Child Mental Health for Pediatric Clinicians

59 ADHD, Anxiety, and Hormonal Changes in Teenage Girls with Laurina

• Elise Fallucco • Episode 59

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Dr. Elise Fallucco welcomes Laurina, a pediatric nurse practitioner and mom of four. Laurina shares her experience parenting her teenage daughter, Beth, who has ADHD and anxiety. The discussion covers Beth's initial symptoms, her treatment journey and the discovery of Beth's premenstrual dysphoric disorder (PMDD). Laurina offers insights on tracking symptoms and treatment options, providing valuable advice for clinicians and parents alike. Tune in to learn about managing ADHD, anxiety, and hormonal changes in teenage girls.

00:00 Introduction WHAT TO EXPECT and Guest Welcome

01:13 Lorena's Clinical Background

02:10 Recognizing ADHD and Anxiety in Beth

04:55 Medication for ADHD and ANXIETY

07:36 ADHD and Anxiety PLUS HORMONAL CHANGES

14:20 DEPRESSION or PMDD?

19:00 Beth's Transformation and Creative Talents



Check out our website PsychEd4Peds.com for more resources.
Follow us on Instagram @psyched4peds

Dr. Elise Fallucco:

Welcome back to Child Mental Health for Pediatric clinicians, the podcast formerly known as Psyched for peds. I'm your host, Dr. Elise Fallucco, child psychiatrist, and mom. Thanks so much to all of you. Who sent messages on our website or through our newsletter about how much you enjoyed the mystery case last week. And as a follow-up, we have a treat. This week we're gonna share a real life example of the clinical symptoms we discussed in our mystery case. And to do that, we have the honor of talking with a parent who. Is a pediatric nurse practitioner. She has four children and she's gonna tell us about her journey parenting a teenage girl with a DHD and anxiety, and in particular how her daughter's symptoms changed and fluctuated once she started getting her period. So without further ado, let's give a great big welcome to the podcast to Laurina.

Laura:

Thank you so much for having me. I'm excited to be here.

Dr. Elise Fallucco:

Yeah. I'm really grateful that we get the chance to really talk about your experience as a parent raising a daughter with a DHD. And I think it's, I'm extra excited because you can share the perspective as a parent and also you're a clinician. why don't you tell our listeners a little bit about your clinical role

Laura:

So I am a pediatric nurse practitioner and I've been a nurse since 2007 and I only have been a nurse practitioner for practicing for the past year. But I feel like I finally landed in my calling because my experience with my kids has brought me to where I feel like I was meant to be. It was through getting them diagnosed and learning and fighting for them and learning how to help them in these battles is what prompted me to want to go back to school and help other kids and other families. So they didn't have to go through the same struggles that we did and that I could help them in ways that we didn't have.

Dr. Elise Fallucco:

And I am sure your patients are benefiting from all the experiences you've had with your own family in addition to your clinical training. So now let's talk about your journey as a parent of a teenage daughter with a DHD and anxiety. Can you tell us about what symptoms that she had that first made you concerned about A DHD and anxiety?

Laura:

Beth, my oldest daughter, she's my second child, and her older brother had been diagnosed with A DHD when he was much younger and he was the typical A DHD zooming around, very inattentive driven by a motor. And Beth was much more subdued and she just would stare off into space a little bit and a little bit forgetful. It wasn't until I was in her IEP meeting for speech. When she was in the fourth grade, that her teachers and the school guidance counselor looked at me and they said, we're really concerned that she may have a DHD. And we're seeing a lot of signs of anxiety when we move on to different subjects in the class. She starts to panic and she gets really upset and she'll even cry when we are moving on to the next subject. And she's not done with her work. she was in the gifted and talented classes in school and had always done extremely well in her schoolwork. And so this was just a really big surprise actually to me.

