Tachycardia with stimulant? When to discontinue?

[shahseh22]

Hi,
CAP fellow here. I have a 7 yo kid who I inherited from another doctor with a history of PTSD, ADHD and Intermittent Explosive Disorder. He's been on many different antipsychotics in the past due to behavioral outbursts. I have him on Focalin XR 20 mg qAM and Focalin XR 5 mg qNoon (insurance does not cover IR for reasons beyond me), Clonidine 0.1 mg qHS and Abilify 2 mg qAM (he was on a higher dose before but trying to lower as he is quite overweight).

At any rate, the parent has been saying having the Focalin XR has been helping him a lot at school (especially the morning dose and noon dose). I have been checking his HR and its quite elevated 120-130 bpm. BP has been normal. He is asymptomatic and no cardiac history. I still plan to get an EKG anyways.

I know we should treat the pt, not the number, but at what stage should one lower the stimulant dose in light of tachycardia? The kid has a history of being very impulsive and has had issues with placements/school in past.

Thanks for any input.

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[TexasPhysician]

What was the pulse pre-stimulant?

Are parents journaling his pulse at intervals on/off meds?

 

[shahseh22]

What was the pulse pre-stimulant?

Are parents journaling his pulse at intervals on/off meds?

No, unfortunately the parent doesn't even have a BP cuff. I don't know what the pulse was before stimulant because he has been on it since he has been seeing me. However, at the lower dose (15 mg) it was still in the high 90's from what I recall.

 

[Merovinge]

No, unfortunately the parent doesn't even have a BP cuff. I don't know what the pulse was before stimulant because he has been on it since he has been seeing me. However, at the lower dose (15 mg) it was still in the high 90's from what I recall.

I actually think you should treat the number in this case. If you have documentation of normocardia on a lower dose and persistent tachycardia across 3+ readings I absolutely would at least add a daytime alpha-2 agonist and then pending tolerance or change on that try to lower back down the dose. Focalin XR tends to be the absolute least noradrenergic of stimulants so not much option to change there.

I know its largely tangential to your original question but these diagnosis and treatment plan in your initial phrasing are a little concerning. IED is such a garbage diagnosis unless you know the patient has ASD/ID and need to get insurance to pay for a hospital admission. Does he have large outbursts due to his trauma (singular or complex?), is there a LD/ID/ASD or sensory processing disorder? Did he have outbursts due to his ADHD being poorly controlled, poor school fit? Overweight 7 year old's on Abilify (much worse metabolic impact in children than adults) without ID/ASD except in the most extreme cases is one of my biggest concerns in CAP, particularly if it's actually being Rxed by a fellowship trained attending.

 

[Mass Effect]

Yeah, I agree with the above. His regimen sounds terrible. Why would a 7 yo require Abilify? What's at the root of his explosive behavior? Has he exhausted all other medication options?

As for the pulse, I would get parents journaling his HR over a few drug-holiday weekends/winter break and go from there. With a HR that high, I would either cut back on dosing or consider other options. I agree that you could add an alpha agonist during the day, but I'd rather err on the side of limiting polypharm.

 

[Merovinge]

I agree that you could add an alpha agonist during the day, but I'd rather err on the side of limiting polypharm.

I almost always agree, particularly in young children, with limiting polypharm with the very notable exception of stimulants and alpha-2 agonists. We have fair data to suggest the combination is more effective than either in isolation and a combination often allows for lowering the stimulant dosing. The combination of the two also often cancels out SEs (sedation, hypo/hypertension), which is very rare in clinical practice. I see majority public aid patients and even most of them have guanfacine ER and stimulant ER covered for once daily administration.

I think this has some similarities to if decent placebo controlled RCTs show that adding in thc/cbd pharmaceutical agents lowers the dosing of opioids, improves nausea, and does not increase sedation (as an example, I don't actually think this will happen). I don't think many PCPs are just going to say, well lets give em a higher opioid dose then, yet here we are Rxing higher stimulant dosages in the name of parsimony or avoiding polypharmacy.

