AWARD-WINNING A.D.D. TREATMENT SNAFUS

 

I request patients / parents contribute their own goofy stories to this section of our Clinic material.  These are some of my favorite stories (dating back over 38 years in practice now).

 

“OUR DOGS ATE THE KIDS' MEDICATION!”  Say what?  {Dogs are supposed to eat the kids' homework?}  It was a typical crazy-making afternoon in the Miller house: 4 PM, when all three ADHD boys [ages 6, 9, and 11] were due to receive their 3rd dose of Ritalin 10 mg tabs, and all three family dogs were on schedule to be fed.  Mrs. Miller had just picked up bottles from the pharmacy containing 90 Ritalin tabs for each boy, a month's supply, since they all took the medication 3 times per day (this was 1975).  She opened each bottle and placed them on the kitchen counter, but was then distracted by all their dogs barking in unison demanding their dinner first.

 

So she dutifully opened the bag of dog food, called for the dogs, and started pouring the standard amount into each dog food bowl.  Regrettably, one of the bowls slipped along the counter and knocked over all the medication bottles, spilling all 270 Ritalin tablets onto the kitchen floor.   Naturally, the dogs immediately cleaned up the floor, scarfing down all the Ritalin tabs. 

 

THE RESULTS:  Mrs. Miller said:  “You should have seen these dogs go!”  Revved up Cocker Spaniels rampaged all around the house for the next hour, then began throwing up, having diarrhea, howling as if being made to do the kids' homework, and then collapsed.  Her calls to the vet went unanswered, but after a horrific night all the dogs were perfectly OK the next morning.

 

However, initially overlooked in the doggie mayhem, all three (very hyperactive) boys did not get any of their anti-ADHD meds that afternoon, and by 6 PM they were overstimulated by the rampaging dogs and by their own untreated ADHD problems.  This proved to be a memorable evening in the Miller home as the out-of-control boys revved more and more up while the dogs were howling, barfing, defecating all over the living room, and passing out on the boys' beds. 

 

MORAL OF THE STORY:  Thoughtful pet owners may want to avoid being ADHD kids' parents unless they have a high tolerance for chaos.

 

GRANDMA BECOMES A CLEAN FREAK!  52 y/o Carrie H., considered by all her friends and family as THE worst living Pack Rat Slob in the most chaotic home this side of Lower Slobovia, finally consented to A.D.D. evaluation, basically dragged in by her 30ish daughter, Mary.  I prescribed Dexedrine 5 mg tabs, “1/2 tab QID” (4 times per day). This should have worked very well.

 

Four days later Mary and her children (5, 8, and a 2 y/o toddler) drove over to visit Grandma Carrie.  The older kids raced into the house while their mother extracted the toddler from her car seat.  Then they burst out the front door screaming “Grandma doesn't live here anymore!”  Mary actually could walk from room to room without tripping over 20 y/o piles of magazines, boxes of Tupperware, and bedrooms so full of old clothes she couldn't remember if the floors had rugs.  The house appeared ready to show in “House and Garden” magazine.  Grandma was found in the garage scrubbing shelves which had been piled with useless old junk since Medieval times, according to family legends.

 

Mary soon solved the mystery:  Her mother said she had been taking 2 Dexedrine tabs 4 times per day, “just like the doctor ordered.”  That is what the medication bottle instructions read, too, but Mary remembered I told her mother to take ½ tab 4 times per day.  The pharmacist goofed and left out the fraction, so ½ became 2.  Carrie had been taking 4 times  her prescribed dose of Dexedrine. 

 

MORAL OF THE STORY:  Let us all celebrate when some pharmacist errors are helpful, unlike the next case.

 

SARAH GOES OFF THE WALL!   An inattentive pharmacist at a very well-known “chain” drug store kind of, er, uh, Darn – inspected Sarah's prescription for the tranquilizer SEROQUEL, but somehow managed to grab the box containing the anti-depressant SERZONE from the shelf.   He filled the prescription bottle with 200 mg Serzone tabs, and then typed SEROQUEL on the label of the bottle.

 

Sarah was being treated for Bipolar Disorder, and Seroquel was her key anti – manic medication.  Like most anti-depressants, Serzone is well-known to trigger manic behaviors in Bipolar patients.  When Sarah's frantic mother called and told me Sarah was running up and down neighborhood streets naked and screaming she had to kill her baby, naturally I told her mother to give her more and more “Seroquel” while we tried to arrange for hospital care.  She followed my directions, neither of us knowing the actual medication being given was Serzone, which of course was aggravating the situation.

