Optimal Management of ADHD - Episode 11

Addressing Drug Holidays for ADHD Medication

March 19, 2021
Andrew J. Cutler, MD, SUNY Upstate Medical University

,
Rakesh Jain, MD, MPH, Texas Tech University School of Medicine

Rakesh Jain, MD, MPH, shares his thoughts on whether drug holidays are appropriate for children taking medication for ADHD.

Rakesh Jain, MD, MPH: Very often, parents approach me, or sometimes even patients approach me and say, “What do you think about drug holidays?” You have to ask them, “Are you wanting to take your drug to a holiday? What exactly do you mean?” Of course, I’m teasing them. What they mean by that is taking a break from their medications.

Perhaps you know, in years gone by that used to be recommended by many clinicians, until we realized that was not a good recommendation. If you think about it, if ADHD [attention-deficit/hyperactivity disorder] is a newer psychiatric disorder, which we know it is. If it is a disorder that causes impairment in every aspect of human life, which it does, then why would you want to take a holiday from covering those symptoms, particularly younger individuals who are shaping their lives on a daily basis? You would not.

Therefore, the conversation in the field has changed quite a bit to walking away from drug holidays. But instead of telling people, “Bad idea; don’t do it,” it is so much wiser to understand what their motivation is. Did they hear that from their neighbor? Is the medication causing adverse effects? Is there another issue? Is it cost, perhaps? Maybe they’re trying to minimize how many pills they’re taking per month? The only way to find out is to find out. Once I do, then I can educate them. If they’re afraid of growth suppression, which many parents are, I sympathize with them. Then I show them if their child was in the 45th percentile and is still at the 45th percentile, there’s no challenge. But if there is, then I would agree with them and look for another treatment option. I might offer to switch them to a nonstimulant. What if the patient is reporting rebound symptoms? I can work with them to address that so they can overcome their challenges without resorting to a drug holiday. 

In summation, what I would say is the following: A request for a drug holiday is very common. No. 2, I always try to approach it with respect and sympathy and curiosity. Why? What is your belief system about drug holidays, and why are you requesting 1? The final step I take is I offer psychoeducation and, if appropriate, a medication switch. I will almost always find a way to meet the patient in the middle in such a way that while they feel listened to, I’m still able to make sure they get as near a continuous coverage of symptoms as possible.

During these very challenging COVID-19 times, many parents wonder, “Is this a good time to take a drug holiday?” I have often said to them, “If there was a worse time than now, I have never met that time.” I tell them, “No, it just doesn’t make any sense. You are now the teacher. The child doesn’t even have the advantage of being in front of their teachers and with their peers to help some with organization. This is the worst time, in many ways, to think about a drug holiday.” 

One more time, I would urge every colleague online to appreciate the following: If a parent is asking for a drug holiday, it may be a very good idea to explore why. There may be other reasons. There may be a spouse with a difference of opinion. It may be the child is having insomnia and the parent is noticing it, or there’s irritability. Those are fixable problems. But a drug holiday solves nothing. Often, it compounds the difficulties the child and the family are having. So I would not support drug holidays, but I will very respectfully explore why the conversation is being brought up and do my best to address it.

Remote schooling is common in Texas, as I suspect it is in very many places. That places a tremendous burden on the child, or the adolescent, as well as the family. It is psychologically distressing. Exercise is reduced. The weather doesn’t always cooperate in letting kids run around to get physical exercise. There are a whole bunch of challenges. If there ever was a time where 100% adherence to pharmacotherapy for ADHD was a necessity, this is it, folks. 

I do have to work with my parents, who themselves might have ADHD. If you recall, this is 1 of the most common inheritable conditions. I have to make sure that we create a system of reminders. Sure, you’re starting school at 10 o’clock now because it’s home based. That doesn’t mean we change the time the medication has been taken previously—7:30 or 8 AM. Two or 3 hours later could be a small but important thing to consider. 

We should be frowning upon drug holidays and asking our parents to reconsider if they’re requesting 1. I may even have to adjust medications. I may have to switch medications. That’s all OK, as long as I remember the final goal, which is to help the child not fall behind academically and help the child not fall behind emotionally in terms of confidence and self-respect. By whatever means necessary in these times of crisis, we should employ every tool we have. If not now, we might have to ask ourselves when we will bring our A game to the table.

Transcript Edited for Clarity


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