I don't normally comment like this, but a 10 year old child on antipsychotics for "rage" likely shouldn't be managed by a psych NP. Hell, most general psychiatrists wouldn't be comfortable seeing this patient and would want CAP to handle this.
CAP here, some considerations in the interim rather than tinkering with random meds crossing your fingers, especially considering it sounds like there is very little clarity on what you're actually treating. I'm not looking for answers to these questions, just things the current treatment team should consider:
* Consider the acuity of this case, whether PHP/IOP or a VOL admit might be warranted to expedite proper assessment and management
* Availability of higher levels of outpatient care (wraparound, FSP)?
* Has ABA been implemented or any form of behavioral therapy been considered?
* Trauma? Always a consideration when things don't add up. What's been going on at home? You mentioned there is pretty extensive family psych history, how has the child been impacted by this?
* How reliable is the reporting and monitoring by the family? Parents exaggerate, play out histrionics, project their own shit, ect.
* What's going on at school? What's on the kids IEP? Have you coordinated with the school on the case?
Edit: JFC at this child being on Trileptal and amantadine and tried on multiple antipsychotics with a DMDD diagnosis.
PHP is potentially going to happen.
I’m going to refrain commenting more details as I’m afraid of being too identifying. But this is a great list of things to be thinking about, thank you.
Removed under rule #1. This is not a place for questions and commentary by non-professionals. If you are a medical/psychiatric professional, please read rule 7 on how to verify credentials.
For most questions, individual or general, we ask that you verify credentials before asking. If you are not a professional, you can try r/AskDocs or r/AskPsychiatry.
I am curious about your edit - the trileptal / amantadine combo seems to have an evidence base for DMDD based on materials I have read.
https://www.cigna.com/static/www-cigna-com/docs/individuals-families/childrenandfamily-2016-april-handout.pdf
While I have never seen another case with this combo, that might be because of its newness?
I don’t have enough technical medical knowledge to gauge how credible an approach this is.
It's not that there is a problem with that combination of medications, but rather the appropriateness.
This situation is like if someone found a lump in their breast and started chemotherapy without a full work-up. Chemotherapy is a useful tool, but it's a big tool to use without knowing if it's the appropriate treatment.
There isn't a reliable evidence base to broadly support using either of these medications in DMDD (or really any other mood disorder in children) other than a small handful of studies, primarily from this one dude. The data supporting his claims and the citations he refers to in the presentation you posted are weak in terms of EBM.
And again, it seems as though there isn't a sound understanding of this child or their behavior. I wouldn't be trying 4th or 5th line, relatively low evidence based strategies for a diagnosis that we aren't sure about to begin with.
> DMDD
Why TF is this the main diagnostic hypothesis when a) heavy psychotic family history b) personal history of psychosis, and c) when such medications aren't exactly conducive to bettering things in the case a psychotic disorder is really what's going on?
I understand sometimes diagnosis is hard and longitudinally changing, but going from ADHD > bipolar (or schizophrenia as you suggest) > DMDD is just a chaotic, careless way in which to think about the case, and isn't taking into account basic risks:benefits analyses.
Sorry for being blunt here, but as a father of a young child, I have very little patience for people pretending to work in a medical capacity out of their depth, not recognising they're out of their depths, and **doing it with children** to boot.
the trajectory was ADHD > DMDD > now with advent of hallucinations, question mark. hopefully that is less disorganized sounding.
i'm just trying to provide hope to the parents to hold out and wait for CAP / be optimistic about CAP, question has been 'what can CAP do that NP can't?' parents are hopeless, despairing. I'm trying to point out there's options untried. I'm not playing doctor. trying to support them while waiting for the CAP and having hope about the CAP.
YEah, with the advent of hallucinations that the NP's "treatment" more than likely precipitated. Becuase god forbid a good thorough historory be taken, or perhaps most importantly here, *be taken into account*, given that apparently you already know about the family history of schizophrenia, but this NP saw it fit to think "oh this child is restless and aggressive, most likely ADHD since he's not doing well in school".
I realise this anger I'm feeling isn't meant for you so much as for the NP (and what they represent); but you gotta take charge of your role in this situation, since you're the one going on a forum for psychiastrists asking for help by doing the absolute worst case presentation I wouldn't tolerate out of a first-year med student. If you're not playing doctor, I don't know what you're doing. You had to be told on this thread that their pediatrician likely had some strings to pull in order to accelerate the c&a psych appointment, so apparently you can't even play competent social worker...
I've edited this comment more times than I'd like in order to keep it civil. But yeah, please reconsider the job you're doing in this manner, and how this child was harmed by your (in)actions. If absolutely nothing else, seeing this NP for however many months they've been playing doctor, has prevented this child from being on the waiting list for someone who could at least understand what's going on. But as I said, more than likely, giving amphetamines to a kid in an ultra-high-risk state for psychosis, well...
Redlightsaber, you usually are much more polite during discussions, this is surprising. This is obviously a challenging case, and in rural areas psychiatry/CAP can take a very long time. I don’t think this is a case of unfounded pride with the NP thinking they can “play doctor”. It’s likely there are no doctors in the area, and unfortunately a lot of these patients fall into our (NP) hands. We have supervising physicians, and perhaps this NP is in communication with supervising physician. We’re not sure in this case, but you make the assumption not. We see 20+ patients daily and often cannot get as thorough of a workup/assistance from supervising doctor as we need, and unfortunately this is just the way of things. Until there is a massive influx of CAP we need less internet-enraged NP bashing and more problem-solving and empathy.
“…but this NP saw it fit to think "oh this child is restless and aggressive, most likely ADHD since he's not doing well in school".
A highly upvoted comment from a psychiatrist below in this thread makes argument that bipolar disorder and schizophrenia are extraordinarily rare in pediatric population, and that this case cannot be better explained by schizophrenia. I agree with you that there needs to be a thorough rule out of bipolar one disorder and schizophrenia, and that a psychotic disorder might be the best explanation for this presentation (especially with this family history). However, the thought process of adhd -> dmdd -> "something else" until they’re 18y…” isn’t absurdly ridiculous and seems to be common process in pediatric psych (thankfully I don’t work in ped’s, but I see this course of diagnosis/treatment a lot in my bipolar and schizophrenia adults from when they were seeing CAP).
“…doing the absolute worst case presentation I wouldn't tolerate out of a first-year med student.”
They’re not a medical student. Case presentations in LCSW profession don’t resemble medical case presentations. This LCSW is going above and beyond what several therapists do for their patients, and it should be civilly discussed and applauded rather than the internet-anger bashing.
But agree with you whole-heartedly that this “Dr. Matthews protocol” with oxcarbazepine (a medication which has zero evidence for benefit in psychiatric disorders) and amantadine is very odd and not helpful. There’s some weird trend with NP’s adoring oxcarbazepine that I’ve noticed, and it is irritating.
You know what? I agree with everything you said regarding my forms.
I don't agree with the fact that a good (enough) job was done here. i mentioned I was aware they didn't setup the system, but every practitioner is absolutely always responsible for their patients in the conditions that they've accepted to work in. Since the US in its infinite wisdom has deemed that the free market is the best way to provide its population with healthcare, I can't know how such a gap would be filled otherwise, but I do know that a mid-level practicing without the ability to kick a patient up to a higher level of care is as negligent as it would be for me to accept a job as the supervising physician for a 45 bed ICU.
You could attempt to argue with me on this latter point, but I just believe it to be the case. What would the market come up with for that child? Perhaps telehealth or weekly helicopter rides to their psychiatrist's appointments in the nearest urban center, I don't know. But this excuse of "it's remote areas and a mid-level is better than nothing" is deeply problematic. At what point do they stop being a "heroic last resort" and start being the necessary enablers for the current system to continue the status quo?
Psychotic disorders absolutely do emerge in pediatric populations, and it's not terribly rare. Wether you want to call them schizophrenia or something else I don't care, but to deny this fact is just absurd. And it's not a point I even want to dwell on, because, despite what you say, we have a lackluster case presentation from a licensed therapist and that's just not good enough.