 

Many months later, after 2 months in a State Hospital and 3 months of Day Treatment, Sarah and her mother found the bottle of “Seroquel” Sarah had been taking prior to hospitalization while they were cleaning out a drawer.  NOW THEY NOTICED the pills in the bottle looked different from (real) Seroquel I had prescribed in the past, and the same meds she was taking now.  Sarah and her Mom brought this  bottle to my office show me, and even I could immediately see the bottle labeled “Seroquel” actually contained Serzone tabs.  AH HA!  So that was why Sarah flipped out six months ago, and got even worse when I told her Mom to give her more! 

 

It was pretty funny, at the Pharmacy Board hearing (like a trial) to listen to the pharmacy's attorney argue the error must have been because I wrote the prescription illegibly.  That was 'way back when drug companies freely provided doctors with preprinted prescription pads for standard drugs, with – on my demand – underlying copies I always stapled onto my progress notes.  So I opened the chart and showed the Board members the copy, which in large bold capital letters read SEROQUEL, and then had boxes to be checked for 25, 50, 100, 200, and 250 mg, with the 200 mg box clearly checked.  I gather the pharmacist and that drug chain were kind of severely penalized, and then there was the civil suit for damages like loss of consortium, and punitive damages, and then there was a settlement for $XXXXXX which I still think was less than Sarah deserved.

 

MORAL OF THE STORY:  If my pharmacist goofed up like that and I were the lunatic fat Nut Case running naked all around my neighborhood screaming insane stuff, I might even still feel somewhat embarrassed!  I might even still feel a sense of resentment!  However, of course, in my situation there would be a wife of some 37 or so (? who knows exactly, like, who remembers “anniversaries” more than once every 10 or 20 years?) sarcastically saying “Yeah, yeah, blame it on your doctor, blame it on your pharmacist, but you were the Fruitfly Brained dumb-dumb who chugged down pills which were obviously different from the pills in your last med bottle.” 

 

Some “wise” people might say:  “Better check and make sure you always get the right meds.”  But that is not necessarily a good idea in the current economic collapse.  If we all get everything right, what will attorneys do?  If they can't stay busy and make $$$$$$$$ suing doctors and pharmacies and drug companies, they will have too much time on their hands and have to invent other people to sue – like you.

 

PARENTS WORKING TOGETHER: Seemingly devoted, conscientious parents Donna and Wally enthusiastically agree with my recommendation to treat their 9 y/o son Ronnie for ADHD.  I prescribe Concerta, one 18 mg capsule in the AM for 1 week, then 2 in the AM the next week.  Nine days later I get a frantic call from Donna saying:  “He was up all night last night, picking at his face and arms and seeing snakes and monsters.  Totally psychotic!  He is having an awful med reaction!”  He is evidently sleeping now, so I tell his parents to wait until he wakes up and then bring him directly into my office.

 

Now, at 4 pm the day after the “reaction,” he looks and acts perfectly OK.  Both parents and Ronnie agree he was much improved with respect to all ADHD problems the past week, and Ronnie's teacher even called Donna to report he was much better at school.  Hmm – what could have gone so wrong?  Ah, ha:  The day he went psycho was the day he was supposed to be given two Concerta capsules in the morning instead of one!  But I thought that was odd, since Ronnie was a big, robust kid for age 9 – 95 pounds – and probably would need at least 54 mg for optimal benefit.

 

THEN, upon further review, new information was revealed when Ronnie piped up and said:  “Maybe I shouldn't have taken the pills Mom gave me that morning, since Dad gave me pills before he went to work, too.”  OOPS:  Dad gave him two caps of Concerta 18 mg that AM before he left for work, then Mom got up a bit later, and not knowing Dad already gave Ronnie his meds, she gave him two more. So he went from a dose of 18 mg for the past 7 days to a dose of 72 mg the day he went “psycho.”  He was unintentionally OD'd by his parents!

 

BUT IT GOT WEIRDER:  After Ronnie's parents finally simmered down and stopped screaming at each other, they united by blaming me and “this damned toxic medicine”  for Ronnie flipping out that evening.  They blamed me and the medication instead of recognizing they “kind of” created the problem by giving their child 2 X the prescribed dose that morning because they did not communicate and plan ahead and agree which parent would give Ronnie his pills.  So they stalked out of my office angrily, vowing never to see me again or give their child anything like this medicine again! 