Dr. Elise Fallucco:

While she had some of the inattentive symptoms, she was would stare off into space and was forgetful sounds like she was pretty bright. But the thing that the teachers noticed was just that she seemed, easily overwhelmed by moving from one subject to the next

Laura:

She she wasn't getting stuff done. So I think it was more of a processing kind of a thing. And and then there was that anxiety piece as well. And I, that will slow you down when you're worried about it. And you see everybody else being done, and then you're like, I'm not done. Then you get more nervous and it slows you down more

Dr. Elise Fallucco:

You describe it really well. It's this combination of A DHD and the anxiety and some processing issues. So it's taking longer to process what she's reading and to think about how to answer things or how to write things. And then also she's worried about, am I gonna run out of time and, oh no, people are leaving and I wanna do the best that I can. And so you go into a panic mode and then that makes it harder for your brain to think and to process the information. And then it cycles over and over. So that must have been miserable for her. Yeah.

Laura:

so we started with some Concerta when she was in fourth grade. And that worked pretty well, but she would forget to take it because it was first thing in the morning. And about that time her younger sister was already taking medicine that was a little newer on the market, called Jornay PM

Dr. Elise Fallucco:

and as a reminder, JORNAY PM is delayed extended release methylphenidate. You typically dose at 10 hours before you expect it to begin working. So for example, you could give it at 8:00 PM and it would start working about 6:00 AM the next morning and should last throughout most of the day.

Laura:

We loved that because we dosed it at night, which was easy to be very consistent with and it's worked wonderfully for her. It definitely made the mornings a lot easier. Instead of us nagging go get your breakfast, go brush your teeth, and like constantly chasing after them with the next thing that they have to do to make sure that they got ready, they would go do things and then come back and run a checklist. It completely transformed our morning routine. The other thing that has been great is that they have not required booster doses because as you increase the dose, it increases the longevity through the day. So they haven't needed to take a, a booster dose at school, which has been huge because especially girls, they're really conscious about having to go to the nurse and take their meds and

Dr. Elise Fallucco:

you just don't wanna be different than anybody else in your class. You don't wanna draw attention to yourself. Some people have aha moments after they start treatment for A DHD and they're like, wow, this is really different. What was her reaction to treatment?

Laura:

I honestly, I feel like it was just, just relief. She was like, ah, I can get my schoolwork done in class. She was just so happy to be able to get done with everyone else and not come home to two hours of homework because they only had homework if they didn't finish their working class. So she went from having all this homework to not having homework, and so she loved that because now she could come home and read and play outside. So she really liked that. So once we started the Jornay, we noticed that she still had some anxiety symptoms and we had, been able to do a gene site test actually and the only medication that was in the green, was Pristiq. And so we we tried a little of that and it helped significantly.

Dr. Elise Fallucco:

So Beth had anxiety and A DHD and they seemed to be fairly well controlled for a while with, JORNAY for the A DHD and then Pristiq for anxiety. What happened next

Laura:

When she got be about 14 or so, that's when she started her cycle and we did see a little difference in her focus and her mood and anxiety that was waxing and waning through the month.

Dr. Elise Fallucco:

Waxing and waning focus throughout the month.

Laura:

It felt like her focus, anxiety, everything was under control. And then two weeks later NOT.. So at that point, we were looking to try to fix two things, at once. And so we looked into Qelbree actually.

Dr. Elise Fallucco:

And just as a review, QELBREE is an NRI noradrenergic reuptake inhibitor. That is used for A DHD. It's generic name is VILOXAZINE er. It works similarly to Stratera or Atomoxetine. Another NRI. The two main differences are that Kere tends to work a little bit faster. Some people can see a response within the first week of treatment as opposed to three to four weeks in, and also QELBREE or VILOXAZINE can be sprinkled for those kids who have trouble swallowing pills.