 

[whopper]

L-Theanine, an amino acid, but available as an OTC gummy has data showing it increases alpha activity in the brain and can be calming in children in ADHD.

 

[cara susanna]

Not a psychiatrist, but I'm also wondering about how much of the behavioral issues are also related to PTSD. It seems like it'd be really difficult to definitively diagnose ADHD in this patient given the symptom overlap.

 

[shahseh22]

Yeah, I agree with the above. His regimen sounds terrible. Why would a 7 yo require Abilify? What's at the root of his explosive behavior? Has he exhausted all other medication options?

As for the pulse, I would get parents journaling his HR over a few drug-holiday weekends/winter break and go from there. With a HR that high, I would either cut back on dosing or consider other options. I agree that you could add an alpha agonist during the day, but I'd rather err on the side of limiting polypharm.

I wish I had a good answer for this but with some of these children getting a good history is difficult. Root of explosive behavior appears to be in response to when he is told "no" by teachers of parent. There is definitely room for going up on Clonidine. I plan on discontinuing Abilify because I don't think it has helped at all and its such a tiny dose at 2mg.

 

[shahseh22]

I actually think you should treat the number in this case. If you have documentation of normocardia on a lower dose and persistent tachycardia across 3+ readings I absolutely would at least add a daytime alpha-2 agonist and then pending tolerance or change on that try to lower back down the dose. Focalin XR tends to be the absolute least noradrenergic of stimulants so not much option to change there.

I know its largely tangential to your original question but these diagnosis and treatment plan in your initial phrasing are a little concerning. IED is such a garbage diagnosis unless you know the patient has ASD/ID and need to get insurance to pay for a hospital admission. Does he have large outbursts due to his trauma (singular or complex?), is there a LD/ID/ASD or sensory processing disorder? Did he have outbursts due to his ADHD being poorly controlled, poor school fit? Overweight 7 year old's on Abilify (much worse metabolic impact in children than adults) without ID/ASD except in the most extreme cases is one of my biggest concerns in CAP, particularly if it's actually being Rxed by a fellowship trained attending.

I definitely see IED symptoms in him. No doubt he has had trauma which may explain it. There is not ID or LD. There was rule out for ASD in the past but I'm not getting that impression. He can get very easily ticked and angry to the point where the parent fears for their safety.

 

[Merovinge]

I definitely see IED symptoms in him. No doubt he has had trauma which may explain it. There is not ID or LD. There was rule out for ASD in the past but I'm not getting that impression. He can get very easily ticked and angry to the point where the parent fears for their safety.

What are IED symptoms, and please don't simply list the diagnostic criteria from the DSM. No one should simply be attributing highly problematic behaviors to "it meets IED", a "disorder" with no known cause or treatment despite neuroimaging and neurophysiologic research. I am interested in you expanding on the root cause or proposed root cause of this dysfunction and addressing this.

I wish I had a good answer for this but with some of these children getting a good history is difficult. Root of explosive behavior appears to be in response to when he is told "no" by teachers of parent. There is definitely room for going up on Clonidine. I plan on discontinuing Abilify because I don't think it has helped at all and its such a tiny dose at 2mg.

2mg is not a tiny dose of Abilify for a 7 year old, its a very reasonable therapeutic starting dose (in patients with ASD or ID). If explosive behavior is triggered by being told "no" predominantly you have a pretty solid framework to begin addressing this through PMT and incorporating a similar reward/consistent boundaries system between school and home. This kid is 7 years old, has been on multiple antipsychotics, people "fear for their lives" around him. I really think it's time you talk to your best PMT psychologist and best trauma psychiatrist and come up with a real treatment plan other than medication roulette.

 

[downwithDTB]

I really think it's time you talk to your best PMT psychologist and best trauma psychiatrist and come up with a real treatment plan other than medication roulette.

It bears remembering that many of these kids with history of abuse have parents (if they are lucky) with extreme limitations in the best caae and are lucky to get 15 min q 3 month med checks and a master's therapist with terrible training to see infrequently. I hope, but highly doubt this kid has access to a psychologist or even someone with PMT training. Would the parent(s) even come for PMT or participate?

