Dr Chepke Discusses Next Steps in Complex ADHD Case

In this video, Psych Congress Steering Committee Member Craig Chepke, MD, FAPA, Medical Director, Excel Psychiatric Associates, Huntersville, NC, discusses how he treated a case of pediatric ADHD with an atypical antipsychotic.

Read the Transcript:

Craig Chepke:  Hi. My name's Dr. Craig Chepke. I'm a psychiatrist in Charlotte, North Carolina. I have a private practice and also some academic affiliations. I'm also on the steering committee for Psych Congress.

Thanks so much for reading my case on how to treat pediatric ADHD and for taking the questions. I'm excited to tell you about what actually I did with the case.

If you remember, Becky was a 14-year-old girl who started to see me a couple years ago. There was a little bit of trouble getting her stabilized. Things would get better. Things would get worse. As you remember, it culminated in not such a great situation.

I put down a couple choices and I'm curious to see what you thought. I think a lot of those could be potential options that we could have taken, but the one I actually took was starting an atypical antipsychotic.

It might not have been everybody's first choice, but let me tell you why. What I realized when this event happened is I was struck by the cyclicity of her illness. It came and went, no matter what we did with the stimulants, with the antidepressants. It was chronic. There was these comorbidities that she had.

I was reminded...what I had known from the day that I met her that her biological mother has bipolar disorder amongst substance use disorder and ADHD. I realized that cyclicity fit perfectly with bipolar disorder.

She would have these projects that she would have that she would get hyper focused on. It wasn't a hyper focus of ADHD. That was her goal directed activity from mania. She would have periods of decreased need for sleep. The aggression. She had all the symptoms that we would think about it, but it was disguised.

She had been diagnosed with the other conditions by previous child psychiatrists and I hadn't taken the time to reconsider the diagnosis. I reconsidered the meds, but I didn't stop to think until then, "Hey, am I barking up the wrong tree?"

I started off trying to see if she would go with a mood stabilizer treatment. She was not having any part with that. That's why I went with the atypical antipsychotic that's approved in the adolescent age bracket for bipolar one.

It worked really beautifully for her. It completely changed her. She was like a different person. She had to change schools several times prior to that because of some of the fallout from the mania. Obviously, the relationship with her mother had been really damaging and tearing the family apart.

After starting this medication, she calmed down. Her moods stabilized, evened out. The relationship with her mother now is no worse than any average teenage girl's relationship with her mother. She's built better bridges with her sister, with her father, and school's going wonderfully for her.

She has more friends than she's ever had. It's turned out very well. She has, fortunately, been able to get into and engage in a little bit of family therapy. That's certainly also helped, as well. That's something that she had never been able to get into before. She needed the right medication stabilization to be able to participate in therapy is what I realized after the fact.

She still, I do believe, does have ADHD. She continues on a stimulant, but at low dose and has done very well.

Overall, my message here is that whenever you're dealing with adolescents, especially, always reconsider your diagnosis. Constantly reconsider what your assumptions are and challenge those. Go back and think, "Am I going in the right direction diagnostically?"

That's important with any patient, adult or adolescent, but in adolescents when things are changing so quickly and there's so much unknown, then that's especially crucial to think, "Am I even going in the right direction at all?"

I want to thank you very much for taking your time to participate in this case. Have a good day.