64. Mystery Case: 12yo ADHD "acts like she is on speed"

Let's kick off the new year with a NEW Mystery Case! Dr. Elise Fallucco works through the case of a 12-year-old girl with ADHD and a family history of bipolar. After starting a new stimulant medication, the patient exhibits what seems like 'super ADHD.' Could this be a medication side effect, emerging bipolar, or something else? Dr. Fallucco guides you through a detailed differential diagnosis, exploring possible causes and solutions. Tune in to discover effective strategies for managing ADHD medications and ensuring better outcomes for your pediatric patients!

00:00 Introduction and Case Overview

00:15 Initial Diagnosis and Medication

01:33 Evaluating Symptoms and Differential Diagnosis

03:34 Detailed Symptom Analysis

04:37 Ruling out Bipolar in Children and Teens

08:49 Understanding Rebound Hyperactivity

15:40 Managing Rebound and Treatment Adjustments

16:02 Kids at risk for rebound

21:06 Conclusion and Final Thoughts

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Transcript

Dr. Elise Fallucco 0:21

Welcome back to Child Mental Health for Pediatric Clinicians. I'm your host, Dr. Elise Fallucco, child psychiatrist, and mom. I'm really excited to start this year off with a fun mystery case. Okay. I think it's fun and I hope you will too. So here we go. So you have a patient in your office, a 12-year-old female with a DHD, and a known family history of bipolar. Her A DHD symptoms were recently recognized as she transitioned from elementary school to middle school and we've talked before about how that transition to middle school is where we see a lot of A DHD symptoms present themselves very prominently as the organizational demands increase and kids are managing a lot of deadlines, which is a tall executive function order. And so anyway, you diagnosed her with A DHD recently and started her on her first stimulant trial. She was started on Methylphenidate, extended release, 18 milligrams, and now she's coming back to the office for her four week follow-up appointment after starting this new med. And mom tells you, quote, my daughter is acting like she is on speed. Could this be bipolar? So in case you missed it, yes. This child has a family history of bipolar, which typically strikes fear in the hearts of many pediatric clinicians. And now mom is saying the daughter, since starting the stimulant, is acting like she is on speed. Here are some initial thoughts before we get any other history. Here's the differential diagnosis going on in my head, and I imagine you're thinking some of the same things, but what could it be? Multiple choice question. Is it a, the medication is not working and this is just the A DHD that we were trying to treat that now has become unmanageable. After four weeks of a failed med trial. Okay, could it be B? Some sort of medication side effect, like maybe this is worsening anxiety or new onset anxiety that's exacerbated by the stimulant medication, which we know can cause. Increasing emotions and can exacerbate anxiety. Okay, it's a possibility. Could it be C? Are we starting to see some sort of bipolar spectrum that was kicked off by the initiation of a stimulant trial. We know that family history matters a ton in increasing risk for bipolar, and this child does have a positive family history of bipolar, so this for sure should be on everybody's differential diagnosis in trying to understand what's going on there. Could it be D that perhaps the medication is working, that this young lady is trying very hard during the day to pay attention, follow directions. Control impulses and that the acting like speed is just her release when she comes home at the end of the day where she's no longer has to mask her symptoms of A DHD and concentrate and is now free to run and let her hair down, or could it be e something else? Hmm. What are you thinking? I imagine you're thinking that we don't have enough information, which is ultimately the correct answer. So then that gets us to, okay, what are the things that we need to make sure that we ask about to rule out some possibilities to be able to answer this multiple choice question. Okay, so obviously we wanna know more about what does mom mean when she says that she's on speed. So the mom is saying it feels like she is bouncing off of the walls. It's almost like she has super A DHD, a DHD, intensified, and mom clarifies. This is not. The A DHD that they saw before medication, it almost feels worse than that and it's causing a lot of frustration, particularly at home. So we wanna hear more about the super A DHD, and in particular, in the back of my mind, I wanna rule out could this be some sort of bipolar spectrum? And so I'm gonna be asking about cardinal symptoms of mania to figure out if that possibly is what's going on. And you may remember all the way back to our training or to med school, there were funny acronyms to memorize for the symptoms of bipolar, like dig fast or something like that. But I'll tell you, a practical clinical pearl for ruling out bipolar or assessing potential bipolar in children and adolescents really can be done in just