Picking Between the Least Worst Options

So great to stumble upon your blog. I am a single mom of an amazing 5 year old suffering from ADHD and Sensory issues who has tried every drug in the book. But, the side effects are grueling. With Vyvanse, although his symptoms practically disappeared, he developed severe speech dis-fluency. It was just torture for him. I wish that it wasn’t like that, because the Vyvanse did wonders for him. Now, we are going back and forth between Ritalin LA and Metadate. His doctor and I both agree that the proof shows that the meds are doing wonders, it’s now deciding what side effects he can live with. Any words of advice?

One of the great quandries of life as a psychiatrist is a patient’s unpredictable reaction to similar psychiatric medications.  The SSRI treatment of depression is probably the most common example of this–why do well on Zoloft but poorly on Celexa when they both do the same thing.  The differential reaction to stimulants is equally baffaling.  Conventional wisdom says that about 70%of kids will do well on one stimulant (eg a dexedrine product like Vyvanse).  Take the 30% that don’t and give them the other stimulant (a methylphenedate product like Concerta) and, again, 70% will do well.  Between the two types of products, I can generally manage the symptoms in about 90% of kids (give or take).  Why your son would have significant dis-fluency on a dexedrine product (Vyvanse) but not a Ritalin product (Ritalin LA and Metadate) makes no sense . . . but that’s what happens.  But what about the kids who do not do well or do not tolerate either medication?  The obvious solution is Strattera, the only non-stimulant that is FDA approved for the treatment of ADHD symptoms in kids and adults.  Strattera is great when it works but problematic in that the percentage of people who tolerate it well AND do well on it is relatively small.  Maybe half of the patient’s I start on Straterra continue on it.  Not a good number.

For your son’s situation, it sounds like very careful titration of the dose may not be all that helpful, so a trial of Strattera may be in order.  The other thing to keep in mind is that nutritional parameters may also play into how well your son is doing.  I generally encourage patients with focus and concentration issues to take fish oil (they do come in forms that your son can take).  I also encourage sufficient B-vitamines and Vitamin D.  Vit-D is getting lots of press these days for how important it is for mental and physical well-being.  Even if your kids drinks a lot of milk, supplementing with additional sources can be helpful, especially in the dead of winter.

–Dan Hartman, MD

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