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[quote=Anonymous][quote=Anonymous][quote=Anonymous][quote=Anonymous][quote=Anonymous][quote=Anonymous]Anxiety often looks like irritability in children. Autism can make that irritability worse. Stimulants can make anxiety worse. You need to talk to your psychiatrist if the stimulants might be contributing (have you had a recent dose or medication change) or if a SSRI or mood stabilizer (ie, abilify) might be appropriate. Abilify saved our family and I resisted it for far too long.[/quote]

Op - I have talked to our psychiatrist another it, and our gp, and both say that ssris are not a first line treatment for a child of this age and they would prefer to exhaust numerous other approaches before going down that road. These are both highly respected nyc private practitioners - this is not quackery [/quote]

No one said SSRIs were first line treatment, but the OP has tried therapy alone already. Meds are indicated when therapy isn't sufficient.[/quote]

This.

OP, I say this as a parent of an ADHD kid and as someone who is probably ADHD myself and as someone who volunteers in mental health support and education (so I’ve heard many parent stories in a wide range of needs and solutions).

In this situation, after therapy and stimulants, in a kid who has already been diagnosed as ADHD/AUD, trying an SSRI is not “jumping to meds as a first line” therapy.

You seem to have some misconceptions.  SSRIs are not inherently more or less dangerous than stimulants.  Yes, there are some warnings on SSRIs, but those are there to alert you to look for certain reactions which would indicate the med should be stopped. You also seem to be weighing using SSRIs and the possible negatives against no SSRIs without considering the negatives of non-treatment. “Exhausting numerous other approaches” may come at a negative cost to your child.

I absolutely respect your sense that prescribing a pill is not some magic solution, but it can be tremendously helpful.  Trying an SSRI may or may not help. The unfortunate reality is that you won’t know until you try it, maybe not even until you try a few different ones. Trying a medication doesn’t mean you have to stay on it forever. Some meds can be more easily discontinued - like Straterra for instance, than others, like Zoloft, for instance, which is better to step down than stop abruptly.

Here are some medical and non-medical things I would do in your position:

1) explore whether altering the current medication dose or timing might help with irritability.
2) explore if a different stimulant or non-stimulant med might help instead of the current one (or in addition)
3) does your child have a school plan - 504 or IEP - and does something there need to be adjusted
4) explore changes in routine - exercise, diet, downtime, etc. 
5) explore other medical causes or contributors - blood work for thyroid, vitamin D and anemia, all of which can cause irritability/depression - as well as a sleep evaluation (sleep apnea and its contributors from mouth/teeth/tongue crowding, obesity, etc.)

Personally, my child was on a stimulant and SSRI in HS, and the SSRI helped tremendously with irritability. I regret not encouraging it sooner. He probably should have had it in middle school. My trying so many other approaches first came at a tremendous cost to him in terms of negative impact on peer and family relationships, self-esteem, and academics (and, no, I don’t mean grades). He willingly took the SSRI for several years because he himself thought it was helpful. He went off the SSRI before college (his decision). He also went off the stimulant because he chose an educational path and career field that played to the strengths of ADHD and minimized weaknesses (and probably provided some form of self-medication through adrenaline).

You may not realize it, but by treating meds as dangerous and never a first line, IMO, you are contributing to the stigmatization of mental health. I mean if your kid needed insulin, would you insist that he make a tremendous effort to go without insulin through a highly restricted diet plan and mandatory exercise and fail that first before trying insulin?

Some people need meds as a first line - either because their biology is such that they’ll never manage without meds, or because their environment is such and unchangeable enough that meds would be helpful, or because no meds is such a heavy lift it sucks the ability away from doing other things, or because meds could provide a short-term space that allows room to develop the framework to manage life off meds.

You might consider whether what you are hearing back from your “highly respected” doctors is not their “recommendation” but rather their “reflection” of your stated principles. If you as a parent come in and say that your philosophy is that meds should be a last resort after trying everything else, your doctors will reflect back what they heard and give you a recommendation in that context.  They understand that even if they think your kid could benefit from an add-on medication, you have stated you are not interested in hearing it and suggesting or encouraging a med would merely undermine the doctor-patient relationship. If your kid’s condition degrades enough that you become willing to ask for another med, then they can more successfully suggest something.

