ADHD - rebound at night

Brewtowngrl

I asked about this a few months ago, but our trial and error on med management still marches on.  

DS is on prozac for his anxiety and it is working well. We have tried long acting focalin -made his anxiety so bad he couldn't function.   short acting focalin - almost found the right dose, but it would be complicated to deal with at school.  We gave a lower dose 3 times a day so it overlapped and he wouldn't come down.  This would be pretty difficult to manage once school starts in a few weeks.  We also tried a non stimulant.  It didn't do anything except give him a stomach ache.  We are now trying daytrana.  We are trying to figure out when to remove his patch.  On any of the stimulants he rebounds pretty bad night.  He is violent and disruptive.  He also can't fall asleep.  One night was 1:30 and another midnight.  We even upped his melatonin to see if that would help.  We tried a booster of short acting focalin at some point during this.  We gave it at 4 per the pedi and he was up all night that night.  During the day the stimulant works wonders for him.  I can play a game with him for the first time.  He can complete a craft.  I can leave him alone with his little brother for a min to use the bathroom and not worry he will hurt him.  

Doc background:  DS's pedi is on maternity leave for another week.  We chose to see a psychotherapist.  We must not have understood him when we first talked, but he is mainly focusing on med management and not doing much therapy.  He is also not including the family (myself or DH).  This makes it difficult since I don't have tools to help DS at home. We have decided to find a new group that takes a family approach to meds management and therapy, but can't get in till the end of next month.  Currently we are doctorless unless we see the backup pedi that doesn't know DS well.  

Now to the questions.  If your child uses the patch when do you remove it?   Any ideas of how to handle this rebound at night?  The whole family needs to sleep again.  I am not opposed to talking to the backup doc if a different med at night might be needed.  I am tempted to do no meds, but he doesn't like his behavior off of them and I have to worry about his brother's safety.  We can not to a diet modification as he has SPD.  After 7 months of therapy we are finally up to about 15 foods he will eat.  I need to get calories in him any way that I can.  

Brewtowngrl

  Does any have a child using clonidine?  This sounds like it could be a good combo for the issues we are facing.  I also did decide to give the back up pedi a call.  Just waiting to hear back.  

Brewtowngrl

-auntie- said:

Brewtowngrl said:

We also tried a non stimulant.  It didn't do anything except give him a stomach ache. 

GI issues are very common to Strattera. Was that the one you trialed?

No it was intuniv.  

We are now trying daytrana.  We are trying to figure out when to remove his patch.  On any of the stimulants he rebounds pretty bad night.  He is violent and disruptive.  He also can't fall asleep.  One night was 1:30 and another midnight.  

This might not be fixable. A lot of kids become agitated when their stimulant wears off in the evening. Depending on how he reacts, this disequilibrium can result in a kid who can't eat, sleep or behave appropriately. DS always had a couple nights of poor sleep when we titrated his meds to a higher dose to allow for growth, but it was generally just a rocky 72 hours. 

Have you tried any of the longer acting sustained release meds? These typically offer the smoothest taper in the evening because of how the meds are available in his system. Concerta and Adderall are generally the best for maintaining a good effective level through the day and fading gradually.

We had tried the focalin extended release, but he was on the ground not able to talk his anxiety went so high.  He was not on prozac though. 

During the day the stimulant works wonders for him.  I can play a game with him for the first time.  He can complete a craft.  I can leave him alone with his little brother for a min to use the bathroom and not worry he will hurt him.  

That's great. But you may not be able to have that level of control up to bedtime. A behaviorist should be able to give you mods to do at home to help him learn new functional ways to regulate himself. For a kid his age, The Alert program might be an awesome fit.

The new place we are going to go to is all encompassing.  His OT is helping us a little too.  

Doc background:  DS's pedi is on maternity leave for another week.  We chose to see a psychotherapist.  We must not have understood him when we first talked, but he is mainly focusing on med management and not doing much therapy.  He is also not including the family (myself or DH).  This makes it difficult since I don't have tools to help DS at home. We have decided to find a new group that takes a family approach to meds management and therapy, but can't get in till the end of next month.  Currently we are doctorless unless we see the backup pedi that doesn't know DS well.  

Who is writing these prescriptions? Ideally, a psychiatrist writes scripts for psychoactive meds. S/he would do regular checks of your son's mood and the impact of the meds on him. But they don't do therapy, per se. That would be done by a psychologist or therapist with a behavior background. He should also have an IEP in school to offer him accommodations to be successful and interventions to learn better ways to interact. A PCP pedi really shouldn't be overseeing such meds, especially for a child who is taking a cocktail combination of things.

We were seeing a psychiatrist that also did therapy.  We were not a good fit.  We saw him last week and decided to get into this new clinic that comes highly recommended and part of our medical college.  We can't get in till the end of Sept. The doc we were seeing really didn't do much, but adjust his meds.  We really wanted therapy that included us so we could help him at home.  We leave feeling more confused.    

 Any ideas of how to handle this rebound at night?  The whole family needs to sleep again.  

A behavior approach. And you may have to separate the boys if your oldest feeds off the younger brother. 

fingers crossed this mew clinic will help us with this. 

I am not opposed to talking to the backup doc if a different med at night might be needed.  I am tempted to do no meds, but he doesn't like his behavior off of them and I have to worry about his brother's safety.  

Have you tried one of the antihypertensives like Tenex/Intunive or Clonidine? Some docs will offer this instead of a stimulant or in addition pre-bedtime. I wouldn't go this route without a psychiatrist because he's also on an SSRI. The other thing to consider is that, for certain people, SSRIs can be activating at even average doses. Since they tend to build up in the system it might be months or even years on a drug like Prozac before this side effect rears its ugly head. If he's activated by the SSRI, he may need to be switched to a different one, a lower dose or even to one of the neuroleptics like Risperdal. These drugs are often chosen for intractable anxiety with aggression.

We are going to try clonidine.   If that doesn't help we will move on.

We are also on the schedule with his school to start the IEP process once the school year starts.    

Thank you for everything.  a few months ago what you told me was way over my head and now I understand.  This is a huge learning experience.