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Stagg737

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So I had a patient a week or 2 ago who I diagnosed with ADHD and started on a stimulant medication. While going over the medication I gave my usual spiel about not taking the medication during periods when he was off work for periods when he did not need medication to complete important tasks. When I brought this up, he said that his child had also recently been started on stimulants for ADHD but that the child psychiatrist had told him that they needed to take the medication consistently and that the child should not take drug holidays. Both in med school and residency I have worked with quite a few child psychiatrists from different programs and I have never heard anyone emphasized the importance of taking a stimulant every single day like with other medications.

There is anyone know where this idea has come from or is there any data on this? I did some preliminary searches but was unable to find anything and the few attendings I asked had not heard this either. I would be particularly interested if any of the child psychiatrists have heard of this or make this recommendation, but any insight is appreciated.
 

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Drug holidays are optional. In kids we want to give them a break so the appetite and growth are not suppressed as much, which usually is not a concern in adults. Sometimes behavioral problems related ADHD are so severe I'll recommend a patient stay on the stimulant every day, because the risks of damage to relationships and social and occupational functioning is so high. Many times kids with ADHD are abused by parents angered by ADHD symptoms, which is worse than any growth suppressive effects.
 
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Stagg737

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I'm fully aware of the benefits of drug holidays, I was asking about the other side that a child should NOT take drug holidays and needed to take the medication consistently, every day, including weekends. My patient had been told this by a child psychiatrist and was wondering if anyone had evidence or even solid theories regarding why NOT taking drug holidays would be recommended in most children. Apparently this psychiatrist was pretty adamant that drug holidays were bad, but I hadn't heard this before.

Drug holidays are optional. In kids we want to give them a break so the appetite and growth are not suppressed as much, which usually is not a concern in adults. Sometimes behavioral problems related ADHD are so severe I'll recommend a patient stay on the stimulant every day, because the risks of damage to relationships and social and occupational functioning is so high. Many times kids with ADHD are abused by parents angered by ADHD symptoms, which is worse than any growth suppressive effects.

I could certainly see that, but this isn't a recommendation we'd make for every child which seemed to be what the patient was told. I'm more curious about general reasons or evidence against drug holidays. Only thing I can theorize is that taking it consistently over years could play a role in synaptic pathways during development, but I honestly don't know how significant that would be or if there'd be a difference between kids taking the meds every day or those taking drug holidays.
 

WisNeuro

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I'm fully aware of the benefits of drug holidays, I was asking about the other side that a child should NOT take drug holidays and needed to take the medication consistently, every day, including weekends. My patient had been told this by a child psychiatrist and was wondering if anyone had evidence or even solid theories regarding why NOT taking drug holidays would be recommended in most children. Apparently this psychiatrist was pretty adamant that drug holidays were bad, but I hadn't heard this before.

Alan Ravitz is one of those who recommends against drug holidays, something about needing to control the adhd in all areas, not just academic. But, whenever I've seen articles that quoted him or interviews, I've never seen any research cited that backs up his point. Not saying it doesn't exist, just that I've never seen it.
 
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Candidate2017

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My guess: they are treating the child's hyperactivity in addition to attention. Being out of school doesn't mean their inattention and hyperactivity doesn't need to be controlled at home. Adults, however, can outgrow or regulate hyperactivity and may not need stimulants outside the work setting.

There could also be concern that drug holidays in children will condition them to use stimulants as a performance enhancing drug, as well as diversion, which we often see in college kids. I don't want to have a new eval 20 y.o. college student say, "I'd like to have my stimulants refilled. I have an established diagnosis of ADHD from my child psych and my UDS is negative because they said it's ok to use it PRN."
 
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Tl;dr: if abrupt holiday from extended release were to feel as ****ty for my kid as it does for me for the first 1-2 days, I would not want to give her a holiday unless i could taper down and we had more than a 2 day weekend. Would have even more reservations for abrupt holiday for kid with mood/irritability concern. Would a half dose for weekends be better consideration? Not a MD; thoughts based on experience as psychologist with ADHD who has a kid and works with a lot of kids who have ADHD.

Long version: in thinking about this question, how much does it matter whether it is extended release or not, and dosage, and/or concurrent mood disorder/irritability? Anecdata, I know, but I know a few folks- including myself- who take extended release and when they take holidays the first two days are just ****ty- tired, sluggish, kinda depressed, irritable- moreso than pre-med baseline or how they/I feel at the end of a holiday week. If that irritable/tired withdrawal were to be the expected same experience for, say, my own kid (meds are likely a road we will have go to down eventually), I don't know that (barring obvious appetite concerns) I'd want her to have a total holiday each 2-day weekend because it might be like a yoyo with no actually enjoyable "normal" weekend days & engagement in play and less structured time on the weekends is critical when kids get so little of it in school. Also have to consider individual's ability to engage in ADLs at home/ability to be independent and get things done (and not have considerable impulsivity/behavior problems) without constant oversight from patient parents who can't give it on the weekends.