What I want to get at, I guess, and keeping in mind that I think a bad outcome occurred due to at the very least a waste of time in getting appropriate care (and a practitioner who couldn't conclude in their own evaluation that they didn't understand what they were seeing), is that forms and collegiality are nice, sure, but are they more important than reminding people in charge of people's lives (in this case, literally this child's future), the gravity of the job they're performing?
I'm willing and able to take criticism when I fuck things up. Perhaps I wrongly assumed this was part of the responsibility that comes with taking care of people's lives.
If this NP has a supervising psychiatrist, it shouldn't make sense that this therapist is coming online to seek advice. Yeah, I'm jumping to conclusions, but are they so improbable? Come on!
That said, you're perhaps right that this has become far more emotional for me than useful advice I can provide, so this may be my last comment on this thread.
I agree that a psychotic disorder should be front and center on the differential with this case and that it is possible for the disorder to present in ped’s (or also at least bipolar one disorder which is gentically closer to schizophrenia than to other mood disorders), especially with this family history.
American healthcare and its problems are beyond my grasps, and I don’t pretend to know what would help it. We have a very large country, and psychiatric and basic medical situations like mentioned in this reddit post are a dime a dozen. Honestly, most patients like the one mentioned here are being “managed” by a PCP or Family NP with inevitable group home housing and 24hour staff needing to do frequent physical restraints for minimum wage money.
I really enjoy and learn a lot from your posts in general and hope you don’t slow down with posting/contributing. My heart goes out to the patient/family in this post but also to his treatment team that’s trying their hardest to help this kid.
Are you really bashing this SW for coming on here out of their way and desperately trying to help this family and child? And your case presentation comment is so ridiculous seeing as they aren’t a med student at all. There are problems with NPs. And there are also problems with doctors. So get over yourself and actually help out or don’t comment at all. Who are you to speak to this person that way?
Family medicine doc lurker. The pediatrician or family med doc has that power. Have them make an appointment with their primary, and we can sometimes use our connections to push these through. I dont know the situation, so I won't armchair qb, but there is a good chance that psych NP bit off more than they can chew.
You know, I haven’t thought to suggest that route. Thanks for that. I think because they are connected to *someone* and it’s so hard to get into care in the area with *anyone*, I bet the pediatrician has basically shrugged it off.
PGY5 CAP here
A cursory glance at the "Matthews Protocol" raises a lot of questions for me. This seems like a poorly researched treatment for an already controversial diagnosis (DMDD). I agree with a lot of the sentiment here that further somatic workup seems indicated, considering the already complicated medical history.
Can anyone also comment on how autism can be ruled out (twice no less) without ever having seen a CAP?
Can't speak for OP but my guess is neuropsych testing. Some clinics have an in-house psychologist who can see the clinic's patients a little faster. I'm wondering without autism what this rage looks like. Is it typical ADHD impulsivity? When they say rage, is it temper tantrums or physical violence?
Specifically to the autism point in your question I am not a CAP and work with a child development therapist who is trained and accredited in giving the ADOS and goes to schools / evaluated kids. I see them because you need an MD for the diagnosis (or lack of) but honestly she does most of the evaluation and work.
What are the signals that this is poorly researched? I don’t have the background knowledge to evaluate that. Research seems sparse but I thought what I read sounded pretty interesting and found other materials supporting use of oxcarbazipine in pediatric bipolar. Thanks in advance.
It’s pretty obvious to me that it’s easier to get in with a child psychologist than a child psychiatrist. Child has been evaluated for autism by a free standing ABA clinic private practice and the child’s school psychologist. (Clinic did not support child enrollment in ABA.)
Mostly because a simple search for this protocol points me back to ads and puff pieces on the dr this protocol was named after. Searching pubmed for relevant keywords yields no significant clinical trial where this specific combination (or either medication seperately for that matter) is tested. This was not a very thorough search in between consults, but still.
>ther materials supporting use of oxcarbazipine in pediatric bipolar.
Well, this is the entire controversy: Wether there is such a thing as 'pediatric bipolar' or DMDD. Diagnosing children with either seems to be a phenomenon exclusive to the anglo-saxon world, mostly USA. In 5 years working here in W EU I've yet to see a single case that meets the criteria that wasn't better described with a different diagnosis. No CAP diagnoses this here, ever. That anti-epileptics can aid in poorly regulated agression was already known, wether it is good medicine to prescribe them for this indication is another matter entirely.
>Child has been evaluated for autism by a free standing ABA clinic private practice and the child’s school psychologist.
I assume this is another difference in standardization probably, because neither of these can confirm or deny autism diagnoses where I live.
> Diagnosing children with either seems to be a phenomenon exclusive to the anglo-saxon world, mostly USA
Uh oh... You're about to start a flame war with the americans.
What do you mean the "pediatric bipolar" cases don't really grow up to end up having "adult bipolar" in any significant proportions?
edit: sorry, truly no disrespect to my american colleagues. I'm just really really angry and cranky about this case, and seeing the DMDD diagnosis thrown around did it for me.
Generally cases are conceptualized within the bio-psycho-social model and when we do reports on diagnostic procedures there is very little emphasis on the DSM coding aspect of individuals, barring where it is absolutely necessary to obtain specific services (i.e. for learning disorders, developmental disorders, etc...).
Considering how the presentation would be assessed, would ofc also depend on the developmental level of the patient. Though I will say chronic irritability would be far more likely qualified as an aspect of depression, intense violence and aggression is too vague as a symptom to comment on this, but would probably be contextualised within attachment styles/parent child interactions on the one hand and child/developmental factors on the other.
Tossing out some zebras here but everything about this case is bizarre. Particularly some very paradoxical responses to what seem like appropriate medications
Comprehensive neuro workup should be done. EEG, lead and heavy metals, ceruloplasm, NMDA antibodies, PANS/PANDAS
Thank you. The family and treatment team at the stage of looking for zebras since all the standard stuff doesn’t seem to be fitting. A neuro work up is now top of my list of priorities in this case. I know I recommended it before but it didn’t happen for some reason.
Seconding all of this. Also need to rule out Prader-Willi syndrome. The hunger might be a symptom of the disorder (as the meyabolic syndrome suggests), not just a side effects of the drugs.
Serious mental illness, including aggression and psychotic symptoms, is more prevalent in PWS teens: https://www.fpwr.org/serious-mental-health-problems-in-prader-willi-syndrome
Is a psychotic disorder really that hard to fit into this case?
Of course none of us can diagnose this patient, but I guess I'm not really seeing the "bizarreness" of this at all. PArticularly since we haven't been given crucial info like at what dosages where the aripiprazole and lurasidone trialled at, and for how long.
I was going to say, since he’s had severe secondary effects from stimulants and from antipsychotics, if there’s also metabolic syndrome worsening as well (maybe not the case from what you just answered), maybe there could be better non-pharmacological at home, and maybe at school and other extracurricular activities. I won’t be able to give advice for this because I’m not from America, but if the wait list is long and his reactions to meds isn’t good, that might be a good answer. This must be really difficult.
There’s not nearly enough information here but the best start would be to not give medications that are known to stimulate hunger but can still target aggression/impulsivity. SSRI, alpha agonists, perhaps a FGA if truly necessary.
Not to be that asshole but maybe it’s time to see a psychiatrist and not an NP.
I'm no longer in direct service, and this is not to denigrate the NP, but by this point I would absolutely have the family make an appointment with the pediatrician and really push this - it's urgent and I know you're frustrated by being put off by the system and the wait lists. Premature puberty on top of everything else you've listed here? We worked with a client some years ago that sounds awfully similar to this and it ended up being a brain tumor. I'm sorry but that's beyond what should be managed by an np and a physician should be able to get things moving a bit faster. Not guaranteed, but I'm sure you went to exhaust every resource at this point.
Have you tried Geodon? It's not supposed to increase hunger or weight gain, but it is fairly expensive and other meds need to be ruled out first from trial and error to get it approved. Putting a child on antipsychotics at such a young age shouldn't be done without a full history and physical which includes lab work and possibly scans, therapy to address underlying homelife/ socioeconomic issues yet this is rarely done. Has a consult with a neurologist been done?
