CPAN Case of the Month – July 2025

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Each month, PCPs call CPAN with a wide variety of mental health questions. Find out how CPAN helped a PCP during this consultation.

Psychiatrist: Haley Walker, MD   

Consult: An 8-year-old male with a new diagnosis of ADHD started Focalin XR 10 mg. Immediately, the patient and family noticed he was more irritable, not hungry, and listless. In the afternoons, he would melt down with crying and covering his ears. He complained to his family that he heard voices commenting on his actions and occasionally commanding him to hit his dog or throw things. He denies acting on the thoughts. The family stopped the medication and called the PCP.    

Learning Points/Recommendations: Stimulant medication has been associated with the emergence of psychotic symptoms in children, with incidence estimated at about 1/400 in the first several months of starting stimulant, even at therapeutic doses, although this is more often observed with amphetamine derivatives. Atomoxetine also has associations with new-onset mania and psychotic symptoms, even though there is a different mechanism of action. It is thought that a family history of either bipolar or psychotic disorders may have a weak association. There is some evidence that individuals with ADHD during childhood may have an increased risk of developing a psychotic illness later in life.  

The family can expect that the symptoms should resolve within days of discontinuation; however, recovery may be incomplete.  

For ADHD treatment, the PCP and family can consider using alpha agonists, starting at a low dosage and monitoring for efficacy and side effects. If ineffective, a trial of atomoxetine may be considered, with the same advice to start at the lowest dosage and closely monitor. A later trial with a methylphenidate agent that is short acting and low dosage could be considered if the ADHD symptoms remain functionally impairing. 

Follow-up by the PCP one week later indicated that all psychotic symptoms had been resolved.