Laura:

We started with a little bit of Qelbree and that helped for a little while. Then over time it wasn't enough and we kept having to tweak doses. Every month it just seemed like there were different points in the month where she was really struggling and we're like, but this was working a couple weeks ago. Why is it not working now? I started to notice that she was complaining a lot of being really tired and having body aches On the weekends, she would just kind of collapse on the couch and say that she didn't feel good and she didn't even want to go out with us to do something fun because she felt too exhausted and she seemed like she had the flu. She was very irritable and very snappy and, then, she wouldn't eat. She would have no appetite. When I was speaking with her about this, this morning, she told me that for the week before she would start her period, she said she actually avoided mirrors because she, if she saw herself in the mirror, she would start to cry.

Dr. Elise Fallucco:

I wonder why that was.

Laura:

Just being so emotionally overwhelmed, I think is how what she described it as she said, she was just so exhausted and, and tired. I remember in December, Beth came to me one night and she was just in meltdown mode, and it was right before she was supposed to go to bed, eight 30 at night and just absolutely falling apart and saying, I can't do this anymore. I don't want to exist. I want the world to just swallow me up. I can't do this. It was very out of the blue for me to see her that way. It I confirmed that she didn't have any plans or anything for self-harm. It wasn't that she actually wanted to hurt herself, she just. Was so emotionally overwhelmed. She said she had lost all the motivation to do the things she enjoyed. She felt like she couldn't think, very low self-esteem. And she just felt hopeless, she said. I talked to her for a while that, that night, and I remember telling her, we were gonna fix it. We were gonna make it right, and I gave her a little bit of VISTARIL to help calm her down and help her be able to sleep. And that next morning I started doing some research and of course I knew about PMS But then when I started reading the DSM five criteria for PMDD, I was shocked. She actually hit every single diagnostic criteria listed all the way down to the thoughts of hopelessness.

Dr. Elise Fallucco:

All these things are peaking in the week before her period. And then what's happening to those feelings and thoughts? After she's had her period or in the week after her period?

Laura:

They describe it as the symptoms resolve once your period start. It is not a magic wand though. It doesn't just go away as soon as you start your period. It takes a couple days. it would usually take two to three days into her cycle before she started to feel normal again.

Dr. Elise Fallucco:

That's so hard. You bring up a really good point because I think when people think PMS we believe that the moment you start bleeding, like it all gets better. What we know when you actually track estrogen levels throughout your cycle, if day one is your first day of bleeding, that your estrogen levels continue to code down until day two and three. And it's not until really day three of bleeding that all of a sudden you take a turn upwards and your estrogen, your serotonin, your dopamine all start turning around and you start feeling much better. And it's very biologic. And, recent studies have actually tracked hormone levels with these mood symptoms and they found exactly what you're describing with Beth, that it's, it is really very neurobiologic and yet. So hard to figure it out and figure out this pattern. I wonder what made you or Beth begin to think I think that there's a monthly pattern or that there's some, I,'cause I feel like there are people who probably experienced this, who have gone their whole lives without realizing it.

Laura:

Yeah. So we had two months back to back where she had these meltdown and crashes the night before. She would start her cycle and they were just, heart wrenchingly. Do I take her to the hospital? She's not in a crisis of self harm, but it just, she felt so hopeless what do I do to help her? That depth of depression kind of thing. So when we hit the second round, that when I said, there's a cycle here. So that was in January. And then I started mapping out a little bit of her symptoms. Three days into her cycle, she would start feeling better, and then she would have about a week before she started having any symptoms of the body aches or the irritability or things. So she would have about a week that she, felt normal.

Dr. Elise Fallucco:

And just a clinical comment here, I imagine some of our listeners are hearing about all of these depressive symptoms and thinking, you know, could this just be comorbid depression that has some sort of premenstrual exacerbation, but the way that you've described it is that the symptoms really completely go away a couple of days. Into her period, and we wouldn't expect that if it were major depressive disorder. Regardless when we're thinking treatment for premenstrual dysphoric disorder, first line treatment is with SSRIs. And our studies have shown that it's pretty much equally effective to do continuous dosing of SSRIs, just like you would use to treat depression or anxiety or for premenstrual dysphoric disorder. You can also only dose the SRI in the 12 days preceding menses, or what's known as the luteal phase, and then stop it. During the two week follicular phase, so first line treatment would be SSRIs, and then second line treatment would be considering combined OCPs, something like yas, which contains both progestin and estrogen. And YAS is FDA approved for the treatment of premenstrual dysphoric disorder, and the studies have used dosing 24 days of the active hormone followed by four days of placebo.