Personally I've found half dose on weekends and tapering off on holidays when I have 4 or more days off of work to be much more palatable with respect to mood/functioning/energy/my partner's tolerance. I wonder if this would be a reasonable approach for kids- especially maybe kids that already have trouble with mood/irritability - and how the differences of abruptly discontinuing extended versus immediate release might come into play.
 
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I'm a 2nd yr child psych fellow, and I can't think of a single attending or fellow here who would recommend drug holidays. I think drug holidays are a pretty old school theory. I have heard big names in the field including Stahl, Bierderman, Wilens, Spencer, etc say they no longer recommend it.

ADHD affects one's brain every day cognitively and socially, including things like engaging with others appropriately and paying attention to and using social cues; on the weekends kids may be attending sporting events or birthday parties where having increased impulsivity, poor attention, or hyperactivity may be problematic. Teens may be driving more on the weekends and more likely to get into accidents. Plus I feel like noticing your brain works differently on a day to day basis would be somewhat disconcerting. Most kids who are reasonable reporters do notice a difference on the days they forget to take meds, and parents and others around them definitely notice. Occasionally over the summer there may be a reason for a dose reduction if the pt is not gaining weight or growing appropriately, or the demands are minimal.

For adults, I would feel slightly more comfortable with drug holidays, as they are more reliable reporters of the effects and presumably have more self-awareness and impulse control at baseline. Potentially there could be a dose sparing effect, but I also don't generally see a problem with higher doses.

Also don't forget that even long acting stimulants (except Mydayis) only last a max of 12 hrs anyway, so you are getting a drug holiday every night. :)
 
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Also don't forget that even long acting stimulants (except Mydayis) only last a max of 12 hrs anyway, so you are getting a drug holiday every night. :)
Good point. I sometimes recommend for parents where appetite is a concern that they just make sure to give their kid a snack before bed since their appetite is prob improved then, or leave a small snack like a pack of crackers or something by their bed if they tend to wake up hungry in the night. Also good point about the impulsivity of teens and driving....
 

Stagg737

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I'm a 2nd yr child psych fellow, and I can't think of a single attending or fellow here who would recommend drug holidays. I think drug holidays are a pretty old school theory. I have heard big names in the field including Stahl, Bierderman, Wilens, Spencer, etc say they no longer recommend it.

ADHD affects one's brain every day cognitively and socially, including things like engaging with others appropriately and paying attention to and using social cues; on the weekends kids may be attending sporting events or birthday parties where having increased impulsivity, poor attention, or hyperactivity may be problematic. Teens may be driving more on the weekends and more likely to get into accidents. Plus I feel like noticing your brain works differently on a day to day basis would be somewhat disconcerting. Most kids who are reasonable reporters do notice a difference on the days they forget to take meds, and parents and others around them definitely notice. Occasionally over the summer there may be a reason for a dose reduction if the pt is not gaining weight or growing appropriately, or the demands are minimal.

For adults, I would feel slightly more comfortable with drug holidays, as they are more reliable reporters of the effects and presumably have more self-awareness and impulse control at baseline. Potentially there could be a dose sparing effect, but I also don't generally see a problem with higher doses.

Also don't forget that even long acting stimulants (except Mydayis) only last a max of 12 hrs anyway, so you are getting a drug holiday every night. :)

Interesting, as most of the CAP attendings I've met still suggest drug holidays. I can understand what you're getting at, and I don't disagree that for those who have significant symptoms for ADHD taking them regularly may be a necessity. What about those with relatively mild inattentive type though? Would you still recommend daily use?

I guess I'm more curious if there's any actual data supporting consistent daily use over drug holidays. I can see the benefits to either one depending on the patient, I've just always found stimulant dosing to be interesting which is probably part of what initially drew me to child psych.
 

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Interesting, as most of the CAP attendings I've met still suggest drug holidays. I can understand what you're getting at, and I don't disagree that for those who have significant symptoms for ADHD taking them regularly may be a necessity. What about those with relatively mild inattentive type though? Would you still recommend daily use?

I guess I'm more curious if there's any actual data supporting consistent daily use over drug holidays. I can see the benefits to either one depending on the patient, I've just always found stimulant dosing to be interesting which is probably part of what initially drew me to child psych.

I also do not know any CAP who suggest drug holidays. The only evidence for holidays is to increase weight in those who are clearly lowered by the stimulant, research above and others suggest it is effective for that. It's not a huge deal if dosages are missed, which is certainly an advantage of stimulants, but clearly taking stimulants over time for children with ADHD improves a plethora of outcomes (if only such data existed for our other interventions), and without any benefit other then wt gain, I cannot see why this would be routinely recommended. Feels like something I hear from older pediatricians, not from CAP.