asking a couple of questions without having to go through an elaborate acronym or mnemonic. So what I like to ask is, can you describe her mood when she is having this super A DHD? In other words, does it seem like she's excessively happy or. What we most often see in true pediatric bipolar is that they're excessively irritable and grumpy. And what mom says is her mood seems fine. She's not particularly happy, but she's also not particularly unhappy. So that's a good sign. But mood symptoms can be really nonspecific. You can get irritability from at least a dozen different things in our child mental health world. So that's not gonna tell you much. Really the best question to ask somebody to rule out pediatric bipolar has to do with sleep and energy during the day. So I like to ask, over this. The past month that she's been on the stimulant medication, have you noticed that she doesn't need to get a lot of sleep, that she can go a couple nights in a row with only a couple of hours of sleep and still have plenty of energy during the day, What the patient's mom says is that she's always had trouble winding down at night. And sometimes we'll give her a little bit of melatonin, but I haven't noticed any differences in her ability to fall asleep or stay asleep and you know, she's still getting a solid probably eight, nine hours after we account for staying up late for extracurriculars and homework and whatnot. So this is a really good sign because honestly, one of the most sensitive and specific signs of pediatric bipolar is decreased need for sleep. In other words. Being able to go a number of consecutive days without getting sleep and still have plenty of energy during the day without needing caffeine, or any sort of energy drinks. Okay, so good news. The symptoms that are going on do not sound like decreased need for sleep or mood changes that we would see with pediatric bipolar, so we can all breathe a huge sigh of relief there. Now the other thing we wanna know about is, you know, does it seem like she is more worried or more upset or anxious since she has started the stimulant and mom says, no, she really hasn't noticed that, and in fact, she actually feels a little bit more relieved because things are going better at school. So we started by going back to the basics and just asking more details about the chief complaint of, the child's behavior. And then what we wanna go do is make sure that we're asking about the timing of symptoms. A DHD meds typically a very rapid onset and then can have a very rapid offset. So you find out the day that you take them, whether they're gonna be helpful or whether they're gonna cause side effects. And then as the medication is clearing from your system, there's also the possibility to get what we call rebound effects, as the medication is wearing off. And so when we're asking about timing of symptoms, okay mom, when have you noticed that your daughter is acting like this? Is this, starting in the morning, 30 minutes after she takes her medication? Is it before lunch? Is it all day long, all night long? What's the story? And what mom says is actually. She takes the medication in the morning and it seems like she's hyper-focused. We've gotten feedback from her teachers who have said, you know, over the past month she has been quote a rockstar. She's been able to pay attention to focus. Her grades have bumped up. The teachers have noticed. Major improvements and they have also noticed no problems with mood or irritability. She just seems really focused like she's doing really well. And in fact all of these symptoms seem to happen when mom gets home from work, when daughter gets home from school and activities and they've gotta sit down and work on homework and that's when they've noticed probably around. Four o'clock, four 30, that she's bouncing off the walls, that it can sometimes take hours and hours to do a homework assignment. That should only take about 15, 20 minutes. It seems like the daughter is all over the map and is literally dancing around the family room. So it seems like what's happening is that the stimulant medication is actually effective during the day, or certainly is associated with improved focus concentration. We briefly asked about other side effects like appetite suppression, and they have not noticed any of that and it's really that we're seeing this intense super A DHD as the medication is wearing off maybe around four o'clock, four 30 in the afternoon. And I know what you all are thinking. Now we can go back to our multiple choice question and answer. What could be going on? Is it a, that the med is not working? Nope. The teacher would probably argue otherwise. Is it b? A medication side effect like worsening anxiety? Well, no. If it were truly a side effect from the medication, we would expect to see these symptoms occur while the medication is in her system during the morning and at lunch and throughout the day. The teacher's reporting that she's fine. The patient herself says, she hasn't noticed that she feels any mood changes or anxiety or anything when taking the med. Okay, so it's not B. C is this a bipolar spectrum? Whew. We