Anonymous wrote:I will give you a different perspective to think about. My DS went through similar issues at age 9. A doctor thought he was depressed due to issues at school and suggested medication. I had similar concerns about SSRIs and wanted doctors to rule out everything before I went that route. He wasn’t sleeping well and I had him undergo a sleep study. Turned out he had sleep apnea. For many kids the symptoms are similar to depression and ADHD. We got his tonsils and adenoids removed and the behavior and mood issues dramatically improved. ADHD and sleep disorders are common coexisting conditions. Sleep disorders are grossly underdiagnosed and likely account for a large number of ADHD diagnoses.

Here we go! This is the answer. There are a dozen biomedical issues that should be ruled out before ssris are on the table.
Does he have low iron? Does he have convergence insufficiency? Does he have a deviated septum? does he have allergies. Does he have methylation problems? Is his b12 good? Does he have Fraa?
People with audhd are highly prone towards digestion, absorption, mcas,allergies, vision, sleep and orher problems. He should evaluated for them. You will believe your pediatrician would have caught these issues but irs hard to catch them when no one is testing for them.

Pediatricians wait until you are clinically ill before they start looking for answers. Headaches and irritability are a symptom that something is wrong biomedically.

Anonymous wrote:My 12 yo (adhd/ possibly audhd but experts have different povs on that) irritability is off the charts and i dont know what to do. EVERYTHING annoys him. I keep trying to do nice things with and for him and he's just annoyed. He has sooo much anger. He says he's tired all the time, or has headaches (have been to neurologist and all fine). He's in therapy with a great therapist, but i'm at a loss. I prefer not to put him on more medication on top of the stimulants but it's just a little heartbreaking. any advice?

Did his neurologist do blood tests?

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote: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.

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

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

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.

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 that it isn't ideal unless it is clearly a depression oriented situation, 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'.

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. https://www.additudemag.com/?srsltid=AfmBOoqhFDcR1Ohfas7GAzzqh3qtWsGpiBYsaAMeug58yEyua3F5cwfr[url]

Anonymous wrote:My 12 yo (adhd/ possibly audhd but experts have different povs on that) irritability is off the charts and i dont know what to do. EVERYTHING annoys him. I keep trying to do nice things with and for him and he's just annoyed. He has sooo much anger. He says he's tired all the time, or has headaches (have been to neurologist and all fine). He's in therapy with a great therapist, but i'm at a loss. I prefer not to put him on more medication on top of the stimulants but it's just a little heartbreaking. any advice?

Check if any chemical sensitivities are causing the headaches. I have multiple family members who get severe headaches from perfume and fragrances. Pain makes people irritable. I hope you figure out what’s driving the problem in your dc.

I will give you a different perspective to think about. My DS went through similar issues at age 9. A doctor thought he was depressed due to issues at school and suggested medication. I had similar concerns about SSRIs and wanted doctors to rule out everything before I went that route. He wasn’t sleeping well and I had him undergo a sleep study. Turned out he had sleep apnea. For many kids the symptoms are similar to depression and ADHD. We got his tonsils and adenoids removed and the behavior and mood issues dramatically improved. ADHD and sleep disorders are common coexisting conditions. Sleep disorders are grossly underdiagnosed and likely account for a large number of ADHD diagnoses.

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:I’m going to just be super blunt. You lost me at “I prefer not to put him on meds.” Families and the kids themselves deserve some relief. If my parents had towed the “I prefer not to put my depressed and irritable teenage daughter on meds” line, I’d be long dead by suicide. Your child is suffering from a real condition, just like cancer is real. He, and you, deserve relief.

Just to be super blunt as well, stimulant meds are known to cause irritability as a side effect, so prioritizing your kids academic success over their mental health is something to be questioned.

He’s not on tbem for academics - but your defensiveness about ssris and assumptions are both highly unhelpful additions here so please move along

Ok so why give him a medication he doesn’t need that is causing anxiety/irritation …

because he does need it for emotional regulation and impulse control that was causing social difficulties

Clearly the medication could be causing social difficulties now. And I am unclear on what level of emotional regulation could be so serious as to need a stimulant but doesn’t impact academics? I think you truly need to wrap your brain around dropping the stimulant for a while.

Keep in mind, too, that hormones could be at work here. Puberty will make things wonky. We have noticed that with both our son and daughter, both of whom are ADHD. Some of what you are dealing with could be natural life milestones that make all the other things worse.

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:Even if I put him on ssri I still have to figure out what’s not working for him about his life. I do think screens are a big piece bc I’ve noticed him extra irritable when that time is interrupted. But then he has very little downtime too so that could play a part. School also starts way earlier than I wish it did and he has trouble getting to sleep so that’s a piece

OP you said you were British, right? I think I've hit on the reason you're getting all this SSRI advice. What you describe here - your thought process about what's not working for your kid, and the questions you're asking - it's pretty basic. Of course you need to figure out your own kid first. American families are bigger on communication, feelings, and therapy. The SSRIs aren't prescribed in a vacuum, we are doing the hard work along with it. And gently, based on your post here, you have a ways to go with this.

What advice do you need from us to help you figure out what's not working for your DS?

op - are you joking?

