quote:Oh no! I missed much in my extended absense. CT, don't go! Although it is a shallow concern, who else will remain to trip out on Risperdal, you know the drug that makes the groundhogs in the backyard look frickin' huge!
Alucard, I'd like to discuss with you, if I may. My 7 year old is recently diagnosed ADHD, and her doctor has put her on Risperdal. With 0.5mg, she was seeing spiders and other strange things that we couldn't get her to verbalize. We're now down to 0.25 and I'm not sure if that's doing anything at all for her. I'd like a non-medical opinion (dangerous, I'm sure) of what this med is actually supposed to be for and what kinds of things I should be seeing in her and watching for as problems (obviously beyond seeing spiders, etc.)
posted
Actually, Goody, you've asked exactly the right person. Alucard is one of our resident pharmacists.
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Since you are a pharmacist, Alucard, can I pick your brain about some of the things that I see and that I hopefully should be seeing in my daughter? If you'd prefer to discuss off-list, my email is sewunicorn at comcast dot net
posted
No, look, that really is WIERD for medicating ADHD.
I mean, normally, you'd look at the stimulant meds like adderall, ritalin, concerta or the non stimulant med, strattera. Effexor and Wellbutrin are also used to treat ADHD, as well as clonidine.
But Risperdal? Using an atypical antipsychotic for a JUST diagnosed kid with ADHD?
Either there's another diagnosis or I'd be asking that prescribing doctor some serious questions about typical treatment.
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posted
Missy is 7 years old, was diagnosed with ADHD about 4 months ago. First medication was Adderall XL 15mg q am - that stuff sent her into a psychotic fit at the petting zoo that still has her traumatized 3 months later. We got away from that doc fast when he insisted that this was the right med for her.
Current doc started her with Strattera, opening dose 10mg q am ramped up to 25mg. This is working well for us, she's much more focused, able to stay on task, significantly fewer temper tantrums. Slight loss of appetite and some increased difficulty in getting her to go to bed at night.
The doc is concerned about what she calls Missy's "fantasy life". Missy will hold conversations with her toys, dolls, empty space (I'm thinking an imaginary friend but Missy won't tell me when I ask). To address that part of Missy's issues, she's been prescribed Risperdal. We started at 0.5mg q pm, and after about a week of that, Missy started revealing some sensory issues - specifically seeing spiders that weren't there or telling my mother "your face your face" while squooshing Mom's cheeks. We also saw her appetite returning and sleep patterns definitely improved. I don't know if that's an effect of the Risperdal or those were just temporary problems from the Strattera that she's adapted to. Anyway, as a result of the perceived spiders, the doctor reduced to 0.25mg q pm, the sensory things seem to have disappeared but some of the sleep issues have returned. Though all of this adjusting, I've seen NO change in the one-sided conversations that are what the doc is supposedly treating.
Doc now wants to increase to 0.375 q pm to see if the fantasy stuff decreased and the sleep patterns improve simultaneously. She also gave me a sample pack of Seroquel, 25mg, to switch to IF the mid-range dose of Risperdal doesn't help or brings back some of the hallucinatory responses.
Doc also hinted at a possibility of Asperger's at this last visit but wanted me to take the time to do some web research before we discussed that further (my insurance company only gives me 20 minutes per visit so we really have to budget and plan things ahead).
Thanks again for your input! Goody
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Okay, that makes me feel better (and of course it's all about how I feel )
Look, as the kid's mom, your gut instinct holds a LOT of merit. If you don't think the Risperdal is cutting it, you have the right to ask for another medication. There are plenty of atypical antipsychotics out there, many with less side effects (Abilify is a new one that has a low side effect profile), that can be tried when the first doesn't seem to work out terribly well. Thing is, side effects are a trade-off for dealing with the effects of an illness. If the medication isn't working for THAT, and JUST having side effects...well, you're right to wonder.
quote: The doc is concerned about what she calls Missy's "fantasy life". Missy will hold conversations with her toys, dolls, empty space (I'm thinking an imaginary friend but Missy won't tell me when I ask). To address that part of Missy's issues, she's been prescribed Risperdal. We started at 0.5mg q pm, and after about a week of that, Missy started revealing some sensory issues - specifically seeing spiders that weren't there or telling my mother "your face your face" while squooshing Mom's cheeks. We also saw her appetite returning and sleep patterns definitely improved.
