strattera guanfacine - would you add a stimulant??

[amewhit]

Curious if anyone’s kid takes strattera, guanfacine, AND a stimulant? We see our psychiatrist who we love tomorrow so we will ask - but I’m curious…

My son is 12 - 6th grade, 5’6” 117lbs and is finally on therapeutic dose of strattera 60mg. His mood is greatly improved (diagnosed with DMDD and ADHD Inattentive but I think the DMDD may actually be emotional dysregulation due to ADHD). His focus better but not amazing. Still goofs off in class and makes stupid decisions like pulling chairs out from under kids He gets ‘hot’ often with teachers and can be disrespectful when asked to do something “hard” for him. He is on guanfacine as well - which is what we started with and the first thing that worked some for a bit (not sure if it’s doing anything to anymore). So he is on 1mg IR at night and .5mg IR in am along with the 60mg Strattera in am. We started this process in September last year.

Previously, in 5th grade, we tried stimulants. He was a disaster on adderall and vyvanse - suicidal thoughts. Concerta worked for a while but - crash was terrible. We trialed all these for 9 months and finally took a break over summer before trying non-stimulants.

Should we just stay on guanfacine and strattera? He is doing therapy once a week too for about 10 weeks which is going well!

Thanks!!

Amy

[Hidden]

For my son stimulants haven’t worked either- worst 8 months in our family lives…

My son has just turned 10 and he’s doing well on Atomoxetine 40mg daily which is about 1.2mg per 1 kg body weight (it’s a bit over 1.2mg but he can grow into it in his weight). I mean, it’s not perfect and the other day my son punched a boy at school (in reaction to something but still, not the behaviour which is socially acceptable). But I definitely wouldn’t have thought that adding stimulant would help with this type of impulse control.

You are lucky your son has a therapist. In the UK it’s practically non existent for kids. It’s like a kid has to have a death in the family or some serious stuff going on to be eligible for any talking therapies.

What I noticed on stimulants my son was much more anxious, his mood completely dipped, he was irritable, emotionally unstable, even aggressive so he would probably at the time also has gotten diagnosis of DMDD had we carried on with stimulants for longer. He also had a range of neurological side effects to the point that if we carried on stimulants I think he would qualify for autism spectrum diagnosis. And the minute we stopped he’s back to normal self, appropriately sociable, yes, a bit quick tempered and poor impulse control but he stopped self harming his fingers, his tics stopped (he even developed tics on stimulants), he has no anxiety, his mood is fine.

I only learnt here on this forum and in Additude magazine that in the US it is common to mix stimulants and non stimulants and in fact many ADHD meds at the same time. In the UK we have Nice guidelines (National Institute for Clinical Excellence) for practitioners and in ADHD section it says that they recommend against mixing stimulants and non stimulants. They explain that there are no proper longitudinal studies of the effect of such treatment on children. They call for mono therapy and if one medication doesn’t t work they swap for another but they don’t keep adding on. I asked our son’s paediatric psychiatrist and he said that since he is in a private practice he can mix but he would advise against and he said that from his experience with his client it didn’t work well (I mean, it seems he didn’t have much experience mixing…). Since my son is doing well enough on Atomoxetine I think I won’t be pushing now for adding more meds, especially that in the long run stimulants do put strain on heart…I mean I am not sure if there are any longitudinal studies let’s say people in their 80ies and how it has affected their blood pressure and heart health. I know that amfetamins were widely used (not for ADHD) even in 1930-40ies in Europe, students at Cambridge and Oxford were taking these (so they could study and memorise and not go to sleep). Even Sylvia Plath in her book mentions this if I remember correctly (I might be mixing stuff as I read her book as a teenager and now I am in late 40ies😄).

Other parents on this forum recommend Cyproheptadine which is antihistamine but it also has mildly sedating side effect. It also somewhat improves mood, improves appetite in kids (which considering your son’s healthy hight and weight I am assuming is not a problem for him) and acts in a few other ways which seems beneficial. I’d say read some medical journals about it and maybe ask your son’s doctor. I noticed that some parents here were mentioning other antihistamines (and it wasn’t for allergy) or Clonidine as additional meds for ADHD.

Also I think from what I read about side effects of non stimulant ADHD meds- they can work but they can also have side effect of irritability etc. It almost seems like all the ADHD meds can have therapeutic effect but also can rarely cause side effect of mania like behaviours. I’d say the fewer the daily meds the easier it is to determine which medication causes side effect and monitor if the medication is working well.

[SecretAgentIEP]

Hi...which kind of therapy is your child doing? My doctors say my 7 year year son with ADHD is too young for cognitive behavioral therapy but I want to try family counseling. Also, did you read about the differences in the uses and side effects for Guanfacine ER versus IR? Several of my doctors say ER is better for kids. Or if it has no effect try slowly removing it with your doctor. It may increase irritability and those side effects may not be worth it if you don't observe much benefit.

[amewhit in reply to SecretAgentIEP]

Yes, we thought the ER may have been causing night terrors so we switched to the IR. No side effects with the IR so we are sticking with that for now. But may try switching back at some point! I honestly don't even know what kind of therapy he is doing, but the guy is really great with my son. They play video games together, working on frustration tolerance and pushing through negative feelings. He has a lot of emotional dysregulation!

[MaudQ]

My kid is on Adderall and Guanfacine. She tolerates both very well. There was initial weight loss with Adderall but she came back from that and is now on a typical growth trajectory. She had a bad experience with Focalin at first - adderall is the 2nd drug we tried. She experienced an after school crash with Adderall, so the psychiatrist added a small additional dose after school - this also helps with homework. I’m on Ritalin myself and I’m not currently experiencing any side effects. Everyone responds so differently to medication, though …

The way you describe your kid’s symptoms it sounds like the Stattera isn’t doing enough. I’d go back to your prescriber and ask what else you could try. If it turns out that there isn’t a good drug option, you could talk to his therapist. We have had good results by changing our own behavior. Does your son have a 504 or IEP at school? The teacher should understand that his behavior is not entirely intentional and that he needs support.

What does your son think? I assume he doesn’t like feeling out of control and getting into trouble either. Maybe he has some ideas to contribute .

[amewhit in reply to MaudQ]

I take Adderall, my daughter does well on Concerta, but all stimulants just made everything worse for my son. The only one we didn't try was Focalin. He does have an IEP finally after two years - we did an IEE and the district paid for it. So we have an IEP, meds, therapy. We are seeing some improvement! But it's not 'robust'. I wish we would have tried to add back in stimulants after the guanfacine but based on our previous experiences the psychiatrist and his pediatrician said no.

[dancer2973]

My daughter takes both. She takes the stimulant (dexmethylphenidate) in the morning. She then takes guanfacine in the evenings. Her pediatrician told is that she has found that guanfacine on its own typically doesn't do much. but it can help extend the effectiveness of the stmulant if both were taken. We have found it helps the medication last longer in the evenings to help her get through her homework. The stimulant works great on its own while she is at school, but it was wearing off when she got home and she was having a hard time concentrating on homework.