4 year old son with new ADHD dx, on Strattera, mama needs support!

[EvolvingMama]

Hello to all of you,

How did I not see this coming? My 4 year-old son has always been fiesty, extremely active, passionate, exuberant, and willful, but his behaviors have been getting more out of control in the last couple of years. I have been reading "The Spirited Child" for those 2 years! My first child, now 15, was very different - calm, introverted, more flexible. I nurse all my kids for an extended period of time - my 4 year old until he was 3 1/2. I have an 18-month old daughter, too, still nursing, and very happy and easygoing. I've been worried about my little guy for awhile, his impulsiveness and aggression that has rarely responded to my bag of mothering tricks - choices, redirection, etc...and I have been feeling like such a failure as a parent. I bet many of you have felt this, too. It's the worst feeling. On Mother's Day, I really lost it and sobbed hysterically - I think I remember saying something to my husband like, "I CREATED him! What have I done wrong?" I just shut down after that. (The issue was something like we couldn't even play kitchen without my son pushing into his sister and me, yelling and hitting). I actually just shut down.

We had an appointment scheduled yesterday with our family nurse practitioner for both of the younger kids' well-child checks. She is wonderful, very holistic in her approach. (For my own premenstrual irritability symptoms, she recommended organic soy instead of meds - she and I are on the same page). She started off with my son by asking HIM, "So, how do you feel like your body is working for you?" I thought that was great. He visited with her a bit, she checked him out, then we started talking. As we talked, he went into his bored mode of climbing the walls, dismantling the exam table, etc...in a very loud voice. The NP very calmly asked me if I had any concerns about him. I told her that he's doing well, except has gotten so impulsive and aggressive, and we've had problems with his interactions with other children as he's gotten older in daycare/preschool settings. She told me about her own children and that her daughter in her 20s is still taking ADHD meds. I started to have this realization that she was saying that my son has ADHD. and realizing as she gently guided me there that....she is right! I never even thought about it. I am a special ed teacher, too! I started to feel relief and understanding seeping in, and this sense that it's not all my fault and there is something I can do to help my son.

She suggested trying some medication. I can't believe how quickly I wrapped my mind around it. I feel a bit guilty about that! However, I really want to find something that supports him to be his best self without hurting other people or himself NOW, so that when he goes to school (preschool next year), he won't be the problem kid and get his academic career underway with this cloud hanging over his head.

It's so huge. I feel so many things. I HOPE it works to get him to a calmer place. I HOPE it doesn't take too long to figure out a good dose, and I HOPE I can pull from my peaceful parenting skills and be effective. I feel SO ineffective!

I just needed to say all this to some moms who could relate, and ask for others' experiences with such a young child. Oh, and of course, he's very articulate and intelligent, too, and loves to work hard on projects!

He is started with Strattera, 10 mg at first to see if such a low dose is right for him. Anyone else with recent experience along the same lines as us? Thanks in advance,

Laurie, mom to Linnea (1.5), Hayes (4) and Eli (15)

[Bokonon]

I didn't even know that it could be diagnosed that young, and I'm a little concerned that the NP, not even a doctor, handed out the diagnosis so quickly, without referring you for an evaluation.  4 is awfully young for ADHD meds and I would definitely want a second opinion before starting a child that young on meds he could possibly be on for many, many years.

[melissa17s]

I second the concern over the method of dx and starting with meds.  I would want someone more specialized in adhd diagnosing and treating.  I would ask for a referral to a psychologist or psychiatrist for a neuropsych evaluation. Many here also prefer peds that specialize in behavior- the name is on the tip of my tongue and can not get it out.  You can go for therapy and modify behavior with out drugs to some degree depending on the child, and I would want to exhaust that avenue before drugs (sometimes, drugs are necessary, but not always).  Also, drugs can mask the symptoms of what may not be adhd, but a different underlying problem; many different conditions have similar symptoms to adhd.

[karne]

First off, hugs to you.  It sounds like you've been through a lot with your little guy, and you're worried. 