Well, Goody, my now-17 year old son was diagnosed with ADD-innattentive back in kindergarten, and they tried a variety of medications - Ritalin was bad in his case, Adderall was "okay" but no real big effect. I have never heard of using Risperdal for this, or for children. Hopefully Alucard can address that point. (My son no longer takes meds)
However, I wanted to post because the main complaint everyone (at school only, at home we don't mind) had about him was his fantasy life. He still has imaginary friends, still likes to "act out" fantasy games outside (usually involving pretend swords and dragons, etc. just as a young child would) He has a whole fantastic world up in his head that he has told me about in great detail.
However, I don't see the harm in it! He is very much also in touch with reality, and can function normally. The fantasy world is an escape for him like some people use books or drugs or whatever. It makes life easier for him at times. There were times during school when he would retreat to fantasy inappropriately (like crawl under the desk and pretend he was in a starship, complete with sound effects) but he usually only does that when he is either very bored or very stressed.
He is a very loving, affectionate, generous and fun teenager. I guess I question why the doctors think fantasy and imagination is bad -- I view it as a gift.
Now, I'm sure other parents will jump all over me for this -- for not being concerned about my son's imagination at this age. I'm just enjoying it.
posted
I want to echo Farmgirl. Why is the fact that your 7-yr old daughter talks to her dolls and imaginary friends so bad? I thought many children had imaginary friends.
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posted
Many many people on Hatrack were students in gifted/talented/accelerated programs for the very bright (we have established that in previous threads).
I will bet you will find many of these people had very elaborate imaginations as children, or maybe even still as adults. This is a gift.
Do you think OSC could write what he does without a very active imagination? It is just as we get older we tend to surpress it more due to social structure.
Farmgirl
edit: Goody, don't take this as a post against you. It is the doctors I'm concerned about. I had the same type of thing when dealing with doctors for my son. They wanted to "treat" this fantasy world. I said, "what is wrong with it." and they said, "well, you mentioned it, so it must concern you" and I said, "No, you told me to tell you everything about him, so that is part of it. But that doesn't want mean I think you need to treat it. It is the teachers who want you to treat it..." <grin>
posted
"The doc is concerned about what she calls Missy's 'fantasy life.' Missy will hold conversations with her toys, dolls, empty space (I'm thinking an imaginary friend but Missy won't tell me when I ask). To address that part of Missy's issues, she's been prescribed Risperdal."
At seven years old, I would introduce myself to strangers as "Tom Davidson, space hero." I had a small spaceship in the local park, crewed by a number of other kids, and we would have been GRAVELY offended if someone had attempted to persuade us of the fact that, say, we had not ACTUALLY removed spice pirates from the orbit of Neptune.
I'm honestly concerned. In your opinion, is Missy's imagination "excessive?" Do you find that she talks to dolls more than, say, a typically intelligent seven-year-old girl? Because the idea of MEDICATING someone for that issue strikes me as being overwhelmingly evil.
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posted
Goody, I'm not actually trained for this, so don't just ake my word for it, but I'm really concerned about a therapist who would quickly prescribe an anti-psychotic for the symptoms that you described for a 7 year old. As far as my limited knowledge goes, anti-psychotics treat schizophrenia and not general seeing things that aren't there. There are other causes for claiming to see things that aren't there, especially the imagination that other people have brought up. In a 7 year old with autism, you're likely to see less reality testing and thus possibly have a more unfettered acceptance of imagination as reality. This might be a problem (debatable), but, unless it is caused by the biomedical conditions of schizophrenia, I'm pretty sure that anti-psychotics aren't going to solve it. Again, I don't actually know if this is the case, but it concerns me.
ADULTS Doses of Risperdal can be taken once a day, or divided in half and taken twice daily. The usual dose on the first day is 2 milligrams or 2 milliliters of oral solution. On the second day, the dose increases to 4 milligrams or milliliters, and on the third day rises to 6 milligrams or milliliters. Further dosage adjustments can be made at intervals of 1 week. Over the long term, typical daily doses range from 2 to 8 milligrams or milliliters.
If you have a liver or kidney disease, your doctor will have you start with one-half of a 1-milligram tablet or 0.5 milliliter of oral solution twice daily and may then increase your dosage by one-half tablet or 0.5 milliliter per dose. Increases above the 1.5-milligram level are typically made at 1 week intervals.