As above, each person is taking a stimulant holiday every night, and there is no evidence to suggest these medications become less effective over time. Similar to how cocaine abusers still get high in their elderly years despite a lifetime of using.
 
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I'm no expert on this but, from what I remember, studies say that people with ADHD that take stimulant drugs do better than controls for 14 months, then do much worse. The longer they stay on them after 14 months, the worse. This means they should be used when really needed, for example in the final high school year, during college exam sessions, etc.

This is of course a no-brainer for anyone that has used simulants recreationally. They aren't the type of drug that you can take every day and somehow magically end up being better than before after 5 years of usage.... Long term studies only confirm what any 14 year old kid with a bit of brain and curiosity for drugs already intuitively knows.

When it comes to drugs, there is a big difference between short term and long term effects for pretty much any drug out there. That's why long term studies are very important. If someone wants to take X drug every day for 5 years, 1-month studies are irrelevant for that kind of situation.
 
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I'm no expert on this but, from what I remember, studies say that people with ADHD that take stimulant drugs do better than controls for 14 months, then do much worse. The longer they stay on them after 14 months, the worse.
Do you have a source for this worsening in the long term?
 
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I don't treat kids, but does nobody else notice that many adults will report a slow escalation over time? Maybe 5 mg/d worked in HS, they bumped it up to 10 mg/d in college, by their mid 20s they're at 20 mg/d and by mid 30s 40 mg/d? If nothing else I usually suggest drug holidays for mitigation of tolerance effects.
 

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I don't treat kids, but does nobody else notice that many adults will report a slow escalation over time? Maybe 5 mg/d worked in HS, they bumped it up to 10 mg/d in college, by their mid 20s they're at 20 mg/d and by mid 30s 40 mg/d? If nothing else I usually suggest drug holidays for mitigation of tolerance effects.

I would buy a story that involves tolerance, but you have the major confound of this directly mirroring the typical progession in amount and kinds of responsibilities adults go through. In a sense to the extent that ADHD is sensitive to task demands this is exactly what you'd expect to happen.
 
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I don't treat kids, but does nobody else notice that many adults will report a slow escalation over time? Maybe 5 mg/d worked in HS, they bumped it up to 10 mg/d in college, by their mid 20s they're at 20 mg/d and by mid 30s 40 mg/d? If nothing else I usually suggest drug holidays for mitigation of tolerance effects.

The dopamine system does not have the same tolerance issues, particularly when the medicine is on board for 4-12 hours and off the rest everyday. This has been well studied in CAP and there is not evidence of tolerance when taking as prescribed. My understanding of the cocaine literature is that a line of cocaine taken every 24 hours will still get you high every time in stark contrast to substances like LSD, EtOH, or THC with varying degrees of tolerance that grows from daily use.
 
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I would buy a story that involves tolerance, but you have the major confound of this directly mirroring the typical progession in amount and kinds of responsibilities adults go through. In a sense to the extent that ADHD is sensitive to task demands this is exactly what you'd expect to happen.

Ok, except that after they've been off it for a year (e.g., to have a baby), all of a sudden 5 mg/d works great again.
 
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So I had a patient a week or 2 ago who I diagnosed with ADHD and started on a stimulant medication. While going over the medication I gave my usual spiel about not taking the medication during periods when he was off work for periods when he did not need medication to complete important tasks. When I brought this up, he said that his child had also recently been started on stimulants for ADHD but that the child psychiatrist had told him that they needed to take the medication consistently and that the child should not take drug holidays. Both in med school and residency I have worked with quite a few child psychiatrists from different programs and I have never heard anyone emphasized the importance of taking a stimulant every single day like with other medications.

There is anyone know where this idea has come from or is there any data on this? I did some preliminary searches but was unable to find anything and the few attendings I asked had not heard this either. I would be particularly interested if any of the child psychiatrists have heard of this or make this recommendation, but any insight is appreciated.

As someone with ADHD dx as an adolescent, I was often told to take drug goodies. However, when I was about 25, my therapist mentioned to me that it may be helpful to take it on the weekends to help with productivity and to keep my sleep on track. My psychiatrist basically said “idc what you do.” He was a mess in general 😑

Anyway, I couldn’t find much in the research around this and if it was necessary, especially for adults. However, we do know adhd impacts people in every areas... work, driving, planning, cleaning, cooking, paying bills, sitting through a movie, social interactions, emotional regulation, etc. therefore, it would certainly make sense that people would want to continue taking stimulant medication on the weekends. For me and others I work with, weekend tasks like cleaning a kitchen, meal prepping, listening to my friends boring story 😜, etc are drastically more successful with stimulants. Stimulants obviously don’t cure it, but they help. Just because people aren’t working doesn’t mean that their quality is life isn’t drastically improved with the medication. Many tasks outside of work are impaired by adhd. Obviously, some people may not need meds everyday. I just haven’t found anything to support not taking it daily if the patient wants to
 
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