The second thing I would say is that a nurse practitioner is not qualified to dx ADHD, nor would I be comfortable with her prescribing meds for a 4 y/o.  I didn't notice if she had even done an EKG on him?  I would back it all up a bit, immediately.  You really need to be talking to a physician or a child neuropsych. about this, especially with a child so young.   There's a process, which involves more than a conversation.

To even have blood pressure and weight checked (necessary w/meds) in our practice requires a physician visit, and beyond that we keep in routine contact.  I'm telling you this just to say that, personally, I would be extremely uncomfortable with the approach your nurse practitioner has taken.

It sounds like you felt relief at feeling like you found an answer, but IMO, you should be having this conversation with a medical doctor, and your child should have a full spectrum evaluation as a baseline starting point.

ETA: you mentioned that your ds is very verbal and bright.  If you think there is the possibility of giftedness, you might want to look at the Gifted forum--there are many threads re:behavior and gifted issues/sensory issues.

[melissa17s]

Karne- do you mean an eeg or is there a reason to have an ekg?  I have seen it a couple of times on here, and I am wondering if there is concern about the heart related to medication necessitating an ekg?  Some neurologists can read adhd brain waves on an eeg, but I think they have to understand the nuance.

[kbins]

Before starting any child on a stimulant med, they should do an EKG to check heart function. An EEG should be done if trying to rule out seizure disorder, according to our psychiatrist. Either might be done in evaluating a ADHD kid.

[melissa17s]

Originally Posted by kbins 

Before starting any child on a stimulant med, they should do an EKG to check heart function. An EEG should be done if trying to rule out seizure disorder, according to our psychiatrist. Either might be done in evaluating a ADHD kid.

This is good to know.  We have held off on adhd drugs because ds is on aeds, but if we consider them, I will ask for an ekg.  We have done multiple eegs, but not for his adhd.  I had thought about asking neuro, if he could read adhd waves on the eeg, but we are generally distracted by other issues when we are into see him.   

[Emmeline II]

I'd want a second opinion by a specialist before medicating a 4yo based on an NP's opinion at a well-check-- Strattera is not even an approved med for treating ADHD in an under 6yo so I wonder why she'd prescribe that first. Also, with a child this young typically a trial of therapy alone would be recommended before adding in medication. I would make an appointment with a developmental-behavioral pediatrician, and if that appointment is far out I'd go to a child psychiatrist first, and a CBT.

http://www.helpguide.org/mental/adhd_medications.htm

Edited by Emmeline II - 5/15/11 at 6:29pm

[SubliminalDarkness]

Agreed with all of the above. We strongly suspect DS2 has ADHD and his pediatrician has agreed. But there are many more steps to take before we settle on that and choose to medicate him. Not to mention, I don't feel right medicating a 4 year old who's not even in a situation yet where he needs to "perform" academically. For now, we work with him to try and manage what we can, and tolerate the rest. 

[Emmeline II]

Originally Posted by SubliminalDarkness 

Not to mention, I don't feel right medicating a 4 year old who's not even in a situation yet where he needs to "perform" academically. For now, we work with him to try and manage what we can, and tolerate the rest. 

For us it was just as bad at home before ds was in school; essentially I could not take him out in public as he would continually take things off the shelves in stores, be aggressive with other children, and have "I'm being murdered" tantrums in any location--even at relatives homes we had to hover over him everysinglesecond to try to head off property destruction and hurting his cousins. At home everything was a fight and he frequently would hurt his sister. It's not just about performing in school. In any case, the OP mentioned that he has been in daycare/preschool with increasing problems with impulsivity and aggression.

[MamaPalooza]

I second the notion of hugs for you, sounds like your dealing with a lot. I am a first time mom. my baby Casey Jones just turned one, so i probably shouldn't be chiming in here but i feel like i should speak of my own experience. I was diagnosed with ADD as  young a child, i think at about 6. my mother had me try a few medications but they hurt my stomach so i stopped taking them. I didnt start to take regular meds until i was a freshmen in high school. i believe the Adderall that i was put on started a very dangerous and very long lasting drug addiction for me. Having a drug alter how i functioned everyday even when in someways it was positive, made self medicating a very real life choice for me. I went from abusing my medication, to buying illegal drugs, to even selling at a very early age to support my habit. only after the overdose and resulting death of a friend was i able to stop using completely at 20 years old. i am not trying to scare you, but the road i went down is not uncommon. almost everyone of my drug using friends in my youth were also taking ADD and ADHD meds at the time. Believing that staying on meds my whole life because of an incurable problem pushed me in the direction of self medication. I think i would have been better off being told that the symptoms of my ADD will be with me for my whole life and it is important to learn how to deal with it with out altering my mind, cause it is something i will have to deal with forever. some of the things that might be a weakness now could be a strength in the nurtured. i really encourage you to reconsider medication. 