CHILDREN The safety and effectiveness of Risperdal in children have not been established.
OLDER ADULTS Older adults generally take Risperdal at lower doses. The usual starting dose is one-half of a 1-milligram tablet or 0.5 milliliter of oral solution twice daily. Your doctor may increase the dose gradually and possibly switch you to a once-a-day dosing schedule after the first 2 to 3 days of drug therapy.
I don't think you should let that alarm you too much, but I do think it is another source of concern.
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posted
The safety and usage for children has not been established for MOST medications, because no one wants to do trials on children.
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posted
...which is why people prescribing psychoactive drugs to kids have a high standard of dilligence to meet, which I don't think was done in this case. Goody wasn't even told why the drug was prescribed and it doesn't sound to me like the doc in question even looked at the DSM before moving to an anti-psychotic. You don't just go from "My patient claims to see things that aren't there." to prescribing an anti-psychotic drug, especially with children, especially when there hasn't been sufficient study to determine to possible effects of the drug on them.
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quote:The doc is concerned about what she calls Missy's "fantasy life". Missy will hold conversations with her toys, dolls, empty space (I'm thinking an imaginary friend but Missy won't tell me when I ask). To address that part of Missy's issues, she's been prescribed Risperdal.
It sounds like the Risperdal (risperidone) was prescribed for the "fantasy life," not the ADHD, although that may not have been clear until mack did such an excellent job of piecing together the information.
I'm not sure what level of evaluation on GS's daughter was done before the prescription was made. It doesn't seem obvious from the posts above. However, using drugs for off-label purposes is not bad practice, especially if it follows standard of care. Because funding trials in children is pretty much a losing situation for pharmacy companies (they assume risk and cost for little monetary benefit), it's hard to get them to do it, so they don't. Thus a lot of medications are prescribed to children under standard of care guidelines which would still be tagged with that sentence in the PDR.
Also, the PDR lags behind research. By the time of publication, it's outdated. Just the nature of the beast. The use of risperidone in this case is likely based on (among others) a study out of Australia published in the Journal of Paediatric and Child Health ("Use of risperidone in a paediatric population: an observational study"), which showed improvement in 76% of "severely behaviorally disturbed" pediatric patients (n=51), especially those with diagnoses along the autistic spectrum. Side effects were experienced by almost half of the children given the medication, although these were mostly sedation (27%) and weight gain (20%). Anticholinergic symptoms (such as dry mouth, constipation, increased heart rate and blood pressure) came in third at 10%, and then extrapyramidal (tremors, restlessness, involuntary movements) at 8%, which would be the only ones I'd seriously worry about. Even so, these are not lasting effects, and they disappear if the medication is stopped shortly after onset of symptoms. That would be why follow-up assessments in the office would be necessary for anyone prescribed this drug.
As was noted in the editorial comment accompanying the study above, it is extremely difficult to treat children with psychotropic medications due to the differences in symptoms, side effects, and the lack of research support funding by manufacturers. Often the clinician is left with doing the best he or she can with limited information. As you can see via a Google search on "risperidone" and "pediatric," it is not rare to use this medication in the pediatric population. Risperdal has been submitted to be the first drug approved to treat autism. It is not out of line to prescribe it now under appropriate follow-up and to appropriate patients.
May I suggest that since Goody Scrivener didn't originally volunteer anything more than ADHD as a diagnosis for her daughter, she might not have really wished to discuss the full extent of her daughter's symptoms and evaluation regarding possible psychotic features, at least not at the forum here? Since we are all only peripherally involved, by definition we do not have the full story, and I'd rather not press GS for details if it isn't necessary. Hopefully one of the pharmacists will chime in with advice, and hopefully GS's daughter (whatever her extent of symptoms) was evaluated as thoroughly as necessary. Other than that, I'd hesitate to comment on the practice of her physician, as I do not know the details of what went on and the prescribing of this is not necessarily outside standard of care.
Good luck, Goody. She has a loving and attentive mother.
[ August 25, 2004, 05:40 PM: Message edited by: Sara Sasse ]
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The consensus seems to be that it is important to titrate the dose and monitor for side effects carefully, but that these can be very useful agents in the proper population. Risperidone has been studied in children since at least 1995 (see the third article above). Hope this helps. The Google link above has a lot of other potentially useful links, too. Don't forget to address any ongoing concerns with your daughter's physician and your pharmacist.