Hope you can hear the above with the kindness intended.[/quote]

op - thank you. I appreciate the thoughtfulness you put into this hugely and it is a super valuable read and perspective. 
To answer your last q, no, I actually put time with our psychiatrist to ask about SSRI (twice actually) and his perspective is th[b]at it isn't ideal unless it is clearly a depression oriented situation[/b], whereas for our kid, in many ways he's happy, but will have bouts of irritabilty that are impactful. His point was that SSRIs carry numerous side effects for kids and that its important first to do due diligence about what's going on and why. I'm actually pretty shocked this is such a divisive pov - it seems to me obvious that you'd want to go through quite the process with an irritable kid to figure out what's what before you're like 'oh well i guess it's prozac for him'. Again, I really appreciate the above and it's a really great pov - i will certainly bring it up with my dr again. I guess I was just hoping for more of like 'hey maybe something isn't working for him lets think about what that might be' and less of like 'put him on an SSRI you dummy, oh and also, side note, because you're british that's why he's emotionally stunted'. [/quote]

I am PP. A couple things -

1) respectfully, I think your Dr’s framing of SSRI’s only if clearly depression is wrong medically. you have said his is a fancy well-respected NYC psych, and I’m sure it’s reassuring to think that you have the best who will know what is right. I’m here to tell you that’s not always the case. I have had to fire 2 psychiatrists of that type. Psychiatrists are human - sometimes they have their own biases, failures of knowledge, etc.  IMO, a Dr. who says the bold really doesn’t understand that SSRIs can often help with extreme irritability, which can be self-standing or an aspect of depression, anxiety ADHD and autism. I have seen this in my family in different people who have diagnoses of anxiety, bipolar or ADHD.  If the bold reflects that the doctor has a view that SSRIs should only be prescribed for people diagnosed with depression and since your kid is not diagnosed with depression he isn’t eligible for an SSRI - that is also wrong. Some SSRIs like Wellbutrin) and SNRIs (like Atomoxetine) are often prescribed for ADHD for both mood and attention.

2) Many people (doctors also) think of ADHD as just being a disorder of attention, but it is well known that mood and/or emotional dysregulation can be big aspects of ADHD. ADHDers sometimes feel more deeply, ruminate over slights for longer and lack the executive function to regulate mood and have an impulsivity that can contribute to irritable outbursts.  Add in that kids with ADHD may be working hard to “mask” all day at school, and then come home to a safe space and let it all out. Plus, ADHd kids in school are for sure hearing more criticism from teachers, peers and their internal voice than neurotypical kids. Whether one thinks of irritability as intrinsic to ADHD, as a comorbid second disorder like anxiety or depression, or the result of outside influences due to the stigma of neurodivergence, really doesn’t matter in some ways.  And, waiting until you’ve tried everything else leaves the kid in a terrible state for longer than is necessary, suffering knocks to self-esteem, friendships and family relationships.

3) finally on this point you make, “ I'm actually pretty shocked this is such a divisive pov - it seems to me obvious that you'd want to go through quite the process with an irritable kid to figure out what's what before you're like 'oh well i guess it's prozac for him'.”

Can you hear yourself? Can you hear how you are reflecting society’s stigmas about medication use for mental illness - that people who use medications just didn’t want to do the hard work to take care of their illness without pills or were too self-absorbed to pay attention to their children and figure out what was going on, and that you are better than that? Can you imagine how these words land with the parents who have kindly taken time to tell you how helpful meds have been - especially when you really have very little idea about the personal circumstances that led to medication choices and are making very negative judgments on little info?

Go back and look at the first and second posts after your OP.  The initial response came from a person who said that if her parents had been reluctant to put her on meds, she would have been dead from suicide.  Your response to her was to tell her “Every parent should start from a place of reluctance where these hardcore medications for kids this age are concerned,” thus implying her parents were wrong to medicate her - after she shared that it saved her from suicide!

There is literally no parent who goes to the doctor and cavalierly takes a Prozac Rx without thinking about it very carefully, and to suggest otherwise, frankly, is really a reflection of stigma and your own privilege, not just financially but also in terms of being able to access treatment and educate yourself about it. No one is saying run to the doc and get Prozac and don’t bother thinking about other drivers of behavior. What people are reflecting is that sometimes medication is the only or best solution or even a solution that provides space to focus on other drivers while not leaving our children in a distressed state without help for unreasonable amounts of time and thus widening the circle of harm, and that your frame of medication reluctance and as last resort is not necessarily correct.  Does it happen sometimes that parents take medication quickly when another non-medical solution is available. Probably, but when I see that it is often a function of ability to pay for more complex care (lucky you that you can afford a psychiatrist and therapist), or a lack of knowledge about other options or a decision that non-medical options don’t fit the situation, or, a conscious decision that using medications early to improve irritability so there is more receptivity to working on other underlying drivers.

Please educate yourself about ADHD, autism, meds and the range of treatment options. ADDitude Magazine is a good place to start - lots of articles and videos from well known health professionals in the mental health field.  Written in an easily understandable way. [b]https://www.additudemag.com/?srsltid=AfmBOoqhFDcR1Ohfas7GAzzqh3qtWsGpiBYsaAMeug58yEyua3F5cwfr[/b][url][/quote]

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