'gently based on your post' - you have no idea what my parenting is like based on my post. I've actually lived in the US for 20 years, my mother is american, and i was brought up in what can only be described as the kind of environment that would be portrayed as a pastiche by barbra streisand or nora ephron where all feelings were welcome. I have duplicated that for my own children and lean heavily into validation, family systems and other therapeutic methods I have learned thanks to numerous professionals with fewer stereotypes about brits (thankfully) than you seem to possess But thanks for the feedback and, gently, FU.

Yikes OP. As a British-American myself, my stereotypes come honestly. If you have figured out what's not working for your kid, then I'm glad. There's no need to thank me for the feedback, if you found it to be spiteful.

Age 12 is not when boys' irritability tends to peak. Expect your kid's irritability to worsen over the next 4+ years, before it starts to subside. Best of luck.

Anonymous wrote:My 12 yo (adhd/ possibly audhd but experts have different povs on that) irritability is off the charts and i dont know what to do. EVERYTHING annoys him. I keep trying to do nice things with and for him and he's just annoyed. He has sooo much anger. He says he's tired all the time, or has headaches (have been to neurologist and all fine). He's in therapy with a great therapist, but i'm at a loss. I prefer not to put him on more medication on top of the stimulants but it's just a little heartbreaking. any advice?

I mean, if I was tired and had headaches all the time, I'd be angry and irritable too.

Could the present stimulant be causing some of this? Is it possible he needs a med adjustment? He shouldn't be feeling tired all the time.

Anonymous wrote:OP, you’re a PITA. Do some self reflection. I’m irritated with you too.

Irritability can be genetic.

Anonymous wrote:

Anonymous wrote:I’m going to just be super blunt. You lost me at “I prefer not to put him on meds.” Families and the kids themselves deserve some relief. If my parents had towed the “I prefer not to put my depressed and irritable teenage daughter on meds” line, I’d be long dead by suicide. Your child is suffering from a real condition, just like cancer is real. He, and you, deserve relief.

op - sorry i 'lost you' but SSRIs for tweens are no joke. I have been told this by multiple psychiatrists. Every parent should start from a place of reluctance where these hardcore medications for kids this age are concerned. I encourage you to search on this board for multiple examples of why SSRIs are not a first line answer to these issues before you come with such certainty.

So are stimulants but yet you’re fine with using them. Which is weird since they increase irritability.

OP, you’re a PITA. Do some self reflection. I’m irritated with you too.

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote: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.

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

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

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.

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 that it isn't ideal unless it is clearly a depression oriented situation, 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'.

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote: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.

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

OP I understand your reluctance to jump straight to SSRIs - I have been on a dozen different ones as an adult before doctors figured out that like 30% of patients, I don’t tolerate them well and the side effects never resolved properly.

There is an abundance of evidence that lifestyle changes can be as effective as SSRIs at treating and managing depression and anxiety.

I would drill down hard on sleep hygiene (zero access to devices or TV during sleep hours), early morning light exposure either from outside activity (morning walk together?) or use of light box in the morning, meaningful exercise every day, meditation/breathing exercises, journaling, and cleaning up the diet - purge the added sugars and load up on whole food, cut the ultra processed stuff to the bone.

I struggled with refractory major depression, generalized anxiety and periods of suicidal ideation for years. I’m meds free and managing my mental health really well by reducing the negative aspects of modern society by giving my body the things it evolved to need and which promote optimal brain health: food that makes a healthy gut + hydration, plenty of sleep, exercise, light exposure outdoors as much as possible, quiet time away from devices.

Good luck with your boy, and hang in there.

Op - this is awesome to hear!

I’m British and I do find the American attitude to ssris so odd. Look don’t get me wrong they’re a godsend if you need them and can be life changing, but to me it’s more of a journey to figure out what’s wrong first (therapy is part but not all of this) and try to address the root cause before jumping to ssri which regardless of what others may think is not a slam dunk choice for a kid. Even an adult on ssri needs to do this work whether before or after they start their medication. Even if I put him on ssri I still have to figure out what’s not working for him about his life. I do think screens are a big piece bc I’ve noticed him extra irritable when that time is interrupted. But then he has very little downtime too so that could play a part. School also starts way earlier than I wish it did and he has trouble getting to sleep so that’s a piece

Ok but it is making zero sense that you are so cavalier about stimulants (which could certainly be causing the irritability) but so intensely reluctant about SSRIs.

op - no one with an adhd kid is 'cavalier' about stimulants. As ADHD parents we know that there is no substitute for stimulants. To know if there's no substitute for an SSRI would require you to confirm it is depression and then work through a litany of options to better get at the root of what is wrong before you intervene medicinally. That is not the same for ADHD.

Anonymous wrote:Is the irritability mostly with you/other family members or everyone? I have a very very sweet 11 year old and she has bouts of like out of body levels of irritation with us recently, which we have been told might be hormone related and part of the puberty process. I mostly just try to emphasize acceptable behavior but also try not to take it personally. I remember finding my family so irritating at this age. Plenty of exercise, enough sleep and 1:1 time focused around her interests help some. But I do think it can be normal even if it’s painful.

If it’s causing major problems outside the house and none the things you are trying are helping I do think you can tell yourself you are not “jumping straight to meds”.

op - it's mainly with the family