[ August 25, 2004, 03:16 PM: Message edited by: Sara Sasse ]
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Thanks for the heads-up about Abilify (aripiprazole), BTW. I am behind on the new drugs, but I'll make a note to read up on it.
I wonder if the prescriber chose an older atypical because perhaps it was available in generic form? If Goody's insurance will only cover up to 20 minute visits, then her copay and drug coverage are also likely to be not so hot. It might be a cost thing for her.
(Again, though, I feel odd about making such speculations. My apologies if it goes beyond your comfort level, Goody -- just send me an email if you would like an edit.)
[ August 25, 2004, 03:54 PM: Message edited by: Sara Sasse ]
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posted
Noeman, I just do that when someting needs a bump, like this one did....Alucard hadn't posted, and neither had anyone else, and the question still needed addressed.
posted
No problem Kwea, I figured it was something like that. Just gave me an opportunity to be what seemed funny to me, so I jumped on it.
Posts: 16059 | Registered: Aug 2000
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posted
Thanks everyone for the suggestions and links.
The information all of you shared makes me think that perhaps doc is looking at the suspected Aspergers as a diagnosis, either a second or a replacement. I've only started to get into the research on that (because I do a lot of my webcrawling at the office and our servers have been out of whack this week).
Personally, I don't see anything wrong with Missy's indulgences into fantasy. I still hold conversations with myself and occassionally with people that aren't here, so I don't think that her having an imaginary friend is a bad thing. Besides, this might be the door to her becoming yet another voracious OSC fan The school has never made a comment that came across as excessive concern about this either, so I think that's just the doctor's "thing". Maybe she doesn't remember what it's like to be a 7 year old? LOL
Fortunately, my insurance company's Rx plan is pretty good, it's just their mental health coverage that stinks.
As I think I said last night, the Risperdal is definitely helping her maintain a normal sleep schedule and has some small effect on the loss of appetite that is caused by the Strattera. That does make the med less of a burden. But if that's all that it's doing, and there's another medication (or herbal or whatever) that will accomplish the same effects without the risk of the hallucinations that we saw at the beginning of her taking this (and of course without other equally nasty side effects of its own), then I'd definitely be willing to try it.
posted
Herbal. Before you try anything herbal, email Sara please.
Just because it's natural doesn't necessarily mean harmless. And you need to be aware of possible reactions to multiple drugs - insofar as I am aware, most herbal supplements aren't thoroughly researched for their possible drug interactions.
posted
Sounds like you're doing the right thing and getting all the information you can, Goody. That is good. I'm sure you've had full evaluations done on her by different types of docs.
Although I'm a big proponent of herbals and natural alternatives (used to, and sometimes still, sell the stuff), I will have to agree with Trevor on this point. Don't begin herbals as an alternative until you've done a lot of research and also don't mix them with prescriptions. I don't use anything without first doing as much research as I can (not only on the herbal, but on how each company makes it, as far as purity, etc) but I also always talk with my sister (who is a pharmacist) about it. She will let me know if some of them are known for drug interactions, etc.
Best of luck with this -- sometimes treating a child is a world of trial and error and discovery. Feel free to contact me via e-mail if you want to know anything about the various tests my own ADD son went through.
posted
Goody, I'm glad you have good prescription coverage. That will make getting through this easier. You also seem to have a healthy mack-response ("Question Authority" ), and that makes for a good advocate for your little one.
Some things don't seem fully clear, so could I suggest a few questions? (I'd take two copies of a list of questions with you to the appointment -- one to remind you of everything under the time pressure, and one to give your daughter's physician for reference while you are talking and for the chart.)
Q1: Since neither of her parents are concerned about her "fantasy life," and this isn't a concern for any other caretakers (including the school), and she hasn't ever put herself or anyone else at risk of any harm -- why are you concerned enough about her symptoms to treat them with a antipsychotic medication? What exactly are you treating, and why is that step necessary in your opinion?
Q2: How will we judge when she has been successfully treated? What are the endpoints we are shooting for?