already talked about We can rule that out. Everyone can take a huge sigh of relief. Although in this particular case, because there's a positive family history of bipolar and we know that that increases a child's risk of developing bipolar or bipolar spectrum, of course we had to. Think about this and more thoroughly asked questions. Is it D that the medication is working, but just she's just unmasking symptoms after a hard day of school trying to pay attention. If that were the case, we wouldn't really expect it to be, as the mom describes it, super, A DHD. We might have a little period where you get home from school and you're just kind of relieved and. And a little extra wiggly and extra giggly. Usually when that happens, when we're dealing with unmasking, we just tell the kids, okay, let's have a snack. Run around for about a half an hour. Get those things out of your system and then we'll try to regroup. But the way this case. Is presenting is much, much more extreme than just letting your hair down. So the correct answer is E, this is something else. This is rebound hyperactivity that you can see and probably see it. At least in 10% of kids who take stimulants, you can begin to see these type of rebound symptoms. Alright, great job, pat yourself on the back for solving the case. But now we have to get to better understand what's going on and how do you communicate that to the parents. So first of all, what is rebound and why do we call it rebound? Going back to our neuroscience basics, we know that stimulants can increase dopamine and norepinephrine, in particular areas of the brain that are responsible for executive function, organization, higher level control, particularly in the prefrontal cortex. But as stimulant medication wears off, you actually see a rapid drop in these catecholamines, the dopamine and norepinephrine, As the blood level decreases of the stimulant medication, so do the dopamine and norepinephrine levels in the brain. And if this decrease in blood level of the medication happens fairly quickly and you see a steep downward slope, you can get to the point where the brain is actually seeing lower levels of dopamine and norepinephrine than it did at baseline. And so as you see rapid drops in levels, the brain takes a while to readjust and recalibrate and that causes major rebound symptoms where it really does seem like the A DHD symptoms are worse than they even are without medication. The good news is that the brain is highly adaptive and can quickly readapt, figure out what's going on, recalibrate, and usually this can occur within an hour or a couple of hours. The bad news is that while this is all happening, what we're seeing clinically in children is that they can have really big emotions, high emotional intensity, low frustration tolerance, poor impulse control. And in the case that we're seeing here, major increases in hyperactivity, problems with attention and concentration. And I know what you're all thinking. If this is a methylphenidate extended release, how come we're seeing a rapid drop in stimulant medications? I thought that we were only expected to see rebound symptoms in short acting medications and that it was less likely to occur with long acting or extended release medications. Well, I'm so glad you asked, and this is also why this particular case I thought you would enjoy as a mystery case because it presents surprises and goes against what we would clinically expect in some respects. While this young lady was on a long-acting formula, we know that there is variability in the long-acting formulas where they can have rapid drops in blood level. And so you cleverly asked the mom, did you get the generic version or the brand version of this Methylphenidate extended release. And mom says, well, it was definitely generic. If you go back to your records, you had intended to prescribe. Concerta 18 milligrams, which is the methylphenidate OROS or osmotic controlled release system that really, truly has been shown to have a 12 hour duration of action. In some kids, although functionally sometimes it looks more like eight or nine hours, and the Concerta or the Methylphenidate 18 milligrams OROS really should have a much more gradual. Period where the medication is wearing off in the body. But what happened is insurance didn't cover that, but instead would cover generic and the family did not get an authorized generic version. And if you really wanna go into the weeds, the authorized generic of Concerta is made by Janssen Pharmaceuticals and they have, the letters ALZA written on them, and those are much more likely to function more closely to typical Concerta, but. The family did not get that version of a generic, and so really, even though it says extended release, it was functioning much more like a short acting medication. And then you see that rapid decline in blood level, rapid decline in catecholamines, and the increased risk for rebound Aha. So we were able to answer the question. There are medications that can put you at risk for developing rebound, and those would be the short acting medications or the medications with, rapid offset. But