It's fun to talk about ideal care... and then there's what Medicaid will get you. We have no idea what resources are available here.

 

[Mass Effect]

I definitely see IED symptoms in him. No doubt he has had trauma which may explain it. There is not ID or LD. There was rule out for ASD in the past but I'm not getting that impression. He can get very easily ticked and angry to the point where the parent fears for their safety.

There is great overlap in the symptoms of IED and symptoms of PTSD. In other words, how do you know this is IED rather than a manifestation of PTSD? In abuse cases (which I assume this was), the victim was powerless to defend/stand up for him/herself. That lack of power has severe psychological consequences and very easily turns into getting "easily ticked and angry to the point where the parent fears for their safety." If the fearful parent is the one responsible for the trauma the child endured, either by inflicting the trauma or by standing by and letting it happen, it's even more expected that the child's anger would be directed at him/her. But even if that's not the case, I would treat the explosive behavior as PTSD until proven otherwise. I also have to wonder if stimulants might worsen the irritability in this patient.

 

[Merovinge]

It bears remembering that many of these kids with history of abuse have parents (if they are lucky) with extreme limitations in the best caae and are lucky to get 15 min q 3 month med checks and a master's therapist with terrible training to see infrequently. I hope, but highly doubt this kid has access to a psychologist or even someone with PMT training. Would the parent(s) even come for PMT or participate?

It's fun to talk about ideal care... and then there's what Medicaid will get you. We have no idea what resources are available here.

That may be the case in a lot of treatment settings but I would be highly concerned if it were the case for a fellow, particularly since it sounds like its a patient in fellow med clinic. My fellowship training was with 80% medicaid and they were happy to poorly reimburse our 30 minute med appointments monthly (when indicated) as well as apts with pediatric psychology PhD students on a weekly basis. This is clearly a case to schedule a meeting between the therapist and psychiatrist which hopefully happens with relative frequency for any fellowship program.

 

[cara susanna]

I agree, all of the medication in the world won't help if the environment keeps reinforcing this child's outbursts. Granted, as a psychologist I am a bit biased towards behavioral interventions.

 

[Merovinge]

I agree, all of the medication in the world won't help if the environment keeps reinforcing this child's outbursts. Granted, as a psychologist I am a bit biased towards behavioral interventions.

Certainly not biased compared to other mental health professionals. Almost every reasonable CAP is just as interested in these being managed through or at least with the support of behavioral interventions, just most aren't in practice setups where they have the time to work and refine them personally. I'm always interested in establishing an increasing rolodex of peds psychologists who do good PMT or BA.

 

[shahseh22]

What are IED symptoms, and please don't simply list the diagnostic criteria from the DSM. No one should simply be attributing highly problematic behaviors to "it meets IED", a "disorder" with no known cause or treatment despite neuroimaging and neurophysiologic research. I am interested in you expanding on the root cause or proposed root cause of this dysfunction and addressing this.



2mg is not a tiny dose of Abilify for a 7 year old, its a very reasonable therapeutic starting dose (in patients with ASD or ID). If explosive behavior is triggered by being told "no" predominantly you have a pretty solid framework to begin addressing this through PMT and incorporating a similar reward/consistent boundaries system between school and home. This kid is 7 years old, has been on multiple antipsychotics, people "fear for their lives" around him. I really think it's time you talk to your best PMT psychologist and best trauma psychiatrist and come up with a real treatment plan other than medication roulette.

Of course I agree a lot of his symptoms are attributable to previous trauma. But some of the symptoms consistent with IED have been verified by therapist, social worker and his teachers at school. He throws a tantrum in my office when he is told parent tells him he cannot use electronics during the session and starts to posture aggressively at me or starts. He definitely has potential to be very aggressive. I don't want to go into the specifics of his tantrums (for privacy reasons) but I and the therapist definitely agree with historical IED diagnosis.