Q3: I'm interested in giving her a herbal medication named xxxxx instead of an antipsychotic medication. What do you think? What would the possible interactions be?
and then, Q4: <ask Q3 of the pharmacist where you fill your medications>
Like Trevor and Farmgirl, I'd be concerned about using herbal preparations without the awareness of those who provide her other medications. There can be dangerous interactions, and pharmacists have become increasingly better resourced and more savvy about detecting these. (Much as I appreciate Trevor's faith in me , Alucard or Speed would be a better bet for helping you with this. I can use net resources, but they will have access to more and will have more experience.)
If she is seeing a mental health professional and that person is prescribing medicine, then she is probably seeing a psychiatrist, and that means someone was concerned enough about some symptoms to refer her to a specialist. She wouldn't need to see anyone but a regular practitioner to treat ADHD. If you aren't aware of why she is receiving these medicines or seeing this particular person, then you need to find out what is going on.
Risperidone wouldn't be prescribed just to treat decreased appetite, since there are safer medications and dietician recommendations which are safer. You could use the risperidone's side effects as a positive reason to prescribe it, but that wouldn't be a primary reason to use it, AFAIK. That's also why it is a good idea to be clear on the endpoints that you will all use to judge whether this is helpful, or whether you should switch to something else. It looks like you've also discussed using Seroquel (quietipine) instead, so you may have already had this conversation. If it isn't clear to you, though, ask again.
posted
Well, to be fair, I'd run any possible combinations past the two pharmacists, Farmgirl as our self-appointed advocate of all things herbal and since Sara is quite generous with her learned opinion, invoking her wisdom as well.
Between the experienced opinions and your own research, there isn't much space for anything to slip past the safety net.
-Trevor
P.S. Sara? It's not so much confidence in you as your concerns over similar issues would probably carry more weight than mine.
I'm perfectly capable of admitting your credentials are bigger than mine. Posts: 5413 | Registered: Jun 2004
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Sorry I missed this post. I happened to catch it doing something I usually do not do. But anyway, I did email you. I will send more as soon as I can.
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posted
This will be more brief than I would like, but I felt compelled to be a little more explanatory than my previous post or my email.
Risperdal was originally developed as an atypical antipsychotic drug for treatment of schizophrenia and other conditions such as agitation or dementia. But one of the serendipituous effects of the drug were that patients with multiple phychotropic conditions were responding very well to Risperdal. Now, drug reps are pushing for Risperdal to be used casually along-side drugs like Prozac and Paxil for depression and multi-faceted symptoms of depression, agitation, and aggression. So, in short, Risperdal is becoming a hot drug due to its recent newfound abilities and indications.
However, it is not indicated for use in children by the FDA. Sure as Sara pointed out, it can be used effectively for many different conditions in children, and it can be beneficial. Because of this, the manufacturer came out with a batch of new low doses below the lowest 1mg, specifically 0.5mg and 0.25mg. These were earmarked for use in children.
Now the specific use of Risperdal in children I am most familiar with is for the treatment of "night terrors" which can plague a child and destroy normal sleep patterns. If this seems what is helping your daughter the most, then I would say to continue therapy and see how the next few weeks go. If the doctor was prescribing Risperdal not so much for night terrors, but the imagary of spiders and other visions, then I would consider re-evaluating the use of Risperdal and discuss this with the physician.
I cannot overemphasize the fact that you must keep you doctor in the loop of her progression in these medications, and I would only change med therapy under a doctor's recommendation. As for the Strattera, I hope it is helping. For more information, it is an analog of fluoxetine (Prozac), that was also invented by Eli Lilly. Hope this helps.
quote:Using an atypical antipsychotic for a JUST diagnosed kid with ADHD?
I'm seeing it more and more. I think that after Ritalin, risperdal was the most common drug I saw this summer. And it was a toss-up between the two for a good while. It made me really sad to see all these kids at camp with antipsychotic drugs. I wonder if this is going to become a new "fad" drug...
EDIT: My completely non-medical and non-professional experience. I've seen risperdal used for dementia, and also this summer at camp for (presumably, they didn't always say) ADD children.
posted
I emailed Alucard privately with this information in response to his email but wanted to share this here as well. It's also slightly updated now that I see further posts:
Risperdal was actually causing the sensory concerns that I had - the spiders, the "what happened to your face" comments to my mother and most recently, she had a 45-minute long terrified fear of the barbecue grill. I was cooking burgers, she was in the kitchen, and when I flipped the meat for the first time, the melted fats caused the flames to grow. She absolutely panicked, about as bad as her psychotic reaction to the goats while on Adderall instead of Strattera, and it took me 45 minutes to get her calmed down enough for her to be capable of processing what I was telling her. As a result, I D/C'd the Risperdal instantly. Called the doctor, told her what happened, she suggested we try out the Seroquel samples she'd sent us home with from the last visit.