[SubliminalDarkness]

Originally Posted by Emmeline II 

For us it was just as bad at home before ds was in school; essentially I could not take him out in public as he would continually take things off the shelves in stores, be aggressive with other children, and have "I'm being murdered" tantrums in any location--even at relatives homes we had to hover over him everysinglesecond to try to head off property destruction and hurting his cousins. At home everything was a fight and he frequently would hurt his sister. It's not just about performing in school. In any case, the OP mentioned that he has been in daycare/preschool with increasing problems with impulsivity and aggression.

I want to tread lightly as I know the OP is going through something difficult right now. What you're describing doesn't sound to be the case for the OP. She didn't realize at all that what was happening to her son was ADHD or anything else, she just thought it was normal 4 year old behavior that was a part of his particular personality. It doesn't sound like it was debilitating for them. Which lends me to think that it would be reasonable to explore other options before turning to medication, like a change in diet or behavior therapy. 

[Emmeline II]

Originally Posted by SubliminalDarkness 

I want to tread lightly as I know the OP is going through something difficult right now. What you're describing doesn't sound to be the case for the OP. She didn't realize at all that what was happening to her son was ADHD or anything else, she just thought it was normal 4 year old behavior that was a part of his particular personality. It doesn't sound like it was debilitating for them.

     This doesn't sound debilitating to you?

• EvolvingMama

I've been worried about my little guy for awhile, his impulsiveness and aggression that has rarely responded to my bag of mothering tricks - choices, redirection, etc...and I have been feeling like such a failure as a parent. I bet many of you have felt this, too. It's the worst feeling. On Mother's Day, I really lost it and sobbed hysterically - I think I remember saying something to my husband like, "I CREATED him! What have I done wrong?" I just shut down after that. (The issue was something like we couldn't even play kitchen without my son pushing into his sister and me, yelling and hitting). I actually just shut down.

She said she had thought this was normal 4yo behavior (as did we, "he's all boy") but said it was becoming increasingly out of control.

Dealing with his behavior is bringing her to tears and causing her to think she is a failure as a parent--she realizes something is going on, just didn't consider ADHD until the NP mentioned it. We hadn't really considered it either until ds' K teacher said that they did not consider it until 2nd or 3rd grade ("What? ADHD? He's just an energetic boy, who's a little bored"). Also, she describes his behavior as getting worse which was also true for ds at 4yo (and several others I know with ADHD children)--his behavior started to escalate at 4yo which is when he began the "I'm being murdered" tantrums.

Which lends me to think that it would be reasonable to explore other options before turning to medication, like a change in diet or behavior therapy.

I thought I said that in my pp.

[Emmeline II]

Originally Posted by MamaPalooza 

I second the notion of hugs for you, sounds like your dealing with a lot. I am a first time mom. my baby Casey Jones just turned one, so i probably shouldn't be chiming in here but i feel like i should speak of my own experience. I was diagnosed with ADD as  young a child, i think at about 6. my mother had me try a few medications but they hurt my stomach so i stopped taking them. I didnt start to take regular meds until i was a freshmen in high school. i believe the Adderall that i was put on started a very dangerous and very long lasting drug addiction for me. Having a drug alter how i functioned everyday even when in someways it was positive, made self medicating a very real life choice for me. I went from abusing my medication, to buying illegal drugs, to even selling at a very early age to support my habit. only after the overdose and resulting death of a friend was i able to stop using completely at 20 years old. i am not trying to scare you, but the road i went down is not uncommon. almost everyone of my drug using friends in my youth were also taking ADD and ADHD meds at the time. Believing that staying on meds my whole life because of an incurable problem pushed me in the direction of self medication. I think i would have been better off being told that the symptoms of my ADD will be with me for my whole life and it is important to learn how to deal with it with out altering my mind, cause it is something i will have to deal with forever. some of the things that might be a weakness now could be a strength in the nurtured. i really encourage you to reconsider medication. 