Also, he is definitely enrolled in therapy and I have tried to facilitate more parental engagement as well but we are limited in resources and he is getting therapy sessions both at home as well as at school as frequently as we can provide. I am not saying the therapists are top notch but they are doing their best and are good people. We don't have regular sessions together but we collaborate whenever either one of us has a question.

I think you are under the impression I started Abilify which is not the case. If any thing, I have been trying to taper off antipsychotics and most of his medications for that matter. I'm actually very conservative about starting medications in children.

In this particular case, of course I know the child's primarily symptoms would be addressed in therapy, however, his uncontrollable anger is an issue.

Of course, in the CAP setting and especially in the lower socieconomic population, there are a lot of unfortunate things we cannot change especially with regards to their home environment and things are far from ideal.

 

[shahseh22]

It bears remembering that many of these kids with history of abuse have parents (if they are lucky) with extreme limitations in the best caae and are lucky to get 15 min q 3 month med checks and a master's therapist with terrible training to see infrequently. I hope, but highly doubt this kid has access to a psychologist or even someone with PMT training. Would the parent(s) even come for PMT or participate?

It's fun to talk about ideal care... and then there's what Medicaid will get you. We have no idea what resources are available here.

No I see them regularly almost 4-6 weeks and I have the luxury of taking more than 30 minutes if I need to in my setting (have a lot of no-shows at times). Resources are limited but we do the best we can.

I hope no one who is reading this thinks I'm just a pill pusher.

 

[birchswing]

Certainly not biased compared to other mental health professionals. Almost every reasonable CAP is just as interested in these being managed through or at least with the support of behavioral interventions, just most aren't in practice setups where they have the time to work and refine them personally. I'm always interested in establishing an increasing rolodex of peds psychologists who do good PMT or BA.

I didn't find out until years after I saw him that the first psychiatrist I saw when I was 14 was a CAP. Actually very well credentialed (good schools). But he was dead-set against therapy. Actually said it was a waste of time. I went in under the wrong assumption that we were going to talk about my problems. And when he wouldn't let me talk about my issues (what I though the root cause of anxiety was) I asked about therapy, which is when he said it was a waste of time. (He prescribed a pretty heavy dose of Ativan and then later added on a rather small dose of Paxil.) He's still practicing. I was most surprised in later gathering my records that he was CAP. I assumed I had just gotten whichever psychiatrist was available, so it seemed particularly odd that he had been so . . . how do I put it gently . . . unhelpful.

Of course I agree a lot of his symptoms are attributable to previous trauma. But some of the symptoms consistent with IED have been verified by therapist, social worker and his teachers at school. He throws a tantrum in my office when he is told parent tells him he cannot use electronics during the session and starts to posture aggressively at me or starts. He definitely has potential to be very aggressive. I don't want to go into the specifics of his tantrums (for privacy reasons) but I and the therapist definitely agree with historical IED diagnosis.

Also, he is definitely enrolled in therapy and I have tried to facilitate more parental engagement as well but we are limited in resources and he is getting therapy sessions both at home as well as at school as frequently as we can provide. I am not saying the therapists are top notch but they are doing their best and are good people. We don't have regular sessions together but we collaborate whenever either one of us has a question.

I think you are under the impression I started Abilify which is not the case. If any thing, I have been trying to taper off antipsychotics and most of his medications for that matter. I'm actually very conservative about starting medications in children.

In this particular case, of course I know the child's primarily symptoms would be addressed in therapy, however, his uncontrollable anger is an issue.

Of course, in the CAP setting and especially in the lower socieconomic population, there are a lot of unfortunate things we cannot change especially with regards to their home environment and things are far from ideal.

I was just mildly curious as I always am when I hear about defiant children . . . when you say for example that the child goes into a fit of rage when asked to not use electronics, is that in that moment a reasonable request or does it seem like he is being managed to an excessive extent? The reason I ask when I sit in waiting rooms I have observed some parents who want their very young children to sit like statues in the chairs and do this "yell whisper" thing that actually sounds very menacing. And I mean there is literally nothing for the kids to do but wait, but these parents don't want them playing with the toys set out on the floor or looking at the magazines, etc. I mean there's something wrong with the parents. These particular children I've seen are rather docile in response to the unreasonable parents (the children contain the parents rather than the other way around), but your patient's situation sounds different.