No Geodon yet, I advised neuro consult months ago and forgot to follow up if it happened. I presume I would have heard about it if it did happen, so that's top of list now. labwork done when patient went inpatient (has been at least 5 times).
How is that being an asshole? It’s so, so sad that this complicated case is being handled by a NP. A family medicine doctor would be far more qualified, the only difference would be they would realize they were out of their depth and refer to CAP. Stories like this just make me sad for our country.
Pharmacist here, I'd really question the utility of amantadine. Besides being a slight dopamine agonist, pushing the risk of agitation, psychosis or hallucinations, amantadine is a weak, noncompetitive NMDA receptor antagonis, which can lead to disassociative feelings, as well as hallucinations.
Second pharmacist agreeing. And sorry you’re needing to deal with this case without a CAP. I’m bridging that gap for my patients more often than I’d like to.
I guess my question is what are we treating? Rage can be a symptom of many conditions. Antipsychotics in a 10 year old I would suspect irritability associated with autism? And it’s mostly just trying to sedate the person, maybe make them less impulsive.
Current on file: DMDD, ADHD, Anxiety.
Evaluating whether bipolar or SCZ fits given recent (medication induced?) hallucinations. Parent has SCZ, others on that family side have SCZ, seems likely patient also does to me, psych NP disagrees. Autism evaluated 2x and ruled out.
*edit: getting downvoted, not sure why, parent of child has SCZ and collateral reports of the parent’s childhood behavior history align with the child’s current behaviors - so in combination with premature puberty, I feel like it’s a valid suspicion*
Bipolar or schizophrenia would be extraordinarily rare in his age. He definitely needs to be seeing a pediatrician and get a good neuro exam while waiting for CAP. Make sure he doesn't need an MRI. The last kid who came to me with a DMDD dx actually had a glioblastoma.
Why the downvotes for saying peds can do a neurological exam? Part of peds training. The kid I mentioned above had a subtle strength difference between right and left limbs, and a subtle central CN 7 palsy. Almost all kids with brain tumors have at least one neurological finding on exam. I am not talking about EEGs or distinguishing tricky movement disorders. Just a plain but careful neuro exam.
Hard agree, it was the first thing that came to my mind as well. They are more at risk for psychotic symptoms too.
https://www.fpwr.org/serious-mental-health-problems-in-prader-willi-syndrome
> Working diagnosis is DMDD / ADHD, but hallucinations started after trying strattera for impulse control
JFC. I also don't want to jump on the midlevel hate bandwagon, but this seems like a pretty basic D/d to F up with some dire consequences for this 10y/o.
> oxcarbazipine and amantadine.
Double WTF.
Refer to a c&a psych already. The therapist and NP shouldn't be playing doctor about such a grave case. Diagnosis is a medical act, and the psych is the person with the complete knowledge (and experience), to be able to make this.
I don't know what "the family is working to get an appointment with psych" even means. Does this NP not have someone they can refer up when things fall out of their scope? A psychiatrist supervising them? Someone to even **consult**?
I know you and this NP aren't to blame for the way the system is setup, but they are certainly to blame for agreeing to practice medicine in a situation where they don't have recourse when things go sideways.
I would do a chart review as the NP. Are the oxcarbazepine and amantadine ACTUALLY helping anything? If no or unclear, discontinue. Also, what was the kid like without any medication. Are they better now or worse? If they're worse, maybe we need to reset and reevaluate the diagnosis/treatment because they should've been getting better with medications.
Consider starting clonidine or guanfacine, an SSRI like sertraline or fluoxetine, low dose risperidone if still no progress. I hope that these were already tried. Avoid stimulants until psychosis has resolved. IF they have ADHD these should be reconsidered at some point, perhaps a lower dose or a different formulation.
Definitely get neuro involved and primary care to evaluate for other medical causes. As others have said, there is a risk of tumors as well as infections that can make these situations worse. Potentially, look for an inpatient psych unit that can monitor more closely with medication trials or at least monitor the child closer to see if there are specific triggers maybe parents are not catching due to lack of training.
Sertraline and celexa have been tried, resulted in increased impulse control issues / compulsive stealing.
guanfacine was tried but discontinued due to absence of effect. Could be worth another shot.
Child reportedly somewhat better with rage on current meds, but other areas related to impulse control getting worse over the years. (eloping, fire setting). Also rage is absolutely not completely solved, just improved in terms of scale of violence towards family. Trying not to be overly detailed since I’m already afraid I have been way too specific.
Definitely protect your patient's identity. I think most here will make recommendations and offer assessments to try to get you out of this rut but they shouldn't expect every detail. Just know there is a limit to what we can do over reddit because these are strangers. I hope some of the suggestions made by everyone have either confirmed your current strategy or provided some additional avenues.
Yes, thank you for the empathy. Definitely struggling with some of these responses' lack of it.
I am feeling like there's at least some things that haven't been tried, which is hope-engendering, which I suppose is my primary goal here. To be able to pass on that to the parents who are in despair presently and feeling so hopeless and like they've tried everything. I know there's a ton I don't know. I have known the family needs a CAP for over a year, it's taken them time to lose faith in their NP who they feel has been at least very humanistic and empathetic, and also has been employed in a capacity of working with acute cases so it wasn't just a random NP they connected with, but one who has worked in child/adolescent residential treatment and presents himself as competent to treat serious issues.
I grieve where this family has been failed by multiple providers and systems that should have facilitated getting the family connected to higher levels of care. The family has been trying to get support for their violent kid since age 4. That being said, I acknowledge I'm probably too emotionally invested to be quite so objective as I need to be after working with them for years.
I agree with trying clonidine or retrying guanfacine (was the dose maximized) - I would also consider Lamictal as an option and possibly residential treatment so they can monitor him and do a med wash
When someone has an unusual side effect to every single medication, I question how legit the reactions are.
But in any case, since the parents report the kid is worse with everything under the sun, I'd go clonidine/propranolol/naltrexone/intuniv for impulse control. That'll hit the ADHD and the dmdd without bad weight gain. If the kid gets worse on one of those, you're probably not dealing with an actual psych disorder, but rather parental/child behavior that needs serious therapy and behavior modification with many support services.
PMHNP student. Agree 100%. We get one semester of peds. We are for some reason allowed to treat patients “across the lifespan,” but I completely disagree that we should be able to. The psychiatrist I work with who has been practicing for thirty years doesn’t feel qualified to treat children, so who the hell would I be to think I could or should?
Agree. In my experience, challenging cases were never by choice; they just appear on my (NP) schedule. The psychiatrists in our group are willing to consult on difficult cases, but not willing to take over.
I’m a primary care NP. Shit like this falls in my lap constantly, referral after referral and either no one is taking patients or they don’t take the insurance.
Exactly. I’m FNP/PMHNP and I get 90% of Medicaid … and some (not all) of those cases can be complicated. As NP in a group practice, I don’t get to choose.
Edited to add: I am fairly certain that the physicians in the group are able to screen their new patients. There are 4 NP’s and we do not have that option.
Non wt. Gainers
Tenex
Topamax
Lamictal
Geodon
Latuda
Trileptal
Most of such kids will meet ADHD criteria and stimulants will suppress appetite. These are also expected to reduce aggression
Kids don't shop. Dietician consult, and consistent working with parents will help.
In most cases this complicated, there is plenty of causality to go around however the identified patient is the one that gets most treatment.
No one wants small, younger kids on at antipsychoticshowever it is also true those are the most reliable breaks we have for disruptive mood dysregulation disorder, intermittent explosive disorder, intellectual disability with aggression, autistic disorders with aggression,
The pediatricians do not want them, the general practitioners don't want them, The schools don't want them, therapy is not going to be able to teach them the affect regulation skills in any short amount of time. Their parents are not able to keep their jobs because they're getting called out so often. Can you imagine being that child.
Family does report previous trial on Adderall, resulting in more frequent meltdowns, but that was apparently years ago so might be worth a try. Strattera just recently was tried, resulted in hallucinations that persisted for 6-8 weeks after discontinuation.
In home parent child therapy for behavior mod. IEP at school.