there are also particular patients who are at higher risk of rebound, and these are the people we need to make sure that we. Keep an eye out for when you're starting a medication. So if somebody is a really rapid metabolizer of stimulant medications and their body eats it up real quickly, then of course, they're gonna be at increased risk. Any kids that have comorbid anxiety or any sort of mood variability or mood dysregulation, they also are gonna be really sensitive to, stimulant medications in general. The other big risk factor, which is something that we can actually control, is if. The patients are not getting enough sleep or if they're very hungry, that can stress your prefrontal cortex and then put you at increased risk, and make you more sensitive to these changes in catecholamine and neurotransmitters. So something that we need to make sure to tell all of our patients is. Make sure that you have a great breakfast, even if your appetite isn't as strong. Make sure you're getting some good protein and fiber for lunch and excellent snacks, particularly in the afternoon as these meds could be wearing off because we don't want you to be hangry. Plus experiencing stimulant rebound. So we recommend to mom that we pack a lot of snacks and we find something great that her daughter can enjoy in the late afternoon to help with this. You could also consider switching to the non-generic or brand version of the medication, or even an authorized generic version of the medication to see if that would help with the stimulant coming off. But when I hear that, the child then is taking three hours to do homework in the afternoon. What we know is that we're probably just gonna need a booster dose of medication. If we're sticking with the current methylphenidate er 18 milligrams, it seems to be wearing off maybe around four o'clock. And so we're gonna need help to do the homework that we have to do in the afternoon anyway by adding a short acting methylphenidate like Ritalin. In the afternoon to help. And if we're really thoughtful, what we'll do is we're gonna add that short acting medication about 30 minutes before the morning medication wears off. And not only will that help with doing homework after school, but that's gonna help with the rebound'cause essentially, instead of going from a high level of medication to falling off a cliff of medication, you're gonna go back in time and insert short acting. Methylphenidate 30 minutes to maybe an hour before the morning medication wears off to just keep the blood levels more constant and steady in the afternoon in addition to all the other things we talked about. So now the last question is what do we tell the parent? So we tell mom, obviously we explain everything that we've learned and all of our cool neuroscience and psycho pharm info. But the main message that we wanna convey to families is that, that it sounds like the medication is actually really helpful during the day, and what's happening is that for whatever reason, her body is metabolizing this medication really quickly and as the medication leaves her system. That her brain is having trouble adjusting to that rapid decline in blood level, and so what we can do is just help the medication, leave her system more gradually so that it's not causing a problem. And sometimes when we're talking to families, it can be helpful to use metaphors. So I'm gonna share a metaphor that I use to try to explain the phenomenology of rebound from stimulants. If you're used to being in a really bright room and then somebody cuts off the lights, it's really difficult for you to be able to see what's going on because your brain is trying to adjust to that rapid change. But instead, if you kind of gradually dim the lights in a room, over time, your eyes will have time to adjust and be able to see properly. And so what we need to do is adjust the medication a little bit to help your body more slowly and gradually come off of the medication, which will help it adjust to this change. So the good news is you add a little boost of short acting methylphenidate or Ritalin. Right as she gets home in the afternoon, you've also encouraged her to have snacks during the day and have more protein and fiber in lunch. And what's happened is. The afternoons and evenings have become so much better for the whole family. She's better able to focus on the homework that she has to do, and it is no longer taking three hours, thank goodness, so that she can go and just enjoy the rest of her afternoon and evening. Well, I hope you enjoyed this mystery case. And if you have a question or a case that you wanna share, feel free to reach out to us on our website, psyched. The number four peds.com and make sure while you're there to sign up to become a friend and colleague of the podcast so that you can get our regular newsletters and we can be able to email back and forth and continue to share stories. Thank you for everything that you're doing to help take care of kids. And for all of the mystery cases that you are solving on a day-to-day basis. I look forward to continuing to learn with you this year, and I will see you next episode.