Research supports the opposite conclusion; that ADHD left unmediated often leads to self medication, substance abuse, and risk seeking behavior. Medication, appropriately prescribed and taken, together with therapy/coaching are effective treatments. My son absolutely cannot function in school without medication, but he is also seeing a CBT and ST/OT.

ADHD medication is not about "altering" the mind, but about compensating for the deficiency of a specific neurotransmitter, norepinephrine, which helps the recipient operate at the same "level" as everyone else.

I found the book "More Attention, Less Deficit" helpful.

[serenbat]

I find the notion that the mother finds it debilitating there for med for the child and a diagnosis by a NP utterly bizarre, not to mention unprofessional and unjustified!

Short visit=ADHD & meds

Far too many crucial medical steps were grossly overlooked.

The mother working in special ed and being debilitated by this is reason for the mother to get assistance - IMO not jump to meds.

I hope the family (parents) get need medical assistance and a appropriate diagnosis for all.  

[KCMichigan]

Originally Posted by Emmeline II 

Research supports the opposite conclusion; that ADHD left unmediated often leads to self medication, substance abuse, and risk seeking behavior. Medication, appropriately prescribed and taken, together with therapy/coaching are effective treatments. My son absolutely cannot function in school without medication, but he is also seeing a CBT and ST/OT.

ADHD medication is not about "altering" the mind, but about compensating for the deficiency of a specific neurotransmitter, norepinephrine, which helps the recipient operate at the same "level" as everyone else.

Ditto the above:

 As a teacher of kiddos w/ ADD/ADHD and other disabilities-- it is ADD/ADHD that is most often misunderstood. It is a medical issue , same as depression. Sometimes it can be helped by changes of environment, diet, and CBT--- but often that is in combo with meds that help change the chemical imbalance that may exist. Now, often people are so leery of a true dx it makes it difficult for kiddos that really do struggle w/ ADD/ADHD to get help earlier. Even at 4/5 kids struggle with self-esteem concerns and friendships/social skills. It has to be closely looked at 'for EACH child' by someone that is familiar w/ ADHD. I neither for or against meds. Some kids I know do (or would be) fine without them, others they are a life changing medical requirement. Each and every child is different and there is not an age cut-off that is mandatory for qualification, though it is more difficult to differentiate between a 4/5 year old vs a 8/9 yr old since the developmental norms are different.

Also, as a parent with a child on a non-FDA approved med (not for ADD/ADHD thoug). Dr. & PAs have extensive research on meds. Yes, they have risks, yes some are prescribed below FDA approval. Yes, parents need to consider and do their own research. But just becasue FDA has not approved it- does not mean it can not be a good choice medically for your child. Just do your homework and weigh pros/cons. My own DD has taken her med since 6 months and had over 4 Dr approve it for her-- it is not approved for ages below age 8 or so. But it is all that works for her, the damage that would be done physically without it far outweighs the potential side effects. Even FDA approved meds have been recalled and caused problems as well.

A PA can be qualified and experienced, especially if they have tracked a child from birth--- though there is no way of knowing unless you personally are aware of that persons credentials and experience. Usually, it is suggested that a visit to a developmental Ped, an ADD/ADHD clinic, or a psychiatrist is warranted. 

Yes, sometimes it is over dx for 'normal' developmental concerns in young kids (when it does not exist) but I also think now-- for kiddos that really really struggle and could use meds/CBT, etc to help---often people are wary. For some of these kids (yes, even at age 4/5) it really really makes a life changing difference. 

Yes, other evaluations need to be considered (is it behavioral defiance? Is it related to being asked to do skills above developmental level? Is there enough physical movement? Is it a visual/hearing concern? Is it diet/sleep related?).
 

