Appointments with patients and their parents about attention deficit disorder can be like Alice staring into the looking glass. I never know what the agenda may be on the part of the parents or patients. Behavior is a subjective thing, and what is well-behaved to one parent may be holy-terror to the next. Teasing out the various expectations takes some skill, and truthfully, some days I have it and some days I don’t. Late afternoon appointments for attention can be soul wearing after a day of wrangling rambunctious toddlers.
For example, I was puzzled by the tween with significant side effects from her stimulant medication. According to her mother, this patient endured six months of roller coaster emotions ranging from happy, focused student to raging, mean dervish. This follow-up had been long overdue – rescheduled several times. The encounter left a prednisone –like aftertaste in my mind- bitter and lingering. Prior to their arrival, I received an email from the mother and teachers detailing the changes. The patient was failing at least one class and doing poorly in another. Red flag in ADD land especially at the end of the school year. (It’s not unusual for me to have desperate parents in the office at the end of semester trying to salvage the school year with a trial of medication) The email also described aggressive tendencies like grabbing the patient’s younger brother. The mother speculated that all of these differences were due to the ADD medication
About to enter the exam room, I flipped through my chart to see when the last medication evaluation took place. Last office visit was five months prior with no visits or phone calls in between. A lot had happened in the past five months, and I wondered why all of these new concerns had not been on my radar before today.
Starting ADD medication is no small feat in this day and age. With FDA warnings and ECG recommendations, stimulants come with baggage. I have a spiel that I give families about the risks and benefits. We are a team on this, I tell them. If you don’t like the way your child acts on the medication, stop it and call me. There are alternatives. I want the best possible outcome, and every child is different.
So why did it take five months of problems for this patient to step back into my office? Why did they continue to ask for monthly refills? Puzzled and concerned, I entered the exam room. The situation between parent and patient was volatile. Each lobbed accusations at each other. The teen had the aura of a black rain coat covering an arsenal of weaponry to protect her soul.
Not wanting to put her on the defensive, I poked around with small talk questions about how school was going.
“Fine.” She says. Lots of one word answers to follow each of my questions. I was wary of putting her in an even more defensive position by asking “Why did it take you so long to come back when you were having problems?” As her mother detailed some of the more violent encounters, I flipped between the last two visits. Her weight caught my eye. She was down 17 pounds from her last visit five months ago.
“You’ve lost weight.”
“Yeah.” She beamed briefly.
Aha, I thought. A small door suddenly opened to the window to this patient’s mind.
“Do you like being thinner?”
“Yeah, I do.” Another brief ray of light.
“Have you stayed on this medication because it’s helped you lose the 17 pounds?”
“I guess so.” At least part of the mystery was solved about why she had not been to see me for almost half a year.
I had always thought that the appetite suppressant properties of stimulants were pretty weak in the pediatric population. Sure, I had kids that had lost weight, didn’t eat lunch, and stopped taking meds in the summer time to reverse this side effect. But I had never had a patient continue on a medication that seemed to debilitate her family life to pursue this side effect. The drive to be thin is extremely powerful, and a force to be reckoned with.
I took her off the stimulant feeling like I needed to eliminate medication as a variable in her chaotic family life. I bargained with her to try counseling which she had refused so far. She hasn’t come back to see me – lost to follow-up. Her mother appeared one day in my office recently. The patient’s behavior hadn’t changed so we agreed that stimulants didn’t contribute to the unpredictable and wild mood swings. But this encounter has taught me to be very wary of stimulants and my teen girls.