Questioning NP aversion to stimulant medication for 12yr old

[violinteacher]

Our 12 year old is newly diagnosed ADHD combination in December. This came after my own diagnosis at age 35 last summer. My own journey to diagnosis and freedom from previous weight of medication-managed anxiety and depression has been amazing. I have gradually eliminated and am weaning off medications for those conditions and instead using generic Adderall XR 30mg (under the management of a great PMHNP).

But my question is now directed more for my daughter, who sees a different provider. At the time, her diagnosis came alongside those of severe anxiety and moderate depression. Her NP (who is now moving transitioning from family medicine to mental health as well) has a ADHD teen herself, and so I have had high trust in her understanding of ADHD children/girls and current best practice in treating. Her goal was to treat those two conditions with medication and therapy first, concerned that a stimulant would be a poor fit for her for multiple reasons (including low weight).

Now we are at summer, and our daughter experienced amazing improvement in her anxiety and depression (questionnaires are now low and zero scores in many) and I revisited the topic of trying a low dose stimulant before school, so my daughter to make informed decisions about what works well for herself. The RN was opposed. She said she doesn’t medicate her own daughter with stimulants during the summer (“there just isn’t a reason for her to need that focus aid.”). I was kinda troubled by that attitude.

Myself, stimulants aren’t about study skills or productivity in my daily life. It gives me control over my actions, a sense of calm and direction and ability to see clearly what I want and need to do. I am a better mom, wife and friend because of how I manage all those ADHD symptoms with support.

I want for my daughter to understand and experience this too - not to say she “needs” a stimulant daily, but that she can see how she feels and whether it is beneficial for her in academic but perhaps also social settings. I am wondering how best to advocate for her and if that’s appropriate. She has been given such positive support from teachers and her RN and therapist - am I just asking more than is needed for her based on what I need?

Daughter is currently taking atomoxetine 25mg and sertraline 50.

[Onthemove1971]

Thanks for posting on the list. The thing I have learned from this journey is, go with my gut.

I highly recommend a Child Psychiatrist who can help you on this journey, they are medical doctor. Medication is about: type, dose and timing of medication. They could recommend medication that you don't know about.

Good luck with this journey.

[Hidden]

You mentioned that your daughter was diagnosed with ADHD in December. Does it mean she then was immediately prescribed atomoxetine 25mg and sertraline 50? Atomoxetine is licensed exclusively to treat ADHD so it must be that the paediatric psychiatrist felt this is the right medication for your daughter. Then as you mentioned she also suffered from anxiety and depression hence sertraline? I noticed that in US doctors are happily mixing meds so I imagine what you are after is adding a stimulant to what your daughter already is prescribed?

I totally understand that since for you stimulants work so well you would like your daughter to experience this amazing improvement that you have had since you ditched the previous meds and started stimulants for ADHD for yourself.

My son is younger than your daughter but in his case stimulants were really a bad fit for him- he stopped being able to eat, he had a ‘rebound effect’ where he would be irritable and aggressive and not able to control his emotions when the stimulants start wearing off towards 3-4pm. This meant he couldn’t really do play days or after school activities that would be later in the day. For some reason we were hitting the wall when asking psychiatrist about all the side effects that my son experienced in stimulants - my son also started pulling off skin from his thumbs and had wounds, definitely stimulants caused severe anxiety and unhappiness for him. Eventually after 8 months of this nightmare that my son was going through whilst on stimulants (methylphenidate XL slow release) psychiatrist agreed to change to a non stimulant - Atomoxetine. My son is happier since in Atomoxetine, stopped hurting his fingers, eats better (although Atomoxetine also causes appetite suppression but not as much as stimulants).

The benefit of Atomoxetine is that it works 24 hours because it works on neurotransmitters in brain, this means my son can do tennis or football at 5pm and he is still able to focus reasonably well. Then he gets home and is able to enjoy his meal and go to bed at 8pm, always asleep by 9pm. This wouldn’t be so ‘smooth’ on stimulants even if he hasn’t had the debilitating side effects that I mentioned he did have…

Children need to grow and food and sleep are necessary. I just don’t believe that stimulants are the right fit for children, but that’s my personal opinion and my son is only 9 years old.

In the UK it is not considered a good practice to give a non stimulant and a stimulant to a child at the same time. It has to be a mono therapy with one or the other.

However if your gut feeling is that Atomoxetine and Sertraline aren’t right for your daughter because they make her symptoms worse, she is unhappy, sedated etc (side effects) then you need to be assertive about it with the consultant paediatric psychiatrist. However what I understand you said that the current meds help your daughter with anxiety and depression… A hard one… Because I agree with you- Atomoxetine doesn’t make ADHD symptoms go away…

[Sweetkid in reply to Hidden]

my son didn’t do well on stimulants. Do you recommend a non stimulant. Does it help with focus?