Seroquel - also not good. No more seeing things that aren't there, no more panic attacks (at least not that I know of) but back to significant temper tantrums on a daily basis, and every one at about the same time. The worst one came Monday of this week, 35 minutes long, loss of bladder control, all the same problems we saw before she was on any medication at all. It was almost as if the two cancelled each other out or something. Long conversations held with both the school nurse and the classroom teacher about Missy's behavioral changes since the medication change. We'd only been on that for 5 days. So another call to the doctor, another discontinued medication.
We go to see the doc again tomorrow where we'll re-discuss events at length. I'm still not quite in agreement with the doctor's concerns about Missy's "fantasy life" and from my conversations with the staff at the school, neither are they. I'm going to push for keeping MIssy on just the Strattera, which does work but wears off in late evening, and we'll deal with the 8:00 mini-tantrum as I've been doing since the beginning... behaviorally.
BTW: The comment about "multiple psychotropic conditions" turned on a lightbulb too... doc was looking at a possible secondary diagnosis of Asperger's syndrome at our last visit and has repeatedly mentioned bi-polar/depression as a possible comorbidity since her father's family has a history of diagnosed depression. Perhaps her intent was that effect on agitation that you were describing when used with Paxil (especially since you also mention Strattera being similar to Prozac) and for whatever reason that didn't get communicated appropriately.
Thank you everyone for your continued suggestions and support. Is it sad when my online friends know more and help more than my blood relatives - or is it a testament to the power of the 'Rack???
posted
I am just glad you and your family are finding some answers to the situation at hand. I hope I didn't scare you with my usual cold and unwavering description of a medication, but I am finding as a general rule that more and more families are turning to medication for ANY medical condition, and I am afraid medication is overused in many cases, especially the elderly. In your daughter's case, the medication she was prescibed did have a bonified chance of helping her, but as in any situation, you have to weigh the advantages and the disadvantages (and in this case, most definitely the side-effects).
I just wanted to take a few moments to clarify a few points I could not earlier, since I was closing the pharmacy...
Atypical antipsychotics sounds like such a menacing term. The "atypical" part of the title means that these medications are a new generation of drugs that do not have the "typical" side-effect of older antipsychotics such as cog-wheel rigidity, ataxia, and gait. The three terms basically can be summed up as stiffness and medically-induced partial paralysis. Older drugs like Haldol and Thorazine were notorious for these side-effects, but these older drugs do still have their uses in medicine today.
Seroquel and Risperdal are two new drugs that have indications similar to older meds, but without the more limiting side-effects. I actually had a luncheon with two of the drug reps from Janssen, the makers of Risperdal, and they are on a huge campaign to encourage doctors to prescribe Risperdal much more casually. They even give doctors a DSM-IV inspired questionaire of 15 questions to see if a patient may be a candidate for Risperdal therapy.
I was a bit concerned. Strangely, this meeting was a few months ago, and I happened to specifically ask about any FDA-approved indications about Risperdal in children. The reps respectfully answered my question that "no" there were no indications. I asked about therapy for "night terrors" in children, but again, the reps could not answer the question while representing their company.
So that alone was concerning for me.
Hope this helps.
P.S. Sara, I missed you too. Give Mr. Boy "5" for me, and rawk on.
P.P.S. Sadly, the joke I had made about Risperdal was concerning a patient that I was trying to have helped by her social worker because she was hallucinating and suicidal. She invited me over to trip on Risperdone (the chemical name. I was impressed) because they made the groundhogs in the backyard look frickin'huge. I used to giggle when I thought of her propositioning me to do drugs with her, but now the joke is not so funny. Again, Goody, I am just glad your daughter is doing better!
posted
No scares at all, Alucard =) As I said, I already wasn't comfortable with Missy's reactions to either medicine, so even without yours and Sara's posts I still would be pushing to keep her off them. You just helped to support my stance and give me some additional insights. Goody
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