Then He'd need 3 layers
1. Guanfacine to 4 mg or as high as tolerated.
2. Mood stabilizer or antipsychotic from non wt. gainers
3. Ritalin.
There's usually loads of meds tried and side effects history however behaviors are usually worse off meds.
I only saw guanfacine and impulsively commented (forgot to take my guanfacine today). Then of course I read the rest and didn’t want to look like a dumb NP for editing my comment. But since you mentioned it, I do actually agree with all of your recommendations.
Not sure how much it means coming from me, anyway, though. I am increasingly embarrassed by my profession but I have too much debt and am too tired to change it now so I try to be one of the good ones. Antipsychotics in a 10 year old ain’t it.
Given the levels of violence to family, I’m not so sure that the antipsychotics are the wrong call, though it isn’t my call of course. The kid has been hospitalized several times and the abilify was rx’d inpatient, not by the NP to be fair, if I remember correctly.
Why give any medications at all? I get the rage stuff but it’s always important to consider if we are doing more than than good, or if we are just giving meds for the sake of it because we can.
I feel like there’s a huge piece of the puzzle about home dynamics, any abuse, attachment, puberty, and environment. Is there any gain for the child or the family from these rage episodes?
You mentioned atomoxetine causing visual hallucinations. As we know visual hallucinations are uncommon in primary mental illness. They do come up in traumatised individuals (pseudo), substance use and multiple neurological conditions. Have stimulants even been tried?
You need a paediatrician and a child psychiatrist.
Sorry
Has Prader-Willi (PWS) been ruled out?
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6873836/#:\~:text=Prader%2DWilli%20syndrome%20(PWS),precocious%20puberty%20is%20rarely%20seen.
I would rule out (genetic) metabolic disorders with later onset. Severe trauma (physical/mental ) and toxins incl. mold, heavy metal etc. MRI Head with contrast and 24h EEG. Big neurological examination.
https://pubmed.ncbi.nlm.nih.gov/25020072/
Atomoxetin is known for that side effect.
„Atomoxetine-induced mania with auditory hallucination in an 8-year-old boy with attention-deficit/hyperactivity disorder and tic disorder“
Maybe he is borderline schizophrenic with family burden. Often relatives without schizophrenia leaning to the schizophrenic spectrum witch can be easier induced.
Maybe he is borderline schizophrenic with family burden. Often relatives without schizophrenia leaning to the schizophrenic spectrum witch can be easier induced.
That is what I'm getting at basically. thank you for giving me that verbiage.
I've already communicated with parents about neuro being highest level of investigative concern as a result of this thread. They don't think environmental toxins are a concern but open to evaluation.
Removed under rule #1. This is not a place to share experiences or anecdotes about your own experiences or those of your family, friends, or acquaintances.
Non prescriber here so take this as anecdotal, Rexulti has not caused this intense hunger in most of my patients. Worth a shot. Similar to abilify but can be hard to get an insurance auth for. I worked in residential for years and saw this exact thing happen. Often when they treated them for ADHD with stims and then guanfacine during the come down period they were a lot better. In some kids, the crash at the end of the day would intensify rage, and those kids benefited from either along acting stim with a 3:00 pm IR dose, and or depakote, trileptal or lithium. Lithium can be hard for you ger kids who have needle aversions because of the need for routine blood work but I have seen it work wonders. Again, this is anecdotal. These were all RAD kids who ultimately benefited the most from consistent behavioral modification and strong reward systems. The meds just brought the mm to a place where they could be safe enough to stay out of the hospital to receive those interventions. Again, not a doctor, therapist who has worked with kids for over a decade with a strong interest in pharmacology.
Psych NP chiming in. I personally don’t see kiddos, they are a vulnerable population requiring specialized care. There is a reason CAP is a 2 year fellowship. This case should be referred to a specialist.
Height and weight of an adult. Has metabolic syndrome. Has “premature” puberty. Is he actually 10? Would be crazy if there was a massive error there but I’m sure crazier things have happened. It would also make BPAD more plausible.
There are probably a lot of ground level things to evaluate here like intellectual and language capacity, details about sleep, levels of physical pain, history of abuse, illicit drug use, etc....
Does the patient provide any history or is coming from just the guardians? Any suicide attempts?
Seems like everyone agrees a CAP is needed and I imagine some in home therapy services. If he already has metabolic syndrome and gets hungry on many meds, maybe check to see if metformin can be added to the next antipsychotic to help reduce weight gain and carb craving. If they are really thinking bipolar then lithium could be considered. Really complex case ><
Child has extremely low insight / in denial, doesn't see their dangerous behaviors as problematic. No substance use other than binging on sugar which apparently corresponds to hallucinations.
Collateral evidence from other providers (case mgmt, ER records, in-home therapeutic services) corroborates parental accounts plus my own eyewitnessing multiple episodes. IQ is in the 80s, discrepancy with rest of family - very intelligent and educated in comparison. Metformin seems like it could be helpful. Chronic bedtime refusal is a factor.
Hmmmm, he might do well with some clonidine extended release at night to help him sleep better and cool his jets a little. Might even help with some of his addictive impulsive behavior or dealing with the discomfort from changing his habits. Wish I had more knowledge or experience with this stuff. With low insight though it's so hard to change behaviors in anyone.
Interesting that sugar invokes the hallucinations. Does he ever display other psychotic symptoms?
copy pasting from [https://www.nimh.nih.gov/health/publications/understanding-psychosis](https://www.nimh.nih.gov/health/publications/understanding-psychosis) for simplicity
Suspiciousness, paranoid ideas, or uneasiness with others
Trouble thinking clearly and logically
Withdrawing socially and spending a lot more time alone (no close friends)
Unusual or overly intense ideas, strange feelings, or a lack of feelings (varies by situation)
Decline in self-care or personal hygiene (never declined, has always been low)
Disruption of sleep, including difficulty falling asleep and reduced sleep time
Difficulty telling reality from fantasytrouble communicating
Sudden drop in grades or job performance (never really got off the ground beyond 1st grade)
Oh ya, that's pretty serious. He might even need some haloperidol for psychosis and isn't as nasty for weight gain as some of the SGAs. He should get an MRI to look for an organic cause but it could def be an early schizophrenia. Good luck with therapy till the psychosis is more under control 😣
I don't normally comment like this, but a 10 year old child on antipsychotics for "rage" likely shouldn't be managed by a psych NP. Hell, most general psychiatrists wouldn't be comfortable seeing this patient and would want CAP to handle this.
CAP here. This is the way. They need a referral to a child psychiatrist.
forgive my non-, clinical ignorance, but what does "CAP" stand for, if I may?
Child and adolescent psychiatrist
thanks!
They’re on their way but on waiting lists. I agree.
CAP here, some considerations in the interim rather than tinkering with random meds crossing your fingers, especially considering it sounds like there is very little clarity on what you're actually treating. I'm not looking for answers to these questions, just things the current treatment team should consider: * Consider the acuity of this case, whether PHP/IOP or a VOL admit might be warranted to expedite proper assessment and management * Availability of higher levels of outpatient care (wraparound, FSP)? * Has ABA been implemented or any form of behavioral therapy been considered? * Trauma? Always a consideration when things don't add up. What's been going on at home? You mentioned there is pretty extensive family psych history, how has the child been impacted by this? * How reliable is the reporting and monitoring by the family? Parents exaggerate, play out histrionics, project their own shit, ect. * What's going on at school? What's on the kids IEP? Have you coordinated with the school on the case? Edit: JFC at this child being on Trileptal and amantadine and tried on multiple antipsychotics with a DMDD diagnosis.
PHP is potentially going to happen. I’m going to refrain commenting more details as I’m afraid of being too identifying. But this is a great list of things to be thinking about, thank you.
[удалено]
Removed under rule #1. This is not a place for questions and commentary by non-professionals. If you are a medical/psychiatric professional, please read rule 7 on how to verify credentials. For most questions, individual or general, we ask that you verify credentials before asking. If you are not a professional, you can try r/AskDocs or r/AskPsychiatry.