 

BUT IT GOT STILL WEIRDER:  I felt pretty miserable.   I couldn't figure out how I failed to manage this mess better.  But a couple hours later one of my staff came back from an errand she left to do when these parents exited my office, and mentioned they had had a nasty argument she overheard in the Parking Lot, to wit:

MOM:  “You stupid !&%##! why did you lie and make me look like an idiot?”

DAD:  “Because you are an idiot, and, besides, this way we can blame him and he won't have the b---- to bill us for bad check we gave him our first visit.  See, he is gonna be afraid we will sue him, so he won't go after us for the $$$ we owe him.”

 

MORAL OF THE STORY:  Yes, indeed, perhaps sometimes your doctor really is an idiot, too, when he is this naive and actually believes everything parents tell him and does not suspect devious underlying agendas. 

 

This Dad basically did not care about his son's problems at that time.  He was looking for a way to avoid paying his bill.  I never imagined that was his plan from the start.  You see, these parents really had agreed Mom was always supposed to give Ronnie his medication.  This father actually intentionally  double-dosed his son.

 

I wonder how many “medication side effects” kids supposedly develop “psychotic reactions” to standard, routine doses of meds like Ritalin and Adderall occur because of accidental overdoses.  This case was really weird since a parent evidently planned to OD his son. 

 

BY FAR MORE OFTEN:  An overdose like this happens because a parent fails to communicate effectively with a baby sitter or child care facility or school, and the child is then given a second med dose – often because the child is too young to remember or report or communicate he/she already was given meds that AM, or because his/her report is dismissed as unreliable.  Naturally, snafus like this are inversely correlated with the child's age, I.E., more snafus occur with younger children.  And since adverse side effects (like Ronnie's) consistently affect younger children far more than older kids, this is one reason stimulant medications like Concerta or Ritalin or Adderall seem to periodically be “toxic.”  I HAVE SEEN – MAYBE – 3 PRESUMPTIVELY “PSYCHOTIC REACTIONS” TO STIMULANT MEDICATIONS IN 38 YEARS WHEN KIDS ARE GIVEN STANDARD, REASONABLE, DOSES.  All other reports have been found to reflect intentional or unintentional overdoses. 

 

+++ AND A FINAL OBSERVATION:  In 2 of these 3 cases, the child's mother had been diagnosed with Schizophrenia.  And in both these cases it was only the mother who reported “psychotic” symptoms in her child.  There was no corroborating, independent observer.  There are two or more possible interpretations:  1)  Mom may have been projecting  her own psychotic ideas and reporting these as her child's;  2)  Children who have an incipient, prodromal* psychotic condition like Schizophrenia via their genetic endowment from their mother may be prone to psychotic decompensation when given a medication (like a stimulant) which is known to have a propensity for precipitating psychotic symptoms in some Schizophrenic patients.

 

THIS IS ONE REASON WHY PSYCHIATRISTS ARE USUALLY SO EAGER TO EXPLORE NEW PATIENTS' FAMILY HISTORIES:  The genes may be the key to success or failure in treatment.

 

“Prodromal” is a technical psychiatric term which means there likely are subtle but significant developmental problems associated with  but not yet diagnostic of  a major neurobiological condition.  More about this later.

 

But what if the child is adopted?  Well, we now know from more than 25 years of careful research children usually are not “Apples who fall far from their genetic tree.”  Genes account for about 80% of almost all human attributes!  So now there is increased interest in exploring the psychiatric history of adopted children's parents.  But this effort almost always fails simply due to records and reports focusing nearly exclusively on an adopted child's mother's history only.   Uh, hey, did the kid just pop up in a biological mother's womb by mystical insemination?   Probably not.  Every so often there is some sort of (maybe) reliable information that bio Dad had a “drug problem.” 

 

Now, since young men who recklessly inseminate young women typically include perfectly normal but foolish kids, and kids who have impulsive sexual relations in part due to having ADHD, and all sorts of older teens and young men who have Bipolar Disorder, and various other problems.  AND since developing a “drug problem” is a common outcome in untreated or inadequately treated boys who have all of these problems, “Dad had a drug problem” does not convey useful information which contributes to diagnosis of his child.