Even in schools I have some experience having observed teachers through an internship where it seemed like with the children who were labeled as having problems that the teachers would sometimes be on power-trips and needle the children to a point that the children were quite frustrated.

I don't know what the trauma was, but in a very young child with less resources/faculties than an adult, could breaking down when someone says "no" after he previously faced untenable situations in which he had no control (whatever precipitated the PTSD) actually be adaptive/protective given his age? Presumably he was not able to say no to whatever it was that was traumatic. Can these parents contain or do they respond in kind with escalation? Of course it's good for everyone to learn to contain, but could it be asking too much from a child who has been through traumatic experiences to do it all at once? If the parents can contain you can quiet one side of the equation at least. If he has these problems, is self-soothing with a video game so bad? I could see it as a valuable coping mechanism. Is there something of import he is meant to be engaged with otherwise? I assume he's not in the session to help select the medications.

 

[Merovinge]

Of course I agree a lot of his symptoms are attributable to previous trauma. But some of the symptoms consistent with IED have been verified by therapist, social worker and his teachers at school. He throws a tantrum in my office when he is told parent tells him he cannot use electronics during the session and starts to posture aggressively at me or starts. He definitely has potential to be very aggressive. I don't want to go into the specifics of his tantrums (for privacy reasons) but I and the therapist definitely agree with historical IED diagnosis.

I'm still not sure what you mean by consistent with IED. Tantrums when people told to not use electronics is absolutely not IED. I don't think you are a pill pusher, and maybe your fellowship is a lot different than the one I or the rest of my colleagues trained in, but I am encouraging you to look into the research on IED, this is exactly what fellowship is for (to learn how to manage difficult cases, you are training to be a sub-specialist). This diagnosis remains for insurance reimbursement reasons, not as an answer to why a child is acting aggressively (sans a child with TBI sequele or other neuropsychiatric illness). This kid is asking for help, maybe it's feasible or maybe it's not, but someone at least needs to be modeling an environment to give him a chance, that situation you describe in office sounds like a perfect opportunity to do so.

 

[Alemo]

Speaking of tantrums thrown over the removal of electronics, what is the conventional wisdom on “treating” this? Such kiddos make up probably half of the pediatric cases in our psych ER....

 

[Ironspy]

Speaking of tantrums thrown over the removal of electronics, what is the conventional wisdom on “treating” this? Such kiddos make up probably half of the pediatric cases in our psych ER....

Can’t you just have a bowl of iPhones in the waiting room?

 

[cara susanna]

Speaking of tantrums thrown over the removal of electronics, what is the conventional wisdom on “treating” this? Such kiddos make up probably half of the pediatric cases in our psych ER....

Not a child psychologist, but talked to someone trained in ABA and behaviorism about this thread because I was curious about intervention ideas. Basically, differential reinforcement and extinction burst.

 

[shahseh22]

I'm still not sure what you mean by consistent with IED. Tantrums when people told to not use electronics is absolutely not IED. I don't think you are a pill pusher, and maybe your fellowship is a lot different than the one I or the rest of my colleagues trained in, but I am encouraging you to look into the research on IED, this is exactly what fellowship is for (to learn how to manage difficult cases, you are training to be a sub-specialist). This diagnosis remains for insurance reimbursement reasons, not as an answer to why a child is acting aggressively (sans a child with TBI sequele or other neuropsychiatric illness). This kid is asking for help, maybe it's feasible or maybe it's not, but someone at least needs to be modeling an environment to give him a chance, that situation you describe in office sounds like a perfect opportunity to do so.

Oh its not just electronics, there's loads of other violent behavior at school which has been refractory to IEP interventions. I could go on but I really want to maintain privacy regarding the details. Point taken about IED and DMDD as well. Also, I do my best in my sessions to try and give him a chance (keep in mind I'm not a trained therapist nor have I had extensive training in therapy unfortunately, but I try to do my best).