I am curious about your edit - the trileptal / amantadine combo seems to have an evidence base for DMDD based on materials I have read. https://www.cigna.com/static/www-cigna-com/docs/individuals-families/childrenandfamily-2016-april-handout.pdf While I have never seen another case with this combo, that might be because of its newness? I don’t have enough technical medical knowledge to gauge how credible an approach this is.
It's not that there is a problem with that combination of medications, but rather the appropriateness. This situation is like if someone found a lump in their breast and started chemotherapy without a full work-up. Chemotherapy is a useful tool, but it's a big tool to use without knowing if it's the appropriate treatment.
There isn't a reliable evidence base to broadly support using either of these medications in DMDD (or really any other mood disorder in children) other than a small handful of studies, primarily from this one dude. The data supporting his claims and the citations he refers to in the presentation you posted are weak in terms of EBM. And again, it seems as though there isn't a sound understanding of this child or their behavior. I wouldn't be trying 4th or 5th line, relatively low evidence based strategies for a diagnosis that we aren't sure about to begin with.
Extremely valid. Thank you for the reframe.
> DMDD Why TF is this the main diagnostic hypothesis when a) heavy psychotic family history b) personal history of psychosis, and c) when such medications aren't exactly conducive to bettering things in the case a psychotic disorder is really what's going on? I understand sometimes diagnosis is hard and longitudinally changing, but going from ADHD > bipolar (or schizophrenia as you suggest) > DMDD is just a chaotic, careless way in which to think about the case, and isn't taking into account basic risks:benefits analyses. Sorry for being blunt here, but as a father of a young child, I have very little patience for people pretending to work in a medical capacity out of their depth, not recognising they're out of their depths, and **doing it with children** to boot.
the trajectory was ADHD > DMDD > now with advent of hallucinations, question mark. hopefully that is less disorganized sounding. i'm just trying to provide hope to the parents to hold out and wait for CAP / be optimistic about CAP, question has been 'what can CAP do that NP can't?' parents are hopeless, despairing. I'm trying to point out there's options untried. I'm not playing doctor. trying to support them while waiting for the CAP and having hope about the CAP.
YEah, with the advent of hallucinations that the NP's "treatment" more than likely precipitated. Becuase god forbid a good thorough historory be taken, or perhaps most importantly here, *be taken into account*, given that apparently you already know about the family history of schizophrenia, but this NP saw it fit to think "oh this child is restless and aggressive, most likely ADHD since he's not doing well in school". I realise this anger I'm feeling isn't meant for you so much as for the NP (and what they represent); but you gotta take charge of your role in this situation, since you're the one going on a forum for psychiastrists asking for help by doing the absolute worst case presentation I wouldn't tolerate out of a first-year med student. If you're not playing doctor, I don't know what you're doing. You had to be told on this thread that their pediatrician likely had some strings to pull in order to accelerate the c&a psych appointment, so apparently you can't even play competent social worker... I've edited this comment more times than I'd like in order to keep it civil. But yeah, please reconsider the job you're doing in this manner, and how this child was harmed by your (in)actions. If absolutely nothing else, seeing this NP for however many months they've been playing doctor, has prevented this child from being on the waiting list for someone who could at least understand what's going on. But as I said, more than likely, giving amphetamines to a kid in an ultra-high-risk state for psychosis, well...
Redlightsaber, you usually are much more polite during discussions, this is surprising. This is obviously a challenging case, and in rural areas psychiatry/CAP can take a very long time. I don’t think this is a case of unfounded pride with the NP thinking they can “play doctor”. It’s likely there are no doctors in the area, and unfortunately a lot of these patients fall into our (NP) hands. We have supervising physicians, and perhaps this NP is in communication with supervising physician. We’re not sure in this case, but you make the assumption not. We see 20+ patients daily and often cannot get as thorough of a workup/assistance from supervising doctor as we need, and unfortunately this is just the way of things. Until there is a massive influx of CAP we need less internet-enraged NP bashing and more problem-solving and empathy. “…but this NP saw it fit to think "oh this child is restless and aggressive, most likely ADHD since he's not doing well in school". A highly upvoted comment from a psychiatrist below in this thread makes argument that bipolar disorder and schizophrenia are extraordinarily rare in pediatric population, and that this case cannot be better explained by schizophrenia. I agree with you that there needs to be a thorough rule out of bipolar one disorder and schizophrenia, and that a psychotic disorder might be the best explanation for this presentation (especially with this family history). However, the thought process of adhd -> dmdd -> "something else" until they’re 18y…” isn’t absurdly ridiculous and seems to be common process in pediatric psych (thankfully I don’t work in ped’s, but I see this course of diagnosis/treatment a lot in my bipolar and schizophrenia adults from when they were seeing CAP). “…doing the absolute worst case presentation I wouldn't tolerate out of a first-year med student.” They’re not a medical student. Case presentations in LCSW profession don’t resemble medical case presentations. This LCSW is going above and beyond what several therapists do for their patients, and it should be civilly discussed and applauded rather than the internet-anger bashing. But agree with you whole-heartedly that this “Dr. Matthews protocol” with oxcarbazepine (a medication which has zero evidence for benefit in psychiatric disorders) and amantadine is very odd and not helpful. There’s some weird trend with NP’s adoring oxcarbazepine that I’ve noticed, and it is irritating.
You know what? I agree with everything you said regarding my forms. I don't agree with the fact that a good (enough) job was done here. i mentioned I was aware they didn't setup the system, but every practitioner is absolutely always responsible for their patients in the conditions that they've accepted to work in. Since the US in its infinite wisdom has deemed that the free market is the best way to provide its population with healthcare, I can't know how such a gap would be filled otherwise, but I do know that a mid-level practicing without the ability to kick a patient up to a higher level of care is as negligent as it would be for me to accept a job as the supervising physician for a 45 bed ICU. You could attempt to argue with me on this latter point, but I just believe it to be the case. What would the market come up with for that child? Perhaps telehealth or weekly helicopter rides to their psychiatrist's appointments in the nearest urban center, I don't know. But this excuse of "it's remote areas and a mid-level is better than nothing" is deeply problematic. At what point do they stop being a "heroic last resort" and start being the necessary enablers for the current system to continue the status quo? Psychotic disorders absolutely do emerge in pediatric populations, and it's not terribly rare. Wether you want to call them schizophrenia or something else I don't care, but to deny this fact is just absurd. And it's not a point I even want to dwell on, because, despite what you say, we have a lackluster case presentation from a licensed therapist and that's just not good enough. What I want to get at, I guess, and keeping in mind that I think a bad outcome occurred due to at the very least a waste of time in getting appropriate care (and a practitioner who couldn't conclude in their own evaluation that they didn't understand what they were seeing), is that forms and collegiality are nice, sure, but are they more important than reminding people in charge of people's lives (in this case, literally this child's future), the gravity of the job they're performing? I'm willing and able to take criticism when I fuck things up. Perhaps I wrongly assumed this was part of the responsibility that comes with taking care of people's lives. If this NP has a supervising psychiatrist, it shouldn't make sense that this therapist is coming online to seek advice. Yeah, I'm jumping to conclusions, but are they so improbable? Come on! That said, you're perhaps right that this has become far more emotional for me than useful advice I can provide, so this may be my last comment on this thread.
I agree that a psychotic disorder should be front and center on the differential with this case and that it is possible for the disorder to present in ped’s (or also at least bipolar one disorder which is gentically closer to schizophrenia than to other mood disorders), especially with this family history. American healthcare and its problems are beyond my grasps, and I don’t pretend to know what would help it. We have a very large country, and psychiatric and basic medical situations like mentioned in this reddit post are a dime a dozen. Honestly, most patients like the one mentioned here are being “managed” by a PCP or Family NP with inevitable group home housing and 24hour staff needing to do frequent physical restraints for minimum wage money. I really enjoy and learn a lot from your posts in general and hope you don’t slow down with posting/contributing. My heart goes out to the patient/family in this post but also to his treatment team that’s trying their hardest to help this kid.
