CPAN Case of the Month – February 2025
Each month, PCPs call CPAN with a wide variety of mental health questions. Find out how CPAN helped a PCP during this consultation.
Patient: 8-year-old
Reason for CPAN Consultation: Support with clarity of diagnosis and treatment
Explanation of the Case and Outcome of the Call:
A recently adopted 8-year-old youth with ADHD was struggling to sleep. They were on Focalin XR, Clonidine, Guanfacine and Trileptal without a clear history of mood symptoms. They had two siblings, and the adopted parents had no parenting experience. A request to simplify their treatment regime while addressing sleep was a major focus for the parents.
Learning Points:
The major focus for the consultation was to allow for a recognition of the totality of a patient’s experience prior to immediately addressing a specific question. Recently adopted, with no available past medical history warrants some caution in making changes. Therapy to help with the transition for both the youth and their parents would be important. Psychosocial stressors are a significant reason for insomnia. Behavioral interventions to allow for the youth to feel secure in their new environs will be critical. Making one change at a time with clear goals and monitoring the outcome can help avoid unwarranted polypharmacy.
Beyond the recommended therapy and behavioral sleep intervention, the first step was to maximize Clonidine for sleep. Next step, taken several days after the increase in Clonidine (if successful), would be a slow taper off the Trileptal. While there were no current signs of mood symptoms, this could change with the taper. Close monitoring for behavioral changes and one- medication change at a time is the most prudent course. Our CPAN team helped locate therapy options and the search for a child and adolescent psychiatrist to provide ongoing care in collaboration with the pediatrician.
Rule of thumb: When trying to de-prescribe, gathering as much information as possible to identify the purpose of medications is a vital step. In this case, while there were challenges in a few areas, the primary identified diagnosis was ADHD. Given that information, the challenge became best way to manage ADHD, and Trileptal became an easy target to wean given the lack of data supporting it’s use in ADHD and the lack of benefit noted in the patient.