BUT it is not unheard of or unusual for a 4/5 with extreme (outside of developmental norms) to be given a trial of meds in combination with diet/behavioral/etc modifications in place.

I am surprised at how many posters are not-supportive. The OP posted a small snippet of information and was looking for support-- I am fairly positive that it was not a snap judgement from the PA in a child that young. Nor was the OP looking for an easy solution- but support for something that she had not seen before-- but now realizes there is a concern about her DS.There is no blanket answer/solution  to treating ADHD/ADD in kiddos. There is no 'right' answer either-- each and every child has to be considered individually.

If the OP child is headed toward school in the fall, it really is helpful to use the summer to help develop a plan to make sure her son feels more control in his own body. Kiddos in K that have ADD/ADHD (outside of normal developmental levels of impulsivity, activity,etc) really do need some tools (be it work with therapy, social work, accommodations in the class, meds, diet, etc) to help them. The schools/parents/teachers want to be more proactive- rather than trying to play catch up after a kiddo has a really rough year and then spends the next two (or three) playing catch up on material they may have missed.

To the OP. I am glad you have some resources at hand. I also would pursue further evaluation and building a wide base of things to help your DS. 

[serenbat]

  A PA can be qualified and experienced, especially if they have tracked a child from birth--- though there is no way of knowing unless you personally are aware of that persons credentials and experience.

from the posting were are unaware of the experience, usually a yearly WBV plus sick visits do not give a full assessment of the situation 

 

I am surprised at how many posters are not-supportive.

Quote:

Usually, it is suggested that a visit to a developmental Ped, an ADD/ADHD clinic, or a psychiatrist is warranted. 

perhaps thats why is appears many are not-supportive-it comes across as the OP rushed for a script once it was offered

[Ellie'sMom]

As a nurse practitioner and an adult with ADHD, I just wanted to add a couple of things. A nurse practitioner certainly can diagnose ADHD, but I would agree that it doesn't sound like a thorough assessment was done. I also agree that in such a young child a specialist assessment is warranted. Here in the town where I live, one of the most expert childhood ADHD clinicians in town happens to be a nurse practitioner. She is in practice with a developmental pediatrician. It is no different than getting an ADHD diagnosis from a family practice doctor, versus a psychiatrist. I would even argue that most general practice pediatricians are only marginally qualified to make the diagnosis. I just needed to defend the nurse practitioner role a bit. No need to over generalize!

I also want to point out that Strattera is not a stimulant. It is a norepinephrine re-uptake inhibitor, closer to an anti-depressant than a stimulant. An EKG is not needed before starting this medication. I believe it is only approved for children age 6 and up, so again, it is not something I, as a primary care NP, would feel comfortable prescribing without a consult with an ADHD specialist. 

OP: Big hugs to you, and I hope the tone of these posts doesn't discourage you. You and your son deserve a correct diagnosis and expert treatment, 

[EvolvingMama]

Thank you to everyone for your posts, which have broadened my perspective on the topic of diagnosis as well as different parental approaches to helping our children with such extreme things going on. I really appreciate your comments! Please know that I would never make snap decisions for my children; thank you to the poster who recognized that I was giving just a bit of information and asking for a bit of support and solidarity. Of course, there is more to our story. I will continue to pursue more information and support from as comprehensive a group of resources as I can gather about us to find the right supports for our beautiful boy. I value the wisdom of other mothers so much as part of that group, so thank you, again. We are definitely wanting to help him as he prepares for school next year and in the years to come, and are looking forward to a summer of proactive learning on our parts to help him. Best wishes to all of you on your journeys.

[Emmeline II]

Originally Posted by Ellie'sMom 

 I would even argue that most general practice pediatricians are only marginally qualified to make the diagnosis. I just needed to defend the nurse practitioner role a bit. No need to over generalize!

I agree, and make the same recommendation for a specialist as those diagnosed by peds. I run into far more parents that are not happy with the way peds or family doctors are managing the ADHD/meds than a psychiatrists. Often the peds insist on staying with a med that is not showing results longer than a psychiatrist would, they are uncomfortable prescribing stimulants to children, or they only have a couple of meds that they are comfortable prescribing.