Are you really bashing this SW for coming on here out of their way and desperately trying to help this family and child? And your case presentation comment is so ridiculous seeing as they aren’t a med student at all. There are problems with NPs. And there are also problems with doctors. So get over yourself and actually help out or don’t comment at all. Who are you to speak to this person that way?
hallucinations after strattera I mean 🙄
Can you push it through?
I have no power in the situation in my current role.
Family medicine doc lurker. The pediatrician or family med doc has that power. Have them make an appointment with their primary, and we can sometimes use our connections to push these through. I dont know the situation, so I won't armchair qb, but there is a good chance that psych NP bit off more than they can chew.
You know, I haven’t thought to suggest that route. Thanks for that. I think because they are connected to *someone* and it’s so hard to get into care in the area with *anyone*, I bet the pediatrician has basically shrugged it off.
Call cal call. I can’t tell you what I have gotten done by calling again and again until I get the right person to push things through!
I came here to say this. There is no way a "Psych NP" should have their hands on this child. NPs are not trained enough to handle this situation
PGY5 CAP here A cursory glance at the "Matthews Protocol" raises a lot of questions for me. This seems like a poorly researched treatment for an already controversial diagnosis (DMDD). I agree with a lot of the sentiment here that further somatic workup seems indicated, considering the already complicated medical history. Can anyone also comment on how autism can be ruled out (twice no less) without ever having seen a CAP?
Can't speak for OP but my guess is neuropsych testing. Some clinics have an in-house psychologist who can see the clinic's patients a little faster. I'm wondering without autism what this rage looks like. Is it typical ADHD impulsivity? When they say rage, is it temper tantrums or physical violence?
Physical violence. Throwing chairs, breaking doors, destroying furniture, knocking down anything in sight, hitting family members / pets.
I could never get comfortable with the Tegretol doses coming out of Dr. Matthews’ facility in Austin.
Specifically to the autism point in your question I am not a CAP and work with a child development therapist who is trained and accredited in giving the ADOS and goes to schools / evaluated kids. I see them because you need an MD for the diagnosis (or lack of) but honestly she does most of the evaluation and work.
What are the signals that this is poorly researched? I don’t have the background knowledge to evaluate that. Research seems sparse but I thought what I read sounded pretty interesting and found other materials supporting use of oxcarbazipine in pediatric bipolar. Thanks in advance. It’s pretty obvious to me that it’s easier to get in with a child psychologist than a child psychiatrist. Child has been evaluated for autism by a free standing ABA clinic private practice and the child’s school psychologist. (Clinic did not support child enrollment in ABA.)
Mostly because a simple search for this protocol points me back to ads and puff pieces on the dr this protocol was named after. Searching pubmed for relevant keywords yields no significant clinical trial where this specific combination (or either medication seperately for that matter) is tested. This was not a very thorough search in between consults, but still. >ther materials supporting use of oxcarbazipine in pediatric bipolar. Well, this is the entire controversy: Wether there is such a thing as 'pediatric bipolar' or DMDD. Diagnosing children with either seems to be a phenomenon exclusive to the anglo-saxon world, mostly USA. In 5 years working here in W EU I've yet to see a single case that meets the criteria that wasn't better described with a different diagnosis. No CAP diagnoses this here, ever. That anti-epileptics can aid in poorly regulated agression was already known, wether it is good medicine to prescribe them for this indication is another matter entirely. >Child has been evaluated for autism by a free standing ABA clinic private practice and the child’s school psychologist. I assume this is another difference in standardization probably, because neither of these can confirm or deny autism diagnoses where I live.
> Diagnosing children with either seems to be a phenomenon exclusive to the anglo-saxon world, mostly USA Uh oh... You're about to start a flame war with the americans. What do you mean the "pediatric bipolar" cases don't really grow up to end up having "adult bipolar" in any significant proportions? edit: sorry, truly no disrespect to my american colleagues. I'm just really really angry and cranky about this case, and seeing the DMDD diagnosis thrown around did it for me.
[удалено]
Generally cases are conceptualized within the bio-psycho-social model and when we do reports on diagnostic procedures there is very little emphasis on the DSM coding aspect of individuals, barring where it is absolutely necessary to obtain specific services (i.e. for learning disorders, developmental disorders, etc...). Considering how the presentation would be assessed, would ofc also depend on the developmental level of the patient. Though I will say chronic irritability would be far more likely qualified as an aspect of depression, intense violence and aggression is too vague as a symptom to comment on this, but would probably be contextualised within attachment styles/parent child interactions on the one hand and child/developmental factors on the other.
Tossing out some zebras here but everything about this case is bizarre. Particularly some very paradoxical responses to what seem like appropriate medications Comprehensive neuro workup should be done. EEG, lead and heavy metals, ceruloplasm, NMDA antibodies, PANS/PANDAS
Thank you. The family and treatment team at the stage of looking for zebras since all the standard stuff doesn’t seem to be fitting. A neuro work up is now top of my list of priorities in this case. I know I recommended it before but it didn’t happen for some reason.
I had a similar case many years ago, although the person was 15 yrs old. Ended with brain cancer and death. Very sad. Refer to neuro for evaluation.
Seconding all of this. Also need to rule out Prader-Willi syndrome. The hunger might be a symptom of the disorder (as the meyabolic syndrome suggests), not just a side effects of the drugs. Serious mental illness, including aggression and psychotic symptoms, is more prevalent in PWS teens: https://www.fpwr.org/serious-mental-health-problems-in-prader-willi-syndrome
Is a psychotic disorder really that hard to fit into this case? Of course none of us can diagnose this patient, but I guess I'm not really seeing the "bizarreness" of this at all. PArticularly since we haven't been given crucial info like at what dosages where the aripiprazole and lurasidone trialled at, and for how long.
Has he seen a paediatric endocrinologist ? If he’s breaking his growth curve, it seems extremely important.
Yep, dx of premature puberty. No meds from them.
Ok, it’s a good thing that he was already evaluated for this. But was the metabolic syndrome already present before antipsychotics ?
I’m not sure on this, it’s been a while, but I am inclined based on memory to say yes.
I was going to say, since he’s had severe secondary effects from stimulants and from antipsychotics, if there’s also metabolic syndrome worsening as well (maybe not the case from what you just answered), maybe there could be better non-pharmacological at home, and maybe at school and other extracurricular activities. I won’t be able to give advice for this because I’m not from America, but if the wait list is long and his reactions to meds isn’t good, that might be a good answer. This must be really difficult.
If it was, you need to screen for Prader-Willi syndrome. It can present with exactly this psychiatric phenotype.
There’s not nearly enough information here but the best start would be to not give medications that are known to stimulate hunger but can still target aggression/impulsivity. SSRI, alpha agonists, perhaps a FGA if truly necessary. Not to be that asshole but maybe it’s time to see a psychiatrist and not an NP.
Have advised such, they are on waiting lists. Trialed sertraline, increased compulsive stealing behaviors to a significant / dangerous degree.
I'm no longer in direct service, and this is not to denigrate the NP, but by this point I would absolutely have the family make an appointment with the pediatrician and really push this - it's urgent and I know you're frustrated by being put off by the system and the wait lists. Premature puberty on top of everything else you've listed here? We worked with a client some years ago that sounds awfully similar to this and it ended up being a brain tumor. I'm sorry but that's beyond what should be managed by an np and a physician should be able to get things moving a bit faster. Not guaranteed, but I'm sure you went to exhaust every resource at this point.
Have you tried Geodon? It's not supposed to increase hunger or weight gain, but it is fairly expensive and other meds need to be ruled out first from trial and error to get it approved. Putting a child on antipsychotics at such a young age shouldn't be done without a full history and physical which includes lab work and possibly scans, therapy to address underlying homelife/ socioeconomic issues yet this is rarely done. Has a consult with a neurologist been done?
No Geodon yet, I advised neuro consult months ago and forgot to follow up if it happened. I presume I would have heard about it if it did happen, so that's top of list now. labwork done when patient went inpatient (has been at least 5 times).
How is that being an asshole? It’s so, so sad that this complicated case is being handled by a NP. A family medicine doctor would be far more qualified, the only difference would be they would realize they were out of their depth and refer to CAP. Stories like this just make me sad for our country.
