ODD & ADD & Meds
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Q:  ODD & ADD & Meds

After reading your questions and answers I decided to rewrite mine with more history.

My daughter whom is 7 we think is possibly early onset biopolar.  We have a lot of family history and my mother I also think is biopolar.  We have been taking my daughter to therapy and a Dr. whom has her on Depakote for her raging which has decreased tremendously.

We also think she might be ADD, we stuggle with homework and it always goes south, meaning she gets frustrated, has no patience etc.  We are trying her on Strattera but she has been on it for two weeks with no results.  She is extremely ODD, she can never answer without talking back in some form, luckily it has not spilled over to teachers and other adults, but she does struggle with friends which I think is because she is so verbal.  I desperately want to help her with the ODD, it never seems to get any better.

I read that some believe it is a by product of ADD/ADHD and if you treat the ADD/ADHD it could get better if not go away.  She is extremely anxious and has lots of stomach problems (acid reflux, etc.)  What is your feeling about ODD, can we address this with medication?  Do you think it is related to ADD/ADHD???

Help, this is so frustrating to us and her, she is in constant tears over this and we don't know what to do.  She appears not to be able to control it and when her mouth opens anything can spill out.

Can you help us!!


Dear Ms. M' -- 
The frustration is certainly understandable; it must be very, very difficult to live like this.  I'm glad to hear that the Depakote had a clear positive impact.  Now you'd like to target either the oppositionality (ODD=oppositional defiant disorder), and you're hoping it might be a feature of the ADD-like aspects of your daughter's symptoms.  (I'm rephrasing all this because it seems pretty crucial get the question just right; partly because I'm going to duck and declare too-little-knowledge/experience and what little I can say speaks right to this issue of "are we asking the right question?")

So, I'm not a child/adolescent psychiatrist; they have more specific training, and generally they have a lot more experience with this particular question. So, overall you could figure I'm saying "I don't know", but here's one thought I will contribute: 

Watching from the adult-treatment sidelines as the issue of ADD and bipolar is getting worked out, I think I hear one fairly clear message:  treat the bipolar first.  The next message is a little less clear, but it's there:  what looks like ADD can be features of the bipolar disorder, and sometimes you can only tell by treating as such -- i.e. with mood stabilizer-type medications, focusing on cycling, and on mixed state features such as anger/agitation (in this case).  

Then, the other message I hear is much fainter:  worry about stimulants destabilizing or making a bipolar disorder worse.  

So, adding these all up leads me, again as an outsider to this issue, really, to wonder about the wisdom of targeting ADD as a means of targeting the ODD, and to wonder about lumping ODD instead into the bipolar realm and treating it as such, more like a mixed state feature, i.e. with more mood stabilizer (presuming all other non-medication approaches are in place, like routines insuring sleep, like a good family therapist hunting for anything she/he can do to help, like good routines for maintaining other daily regularities like a good balanced diet that happens at pretty close to the same time every day, no late night TV (and maybe even no TV after 7 pm if you want to push the theory)).  

Now I worry plenty about the weight-gain inducing effects of Depakote, and now Zyprexa (e.g. see the whole rap about metabolic syndrome on my site); but as a very short, quick, trial to see about this general line of thought above, you could talk with her doc' about a few doses of Zyprexa to see what that does to ODD-like stuff.  If it works, and it would be my strong hunch/hope that it might, at least better than the stimulant Strattera, then you'll have a real dilemma deciding whether to start metformin too to protect her (per the above link) -- but that might be a lot better than the dilemma you face now, I hope.   Should I emphasize one more time that I'm just an adult psychiatrist?  What do I know, from experience, about this?  Very little.  So take my thoughts with that pile of salt, please.  (I'd be interested to hear what happens -- jimp@psycheducation.org -- either way; remind me with "this is the 7 year-old's story about ADD and ODD and bipolar... thanks)

Dr. Phelps

Published March, 2003


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