Laura:

So we went to see my GYN and. He was so wonderfully kind to Beth and explained everything so thoroughly and validated her feelings and what was going on with her so completely One of the best medications that they use and is actually FDA approved is Yas, and so it's very low dose. And really well tolerated, but they'll skip the placebos. And so you take the packs back to back,

Dr. Elise Fallucco:

And just to recap, Lorena, how you guys used it is, you gave the combination progestin and estrogen dosing and then skipped the placebo week, which would be when you would have the drop in levels. And so then Beth was able to have a steady state of hormones and avoid that premenstrual crash of estrogen. And progesterone. And how long did it take after starting Yaz before you and Beth noticed a difference?

Laura:

I think we started to notice, a little bit of impact by the second month, but by the third and fourth month we were really starting to notice more of an impact. By the time we got to month five, she was much more even her skin had cleared up just overall her hormone levels were just much more steady. We weren't having any of the poor appetite. The body aches, the mood swings, all of that had resolved.

Dr. Elise Fallucco:

Just to recap her premenstrual symptoms were like a really intense PMS, feeling like you're having the flu with the body aches and extreme fatigue collapsing on the couch, feeling like I'm done at the end of the day. And then the suppressed appetite along with the irritability and the snappiness. It sounds like her physical symptoms and her mood symptoms were the most dramatic and the most intense. But you had mentioned that some of her A DHD symptoms also were worse premenstrually, is that right?

Laura:

It is. And when I was doing research on this I found something really interesting. So there is a correlation between PMDD and patients that are neurodivergent, whether they have a DHD or autism, so it's something that I start looking for in my A DHD patients. I even keep it in my education with my parents. Hey. Keep an eye on this. If you start to notice some of PMS symptoms starting to get a little bit extra, let me know. Keep an eye on it, track it a little bit for me because this could be something that we need to look at in the future.

Dr. Elise Fallucco:

neurodivergent kids with a DHD and or autism spectrum are at much higher risk of being very sensitive to hormonal fluctuations and having really intense symptoms. Premenstrually. I love that you've used your experience with your own family and your own daughter to try to educate and help other patients, other families, so that other kids when they're experiencing this will know that this is not normal or typical and that there are things that you can do to try to address these symptoms and you don't have to live that way. How is Beth doing now?

Laura:

She is doing great. She is, in her sophomore year, she has a great group of quirky friends and they are all fun and do their own thing and are quirky together and I love that. And she is a big Brandon Sanderson fan and she has been reading all of his books and she is in the middle of writing one of her own fan novels and she is getting lots of, letters from colleges and governor schools trying to recruit her and she's looking forward to studying psychology.

Dr. Elise Fallucco:

What a long way she's come. So glad to hear that. And I can tell you're so proud of her. Thank you Lorena, so much for sharing about your journey and I really appreciate your vulnerability. It's hard to talk about the down parts and the ups and the downs and all of the in between, and it's so helpful. And I'm really I know that the story that you shared and your insights are gonna help a lot of other pediatric clinicians hopefully identify this in the girls that they're treating and to think about, treatment options and how to get people help. And to our listeners, I hope that last episode's mystery case and this episode's real life example, will get you thinking about premenstrual exacerbation of A DHD symptoms and mood symptoms and as a helpful resource. I'm gonna share an A DHD and mood symptom tracker that was put out by a DD Aude that helps patients track their symptoms to help them and you identify if there really is a pattern that could be related to hormonal changes. I will share this on our website, psyched the number four peds.com. Thanks for listening. See you next time.