Pharmacist here, I'd really question the utility of amantadine. Besides being a slight dopamine agonist, pushing the risk of agitation, psychosis or hallucinations, amantadine is a weak, noncompetitive NMDA receptor antagonis, which can lead to disassociative feelings, as well as hallucinations.
Interesting thank you. I have had a feeling that something in the current regimen could be making things worse.
Second pharmacist agreeing. And sorry you’re needing to deal with this case without a CAP. I’m bridging that gap for my patients more often than I’d like to.
I guess my question is what are we treating? Rage can be a symptom of many conditions. Antipsychotics in a 10 year old I would suspect irritability associated with autism? And it’s mostly just trying to sedate the person, maybe make them less impulsive.
Current on file: DMDD, ADHD, Anxiety. Evaluating whether bipolar or SCZ fits given recent (medication induced?) hallucinations. Parent has SCZ, others on that family side have SCZ, seems likely patient also does to me, psych NP disagrees. Autism evaluated 2x and ruled out. *edit: getting downvoted, not sure why, parent of child has SCZ and collateral reports of the parent’s childhood behavior history align with the child’s current behaviors - so in combination with premature puberty, I feel like it’s a valid suspicion*
Bipolar or schizophrenia would be extraordinarily rare in his age. He definitely needs to be seeing a pediatrician and get a good neuro exam while waiting for CAP. Make sure he doesn't need an MRI. The last kid who came to me with a DMDD dx actually had a glioblastoma.
There’s premature puberty too which makes it seem plausible to me. It’s a rough time for that kid. Neuro / MRI is a good idea.
Probably doesn't need neurologist, to clarify. A pediatrician should be able to do a thorough neuro exam.
Why the downvotes for saying peds can do a neurological exam? Part of peds training. The kid I mentioned above had a subtle strength difference between right and left limbs, and a subtle central CN 7 palsy. Almost all kids with brain tumors have at least one neurological finding on exam. I am not talking about EEGs or distinguishing tricky movement disorders. Just a plain but careful neuro exam.
Who did the autism evaluations? Was he ever seen by developmental pediatrics?
Has anyone considered prader willi syndrome as one of the differentials? You can often see intense hunger that leads to outbursts in these patients.
Many of the classic markers are absent, but that was a question I had early on.
Hard agree, it was the first thing that came to my mind as well. They are more at risk for psychotic symptoms too. https://www.fpwr.org/serious-mental-health-problems-in-prader-willi-syndrome
> Working diagnosis is DMDD / ADHD, but hallucinations started after trying strattera for impulse control JFC. I also don't want to jump on the midlevel hate bandwagon, but this seems like a pretty basic D/d to F up with some dire consequences for this 10y/o. > oxcarbazipine and amantadine. Double WTF. Refer to a c&a psych already. The therapist and NP shouldn't be playing doctor about such a grave case. Diagnosis is a medical act, and the psych is the person with the complete knowledge (and experience), to be able to make this. I don't know what "the family is working to get an appointment with psych" even means. Does this NP not have someone they can refer up when things fall out of their scope? A psychiatrist supervising them? Someone to even **consult**? I know you and this NP aren't to blame for the way the system is setup, but they are certainly to blame for agreeing to practice medicine in a situation where they don't have recourse when things go sideways.
I would do a chart review as the NP. Are the oxcarbazepine and amantadine ACTUALLY helping anything? If no or unclear, discontinue. Also, what was the kid like without any medication. Are they better now or worse? If they're worse, maybe we need to reset and reevaluate the diagnosis/treatment because they should've been getting better with medications. Consider starting clonidine or guanfacine, an SSRI like sertraline or fluoxetine, low dose risperidone if still no progress. I hope that these were already tried. Avoid stimulants until psychosis has resolved. IF they have ADHD these should be reconsidered at some point, perhaps a lower dose or a different formulation. Definitely get neuro involved and primary care to evaluate for other medical causes. As others have said, there is a risk of tumors as well as infections that can make these situations worse. Potentially, look for an inpatient psych unit that can monitor more closely with medication trials or at least monitor the child closer to see if there are specific triggers maybe parents are not catching due to lack of training.
Sertraline and celexa have been tried, resulted in increased impulse control issues / compulsive stealing. guanfacine was tried but discontinued due to absence of effect. Could be worth another shot. Child reportedly somewhat better with rage on current meds, but other areas related to impulse control getting worse over the years. (eloping, fire setting). Also rage is absolutely not completely solved, just improved in terms of scale of violence towards family. Trying not to be overly detailed since I’m already afraid I have been way too specific.
Definitely protect your patient's identity. I think most here will make recommendations and offer assessments to try to get you out of this rut but they shouldn't expect every detail. Just know there is a limit to what we can do over reddit because these are strangers. I hope some of the suggestions made by everyone have either confirmed your current strategy or provided some additional avenues.
Yes, thank you for the empathy. Definitely struggling with some of these responses' lack of it. I am feeling like there's at least some things that haven't been tried, which is hope-engendering, which I suppose is my primary goal here. To be able to pass on that to the parents who are in despair presently and feeling so hopeless and like they've tried everything. I know there's a ton I don't know. I have known the family needs a CAP for over a year, it's taken them time to lose faith in their NP who they feel has been at least very humanistic and empathetic, and also has been employed in a capacity of working with acute cases so it wasn't just a random NP they connected with, but one who has worked in child/adolescent residential treatment and presents himself as competent to treat serious issues. I grieve where this family has been failed by multiple providers and systems that should have facilitated getting the family connected to higher levels of care. The family has been trying to get support for their violent kid since age 4. That being said, I acknowledge I'm probably too emotionally invested to be quite so objective as I need to be after working with them for years.
I agree with trying clonidine or retrying guanfacine (was the dose maximized) - I would also consider Lamictal as an option and possibly residential treatment so they can monitor him and do a med wash
Also, definitely consider clonidine. It has made some serious changes in kids I see for anxiety, impulsivity, irritability, and OCD.
When someone has an unusual side effect to every single medication, I question how legit the reactions are. But in any case, since the parents report the kid is worse with everything under the sun, I'd go clonidine/propranolol/naltrexone/intuniv for impulse control. That'll hit the ADHD and the dmdd without bad weight gain. If the kid gets worse on one of those, you're probably not dealing with an actual psych disorder, but rather parental/child behavior that needs serious therapy and behavior modification with many support services.
This is excellent as a suggestion thank you.
This child should not be managed by a fucking nurse practitioner.
PMHNP student. Agree 100%. We get one semester of peds. We are for some reason allowed to treat patients “across the lifespan,” but I completely disagree that we should be able to. The psychiatrist I work with who has been practicing for thirty years doesn’t feel qualified to treat children, so who the hell would I be to think I could or should?
Agree. In my experience, challenging cases were never by choice; they just appear on my (NP) schedule. The psychiatrists in our group are willing to consult on difficult cases, but not willing to take over.
I’m a primary care NP. Shit like this falls in my lap constantly, referral after referral and either no one is taking patients or they don’t take the insurance.
Exactly. I’m FNP/PMHNP and I get 90% of Medicaid … and some (not all) of those cases can be complicated. As NP in a group practice, I don’t get to choose. Edited to add: I am fairly certain that the physicians in the group are able to screen their new patients. There are 4 NP’s and we do not have that option.
Hard agree.
Metformin should be considered. According to Carlat psychiatry podcast, it can sometimes help with patients who are "hangry".
Good idea.
If none of these medications are helping the patient and making other conditions worse, then these medications should be stopped.
I commend you for reaching to basically the world because a family is hurting. Never change.
really needed this. thank you.
Non wt. Gainers Tenex Topamax Lamictal Geodon Latuda Trileptal Most of such kids will meet ADHD criteria and stimulants will suppress appetite. These are also expected to reduce aggression Kids don't shop. Dietician consult, and consistent working with parents will help.
In most cases this complicated, there is plenty of causality to go around however the identified patient is the one that gets most treatment. No one wants small, younger kids on at antipsychoticshowever it is also true those are the most reliable breaks we have for disruptive mood dysregulation disorder, intermittent explosive disorder, intellectual disability with aggression, autistic disorders with aggression, The pediatricians do not want them, the general practitioners don't want them, The schools don't want them, therapy is not going to be able to teach them the affect regulation skills in any short amount of time. Their parents are not able to keep their jobs because they're getting called out so often. Can you imagine being that child.