[Hidden in reply to Sweetkid]

I think, watching my son and also his class mate who also is on a non stimulant, it helps with focus. If you are in US you can even ask your child’s doctor to prescribe a very small mg stimulant and then full dose non stimulant if you are worried about the focus. In the UK NHS won’t do it but you may have luck with a private doctor.

I personally from all the kids I have heard about in my town and from friends about friends etc- none of them was doing well on stimulants, somehow the eating and sleep and also rebound and anxiety were always a problem.

I think it’s something about how we perceive language and when something is called stimulant then somewhat we think it’s better because it’s ‘stimulating’.

Non stimulants work and also are 2 in 1- help with anxiety and depression etc.

[Sweetkid in reply to Hidden]

Thank you for your reply. My son was on concerta extended release and to be honest it didn’t do much help in school either. He was a wreck when he got home and didn’t want to do any work while on it. I thought it was suppose to help, but made things worse. I would like to try a nonstimulant and see if that helps at all. I am always getting phone calls about him needing redirection and playing. Not sure if that is his adhd or just a 14 year old teen.

[Hidden in reply to Sweetkid]

I’d say give it a go with non stimulant, but these medications need time to start working so let’s say after 2 weeks you will some effect but after 6 weeks you should probably see the whole benefit.

You can always explain to him that maybe it will agree better with him and control his symptoms better even after school. And if not then after a few months you can try something else or go back to what he was on.

I’d say if he is 14 then it’s ADHD that is impacting on his behaviour. A 14 year old should be able to control himself and focus towards his goals. If he struggles, then it is ADHD.

My son is only 10 and by no means perfect on Atomoxetine, but he’s managing much better after school until the evening. At school he is well behaved in the class but at play time he still gets in trouble sometimes. He also is sort of selective and for the teachers at school he’s super polite and trying his best but at home for me he is still speaking in a rude manner and lazy.

I think it’s a shame doctors aren’t so keen on trying something else, to see if maybe that would be even better, and then if not better, we’ll then going back to the previous medication, instead they say ‘If it’s good enough and doesn’t give your child side effects stick to it.’ So we stick with Atomoxetine.

[MaudQ]

If you can get an appointment, I’d talk to a psychiatrist. They are going to have the most informed opinion and expertise. My understanding aligns with yours: ADHD medication is not just for school but also for emotional regulation and clarity. People respond differently to different medication - so your NP’s kid’s experience is not necessary helpful for you. Also, I agree with involving your child in the process. A good child psychologist will partner with your daughter and help explain how the various meds work, monitor weight and side effects, and tweak doses. Good luck!

[ADHD_DAD]

Agree with above comments that recommend seeing a doctor. Nurse practitioners are physician extenders not physicians and the training as opposed to a psychiatrist who has attended college then medical school then at least years of specialized training in pediatrics and psychiatry before being allowed to practice independently is not comparable. We should be grateful for NPs who fill the shortage of medical providers, but not a substitute for a chuld psychiatrist if you can find one. Your NP should have a collaborating psychiatrist if he is now specializing in psychiatry. Perhaps you could start by seeing the collaborator and requesting that the collateraborator recommend a psychiatrist.

[ELucas13]

The nurse is using too much of her personal experience to inform her view of your child. However, if your child is successful on what she is on, part of me would say not to mess with it. I know it was very challenging for us to find anything to work and when we tried to add things, it really messed it up. But this is my own experience and my own child and it's important that the nurse understands that your child will also have a different experience. Stimulants are in and out so quickly, it is a little strange she won't give it a try. But they have potential for abuse, so maybe she is using a cost-benefit analysis that it seems unnecessary so why take the risk. And, appetite suppression and other side-effects are no joke. Feel free to push back to the nurse more, you are, in the end ,her "customer" and she needs to inform you based on the science, chemistry, and not just her experience with her daughter, or for that matter, other patients since people react so differently. Likewise, understand that your experience will also be unique to your daughter's on medication. So what works for you may not be what works for her and vice versa. It sounds like you are doing everything right and that you are advocating for both of you well. Keep it up!

[Snaizy]

I have twin boys (10) both of whom have ADHD. One of them is merely inattentive and takes his meds (Quillivant— methylphenidate) during the school year bc he can’t attend to boring school lessons without it but he does not struggle with emotional regulation or impulsivity so for him, it’s not needed on weekends or summer break. His twin on the other hand has combined type that the greatest benefit of the meds is the emotional regulation aspect. His impulsivity leads him to purposely annoy people/siblings, act inappropriately, do things he knows are wrong/not allowed but then feel remorseful that he was unable to resist the urge even though he knew there would be negative consequences. For him, medication 365/yr makes sense and is humane. He doesn’t feel good about himself and constantly gets in trouble/negative feedback without it. I would say that if your daughters symptoms are a lot like yours and your overall mental well being and personal efficacy are improved by the stimulants I see no reason to limit their use to less than daily. FWIW our physician agrees with this approach tailored to the specific needs of the child. I hope this helps and I ageee with others who recommend you escalate your concern to a Dr if you are not comfortable with the advice of the NP.