted to treat the emotional dysregulation first and some only and I never went for it. To me, it was masking the symptoms of the anxiety, but it was not addressing the anxiety. And they were powerful medications that I wasn't comfortable using unless it became obvious that were absolutely necessary. But, it was the symptom everyone saw. As her parent, I recognized it for anxiety. I knew that when her anxiety was down, the emotional dysregulation didn't happen. As her parent, I didn't want to just mask the symptoms. I wanted to help her learn to cope with her disorder and hopefully overcome them. Unfortunately, my difficult child even refuses to take the lexapro which did help significantly with her anxiety. She's also very good at shooting herself in the foot. So, we keep working on tools, skills and inner resources.

    That's been my experience and is my $.02.
  9. SomewhereOutThere

    SomewhereOutThere Well-Known Member

    Instead of medications, why not interventions?
  10. LittleDudesMom

    LittleDudesMom Well-Known Member Staff Member


    I've read the replies here with great interest. I know my son has adhd, but he also has undx'd anxiety (about a lot of things - school, germs, bugs.....).

    I was very interested in reading pepperidge's reply. It sounds like getting the anxiety under control was first, then adding a very low does stimulant (5 mg adderall) helped (s) her difficult child greatly.

    Perhaps that might be the way to go. Your other children have had some disasterous experiences with stims. However, knowing that going in, starting at the lowest possible dose, watching really closely, it may be worth looking into.

    I know we are so loath to do anything that will upset or change the level of our kid's stability. I guess, were I in your shoes, I would make sure that her anxiety issues are under control; she is able to function at an acceptable level that allows her to lead a "normal" existance for a kid her age; then I would follow the npdoc idea of adding a stimulant (as long as it is the lowest dose reasonable).

    The other issue, at least for me, is the idea that your daughter's anxiety is caused by EFD. I think I have an issue with that theory. I can't see that given your daughter's history. Perhaps giving it a try will get you closer to a solution she can live and thrive with.

    Someone else gave you the advice to follow your gut. That is the same advice I give, do what you feel in your gut is the right thing. It's the very best you can do.

  11. standswithcourage

    standswithcourage New Member

    What in the world is executive functioning?!!!!!!!!!!!
  12. Sheila

    Sheila Moderator

  13. busywend

    busywend Well-Known Member Staff Member

    Given her history, I would be inclined to address the anxiety first.
  14. Shari

    Shari IsItFridayYet?

    For what little its worth, my inclination is that her anxiety contributes to or causes the EFD.

    That said, the stimulant may be the safer path to start with on the "trial and error" route, so I guess unless I had a strong gut feeling one way or the other, I'd try the medication with the least liklihood of causing really bad problems...
  15. Wiped Out

    Wiped Out Well-Known Member Staff Member

    Very interesting for me to read all of this. Lately we've been thinking that difficult child is dealing with a lot of anxiety. It hadn't been something we focused on at all before because we couldn't see a lot of the anxiety. Now we can, so this is a very interesting thread for me.
  16. susiestar

    susiestar Roll With It

    Whatever you decide, make sure your Mommy instinct agrees with it. If it doesn't, whatever it is shouldn't happen.

    I don't know what would help, but I do know that the only times I really really screwed up were when I didn't listen to my mommy instincts. "The gut knows the babies, firsthand" - the pediatrician that was MY pediatrician told me that about my kids. Just seemed a bit odd, but true.
  17. smallworld

    smallworld Moderator

    Thank you all for your thoughtful replies. And thanks, Sheila, for posting that interesting article and the link that explains EFD in detail.

    I had a long talk with our pediatrician this morning. He is an amazing diagnostician, thoughtful clinician and the father of two anxious children. Although he will prescribe medications for ADHD, he refers out for anything neurological and psychological beyond that. But he has been by our side through everything that has gone on with my kids and has a good sense of what should and shouldn't be happen. He told me that in his 20 years of practice, he has found that stimulants have invariably done very little to address EFD symptoms. He said he would not want to see M put on a stimulant. He would prefer we focus on school strategies to address M's EFD difficulties (you're right on the money, MWM).

    In a similar vein, my mommy gut has been telling me that this neuropsychologist is all wet and that anxiety is driving this train. Like Heather's Wynter, this child was born anxious (and anxiety runs strong through our family tree). I personally believe M is distactible and having trouble with schoolwork because she's anxious and mood dysregulated. That's what we need to continue to work on rather than adding a stimulant.

    One further thought: M's older brother J's diagnosis at her age was ADHD/EFD and anxiety. While he did OK with stims for 1.5 years, he gradually became more mood labile and we realized we were addressing the wrong issue. J's psychiatrist at the day treatment program he attended last winter told us that J followed a common path toward a mood disorder diagnosis: anxiety at an early age, ADHD-like symptoms in elementary school and mood disorder blossoming at pubertal onset. I am ever mindful of the role genetics plays, and I don't want us to be chasing the wrong disorder with M. That is not to say that she will develop a mood disorder, but we need to have our eyes wide open about the possibility.

    Thanks again for sharing your thoughts.
  18. SRL

    SRL Active Member

    The understanding of executive functions is in its infancy. I believe that there isn't an official diagnostic code for it so in cases with children and distractability, docs are telling parents EF but coding it ADHD/ADD. I think they're trying the ADHD/ADD medications because they just don't know what else to do with it. For child without other issues trialing those medications probably isn't such a big deal and might be worth it if it's going to help. For a child with other issues complicating the picture, trialing those medications is a big deal.