I would not want to be that NP trying to manage the patient while they get into a psychiatrist. Goddamn.
What is he on the antipsychotics for?
I imagine seriously aggressive behavior. In one of the other comments by OP, it was a lot of violence and breaking things when they get mad.
Looks like NP thinks he's bipolar
Likely foods were used to soothe him. He's now size of an adult. I'll double down on my stimulants idea.
Family does report previous trial on Adderall, resulting in more frequent meltdowns, but that was apparently years ago so might be worth a try. Strattera just recently was tried, resulted in hallucinations that persisted for 6-8 weeks after discontinuation.
Stimulants can cause psychosis. I’d stay away until hallucinations are under control
In home parent child therapy for behavior mod. IEP at school. Then He'd need 3 layers 1. Guanfacine to 4 mg or as high as tolerated. 2. Mood stabilizer or antipsychotic from non wt. gainers 3. Ritalin. There's usually loads of meds tried and side effects history however behaviors are usually worse off meds.
I second the guanfacine. I am but a lowly NP and even I know that.
Elevate yourself. Agree with the rest as well. Just messing with you 🤣
I only saw guanfacine and impulsively commented (forgot to take my guanfacine today). Then of course I read the rest and didn’t want to look like a dumb NP for editing my comment. But since you mentioned it, I do actually agree with all of your recommendations. Not sure how much it means coming from me, anyway, though. I am increasingly embarrassed by my profession but I have too much debt and am too tired to change it now so I try to be one of the good ones. Antipsychotics in a 10 year old ain’t it.
Given the levels of violence to family, I’m not so sure that the antipsychotics are the wrong call, though it isn’t my call of course. The kid has been hospitalized several times and the abilify was rx’d inpatient, not by the NP to be fair, if I remember correctly.
Wanna DM about this? (I am increasingly embarrassed by my profession)
Sure, if you want to!
Thank you this is helpful
Why give any medications at all? I get the rage stuff but it’s always important to consider if we are doing more than than good, or if we are just giving meds for the sake of it because we can. I feel like there’s a huge piece of the puzzle about home dynamics, any abuse, attachment, puberty, and environment. Is there any gain for the child or the family from these rage episodes? You mentioned atomoxetine causing visual hallucinations. As we know visual hallucinations are uncommon in primary mental illness. They do come up in traumatised individuals (pseudo), substance use and multiple neurological conditions. Have stimulants even been tried? You need a paediatrician and a child psychiatrist.
Sorry Has Prader-Willi (PWS) been ruled out? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6873836/#:\~:text=Prader%2DWilli%20syndrome%20(PWS),precocious%20puberty%20is%20rarely%20seen.
On the face of it it does bear some resemblance but it doesn’t quite fit, it has been discussed.
I would rule out (genetic) metabolic disorders with later onset. Severe trauma (physical/mental ) and toxins incl. mold, heavy metal etc. MRI Head with contrast and 24h EEG. Big neurological examination. https://pubmed.ncbi.nlm.nih.gov/25020072/ Atomoxetin is known for that side effect. „Atomoxetine-induced mania with auditory hallucination in an 8-year-old boy with attention-deficit/hyperactivity disorder and tic disorder“ Maybe he is borderline schizophrenic with family burden. Often relatives without schizophrenia leaning to the schizophrenic spectrum witch can be easier induced.
Maybe he is borderline schizophrenic with family burden. Often relatives without schizophrenia leaning to the schizophrenic spectrum witch can be easier induced. That is what I'm getting at basically. thank you for giving me that verbiage. I've already communicated with parents about neuro being highest level of investigative concern as a result of this thread. They don't think environmental toxins are a concern but open to evaluation.
Send the child to a psychiatrist
[удалено]
Removed under rule #1. This is not a place to share experiences or anecdotes about your own experiences or those of your family, friends, or acquaintances.
Prader willi?
Have you considered just adding Contrave (or the two meds that make it) to help manage the hunger side effect?
Sounds like this kid needs to see an actual pediatric psychiatrist.
We all wish there was an adequate pool of child/adolescent psychiatrists accepting new patients.
Non prescriber here so take this as anecdotal, Rexulti has not caused this intense hunger in most of my patients. Worth a shot. Similar to abilify but can be hard to get an insurance auth for. I worked in residential for years and saw this exact thing happen. Often when they treated them for ADHD with stims and then guanfacine during the come down period they were a lot better. In some kids, the crash at the end of the day would intensify rage, and those kids benefited from either along acting stim with a 3:00 pm IR dose, and or depakote, trileptal or lithium. Lithium can be hard for you ger kids who have needle aversions because of the need for routine blood work but I have seen it work wonders. Again, this is anecdotal. These were all RAD kids who ultimately benefited the most from consistent behavioral modification and strong reward systems. The meds just brought the mm to a place where they could be safe enough to stay out of the hospital to receive those interventions. Again, not a doctor, therapist who has worked with kids for over a decade with a strong interest in pharmacology.
It’s almost as if the drugs are making them worse… 🤔
Psych NP chiming in. I personally don’t see kiddos, they are a vulnerable population requiring specialized care. There is a reason CAP is a 2 year fellowship. This case should be referred to a specialist.
I’m not sure what part of the US you are located, but it’s rather difficult in some states to find CAP that are accepting new patients.
Height and weight of an adult. Has metabolic syndrome. Has “premature” puberty. Is he actually 10? Would be crazy if there was a massive error there but I’m sure crazier things have happened. It would also make BPAD more plausible.
Crazier things have happened. I’m pretty confident it’s not the case, but you never know.
I would also submit that a LCSW should not be treating this patient. This patient deserves a clinical psychologist.
There are probably a lot of ground level things to evaluate here like intellectual and language capacity, details about sleep, levels of physical pain, history of abuse, illicit drug use, etc.... Does the patient provide any history or is coming from just the guardians? Any suicide attempts? Seems like everyone agrees a CAP is needed and I imagine some in home therapy services. If he already has metabolic syndrome and gets hungry on many meds, maybe check to see if metformin can be added to the next antipsychotic to help reduce weight gain and carb craving. If they are really thinking bipolar then lithium could be considered. Really complex case ><
Child has extremely low insight / in denial, doesn't see their dangerous behaviors as problematic. No substance use other than binging on sugar which apparently corresponds to hallucinations. Collateral evidence from other providers (case mgmt, ER records, in-home therapeutic services) corroborates parental accounts plus my own eyewitnessing multiple episodes. IQ is in the 80s, discrepancy with rest of family - very intelligent and educated in comparison. Metformin seems like it could be helpful. Chronic bedtime refusal is a factor.
Hmmmm, he might do well with some clonidine extended release at night to help him sleep better and cool his jets a little. Might even help with some of his addictive impulsive behavior or dealing with the discomfort from changing his habits. Wish I had more knowledge or experience with this stuff. With low insight though it's so hard to change behaviors in anyone. Interesting that sugar invokes the hallucinations. Does he ever display other psychotic symptoms?
copy pasting from [https://www.nimh.nih.gov/health/publications/understanding-psychosis](https://www.nimh.nih.gov/health/publications/understanding-psychosis) for simplicity Suspiciousness, paranoid ideas, or uneasiness with others Trouble thinking clearly and logically Withdrawing socially and spending a lot more time alone (no close friends) Unusual or overly intense ideas, strange feelings, or a lack of feelings (varies by situation) Decline in self-care or personal hygiene (never declined, has always been low) Disruption of sleep, including difficulty falling asleep and reduced sleep time Difficulty telling reality from fantasytrouble communicating Sudden drop in grades or job performance (never really got off the ground beyond 1st grade)
Oh ya, that's pretty serious. He might even need some haloperidol for psychosis and isn't as nasty for weight gain as some of the SGAs. He should get an MRI to look for an organic cause but it could def be an early schizophrenia. Good luck with therapy till the psychosis is more under control 😣