Management Approach for Adolescent with Panic, ARFID, Sensory Overload, and Possible ADHD

Your Current Plan Is Appropriate—With Critical Modifications Needed

Your decision to increase sertraline and shift it to morning dosing is correct, but you must address the orthostatic hypotension before considering guanfacine, and you need a more aggressive approach to the ARFID and sensory symptoms. 1, 2

Immediate Priorities: Stabilize Medical Status First

Address Orthostatic Symptoms and Nutritional Deficiencies

The lightheadedness when standing is likely multifactorial—dehydration from restrictive eating, possible nutritional deficiencies, and sertraline's cardiovascular effects 3
Order comprehensive labs: CBC, CMP, magnesium, phosphorus, thiamine, vitamin D, iron studies, and TSH to rule out nutritional deficiencies contributing to fatigue and orthostasis 1
Do not start guanfacine until orthostatic symptoms resolve—alpha-2 agonists like guanfacine lower blood pressure and heart rate, which would worsen her lightheadedness 1, 2
Push aggressive oral hydration (aim for 2-3 liters daily) and consider oral rehydration solutions with electrolytes 1
Dietitian consult is essential—ARFID requires specialized nutritional rehabilitation, not just general dietary advice 1

Optimize Sertraline for Panic and Anxiety

Dosing Strategy

Moving sertraline to morning is correct—this addresses the sleep dysregulation and may reduce daytime sedation 3
Current dose is likely subtherapeutic for panic disorder—sertraline is effective for panic at 50-175 mg daily 4, 5
Titrate sertraline by 25-50 mg every 1-2 weeks until panic symptoms resolve or you reach 150-200 mg daily 3, 5
Monitor for activation/increased anxiety during the first 2-4 weeks, which is common when treating panic disorder with SSRIs 3, 4

Hydroxyzine Use

Hydroxyzine PRN is appropriate short-term but has limited evidence for GAD and causes sedation that may worsen her fatigue 6
As sertraline dose increases, attempt to wean hydroxyzine to avoid reinforcing avoidance behaviors 6
If anxiety remains at 7/10 after optimizing sertraline, increase the standing SSRI dose rather than relying on PRN sedating medications 1

Addressing the ADHD Question

When to Consider Stimulants

Do not start stimulants until:
1. Panic symptoms are controlled (sertraline optimized for 6-8 weeks) 1, 2
2. Orthostatic symptoms resolve 1, 2
3. Psychology evaluation confirms ADHD diagnosis 7
4. Nutritional status stabilizes 1
The "burnout after school" pattern strongly suggests ADHD with executive function deficits leading to compensatory masking at school, followed by collapse at home 7, 1
High achievement at school does not rule out ADHD—many adolescents, particularly females, mask symptoms in structured settings 7
Family history (father with severe ADHD, brother with ASD) increases her risk substantially 7

Stimulant Selection When Ready

If ADHD is confirmed, start with long-acting methylphenidate (Concerta 18 mg) or lisdexamfetamine (Vyvanse 20 mg) rather than guanfacine as first-line 1, 2
Stimulants have 70-80% response rates with effect sizes of 1.0, compared to guanfacine's effect size of 0.7 1, 2, 8
Guanfacine is second-line for ADHD—reserve it for adjunctive therapy if stimulants alone are insufficient, or if tics/severe sleep disturbance emerge 1, 2
Monitor blood pressure and pulse at every visit once stimulants are started 1, 2

Addressing Sensory Overload and ARFID

These Are Not Separate Problems—They're Interconnected

Sensory dysregulation, ARFID, and panic attacks form a cluster that may represent undiagnosed autism spectrum traits, severe anxiety, or both 7, 9, 10
The emetophobia shared with her sister suggests learned/familial anxiety patterns that require family-based intervention 7
Occupational therapy evaluation for sensory processing disorder is essential—pharmacology alone will not address sensory-based food avoidance 7

ARFID-Specific Interventions

ARFID requires specialized eating disorder treatment, not standard anxiety management 1
Refer to eating disorder program or therapist with ARFID expertise—cognitive-behavioral therapy for ARFID (CBT-AR) is evidence-based 1
SSRIs have limited evidence for core ARFID symptoms but may help comorbid anxiety that maintains food avoidance 10
Family-based treatment is critical—parents need coaching on how to support exposure to new foods without reinforcing avoidance 7

Sleep Dysregulation Management

Behavioral Sleep Interventions First

The excessive sleep is likely avoidance-related rather than primary hypersomnia, given the pattern of sleeping in when not required to attend school 7
Establish consistent sleep-wake schedule (same bedtime/wake time 7 days/week) regardless of school attendance 1
Morning light exposure (30 minutes within 1 hour of waking) to regulate circadian rhythm 2
Moving sertraline to morning should reduce sleep interference 3

When to Consider Additional Sleep Interventions

If sleep dysregulation persists after 6-8 weeks of optimized sertraline and behavioral interventions, consider low-dose melatonin (0.5-3 mg) 1-2 hours before target bedtime 1
Do not add sedating medications (trazodone, mirtazapine) until ADHD evaluation is complete—these may worsen daytime fatigue and executive dysfunction 1

School Avoidance and Functional Impairment

This Requires Immediate Multimodal Intervention

School avoidance is a psychiatric emergency—the longer it persists, the harder it is to reverse 7
Coordinate with school for 504 plan or IEP accommodations: sensory breaks, modified lunch environment, PE alternatives 7
Gradual return-to-school plan with therapist support—start with partial days if needed, but maintain daily attendance 7
Family therapy to address parental accommodation of avoidance behaviors 7

Monitoring Suicidal Ideation

Critical Safety Parameters

Intermittent suicidal thoughts require systematic monitoring at every visit 3
Use standardized screening (PHQ-9 or Columbia-Suicide Severity Rating Scale) at each appointment 7, 3
Educate family on warning signs: increased isolation, giving away possessions, sudden mood improvement after prolonged depression 3
SSRIs carry black box warning for increased suicidal ideation in adolescents—monitor closely during first 12 weeks and after dose changes 3

Timeline and Sequencing

Next 2-4 Weeks

Increase sertraline to 100 mg daily (morning dosing) 3, 5
Complete lab workup for nutritional deficiencies 1
Initiate dietitian and occupational therapy referrals 7, 1
Establish consistent sleep-wake schedule 1

Weeks 4-8

Titrate sertraline to 150 mg if panic symptoms persist 5
Psychology evaluation for ADHD completed 7
Begin gradual school reintegration plan 7
Reassess orthostatic symptoms—if resolved, can consider ADHD medication 1, 2

Weeks 8-12

If ADHD confirmed and panic controlled, initiate long-acting stimulant 1, 2
Continue ARFID-specific therapy 1
Wean hydroxyzine as standing sertraline dose optimized 6

Common Pitfalls to Avoid

Do not start guanfacine before addressing orthostatic hypotension—you will worsen her symptoms 1, 2
Do not assume sertraline will treat ADHD—no single antidepressant effectively treats both conditions 1
Do not delay ARFID-specific treatment—this is a medical emergency requiring specialized intervention, not just anxiety management 1
Do not prescribe stimulants before panic is controlled—stimulants can worsen anxiety and panic in the acute phase 1, 2
Do not underestimate the role of family dynamics—with multiple affected family members, family-based interventions are essential 7, 9

Help us tailor your experience