PsychEd4Peds: child mental health podcast for pediatric clinicians

33. Advanced Q+A about Meds for ADHD, Anxiety with Dr. Jeffrey Strawn

• Elise Fallucco • Season 2 • Episode 33

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It's time for some Advanced Q+A with Dr. Jeffrey Strawn about medication treatment for ADHD +/- Anxiety!

?Q:? When do you use alpha agonists (like Clonidine, Guanfacine)??
A:  as adjunctive treatment for kids who are having trouble tolerating stimulants,  and/or who have residual impulsivity when they're being treated with stimulants. 

Q: How can you prescribe alpha-agonists to kids who cannot swallow pills?
A: We've talked about the possibility of using compounding pharmacies to help create liquid formulations of certain short acting alpha agonists for kids who have trouble swallowing pills.

Q: When/ would you *start* treatment for ADHD with an alpha-agonist?
A: Almost Never.  Start with stimulant medication when you're considering medication treatment for ADHD, regardless of how old the child is.   So for preschool aged children with ADHD for whom you're considering medication treatment, start with stimulant medication as opposed to non-stimulant medication. 

Side note: Atomoxetine or Straterra is not as effective as first-line treatments for ADHD, nor is it as effective as our first-line treatments for anxiety.

And finally we covered the amazing resource of Case Studies: Stahl's Essential Psychopharmacology: Volume 4: Children and Adolescents by Jeffrey R. Strawn and Stephen M. Stahl | Nov 9, 2023 available on Amazon and through Cambridge University Press

Check out our website PsychEd4Peds.com for more resources.
Follow us on Instagram @psyched4peds

Dr. Elise Fallucco:

Welcome back to PsychEd4Peds. I'm your host, Dr. Elise Fallucco. Child psychiatrist and mom. So we are continuing the conversation with Dr. Jeffrey Strawn about medication treatment for ADHD and anxiety. We hope you've enjoyed part one and part two of this series in the previous two episodes. And now we're wrapping up ADHD with anxiety, with an advanced, rapid fire Q and a. And before we close, we're going to share an amazing clinical resource hot off the press to help us, as we treat kids with ADHD, anxiety, and even all sorts of other child mental health problems.. So thanks for tuning in. And here we go. You mentioned before that the times where we would consider using non stimulants for kids with ADHD plus or minus anxiety are largely when they've not been able to tolerate stimulant medication. Then you would think about medications like Viloxazine or less preferentially atomoxetine or potentially the alpha 2 agonists. Let's say you have a kid who's not tolerated trials of multiple different stimulants. And you have a choice between an alpha 2 agonist like guanfacine extended release or viloxazine. How do you think through which direction to go?

Dr. Jeffrey Strawn:

So for me, in many of those situations, particularly if I have a lot of impulsivity symptoms related to the ADHD, I'm often thinking about an alpha 2 and specifically there is, as we talked about earlier I'm really going to guanfacine extended release. I think the other issue is, let's go back to that patient, maybe with ADHD and some anxiety symptoms who's treated with a stimulant. I may use the Alpha 2 agonist adjunctively in that patient as well. And certainly we know patients with anxiety disorders may be more likely to experience side effects. And this is where I think the literature is really interesting when we look at these combination treatments of the Alpha 2 plus the stimulant. What we see is that in many of those studies, the kids that are in the combination treatment actually have fewer side effects than do the kids who are in the stimulant monotherapy or the alpha 2 agonist monotherapy. And so really what you're looking at is probably a cancelling of the side effects or it's really a peanut butter and jelly, or if you're a Reese's fan, maybe a peanut butter and chocolate type of combination.

Dr. Elise Fallucco:

Delicious. Yes. so instead of abandoning the stimulant medication, you would think first, especially if a child has high problems with impulsivity of, using an alpha 2 agonist as adjunctive I do the same thing I try not to abandon the stimulants and maybe to the frustration of some of the families that I take care of, because. I really try to give them a try of the methylphenidate and then an amphetamine salt. And even sometimes I'll go back as a third one and talk about dexmethylphenidate, some of the focalin preparations, cause they tend to be a little bit better tolerated. and I'll try those three permutations before I'll consider abandoning stimulants. And going to something like, a norepinephrine reuptake inhibitor, like Viloxazine. And of course, when we're in the stimulants adding an alpha agonist to improve tolerability to do the peanut butter and jelly or the peanut butter and chocolate, which sounds delicious too The other thing when I'm talking to families about the NRIs, norepinephrine reactive inhibitors, at this point in the game, they've tried other medicines that haven't worked and it's hard psychologically to tell them it may take a couple of weeks until we see an effect. It's not like the stimulants where we know the day you take it, whether it's going to be effective. So that makes it a little bit more challenging. Is there a magical medicine that treats ADHD and anxiety without any side effects and works

Dr. Jeffrey Strawn:

immediately? Not that I know of. But I want to maybe jump from that question to something else. I think, probably about 10 years ago, there was a lot of buzz in terms of using atomoxetine for both ADHD and anxiety. And there was a study published by Geller and colleagues that actually looked at that. And so the idea was, could we use one medicine and really address both disorders versus using a stimulant plus an SSRI or some other combination of these medicines that we've been talking about? And for me while the data certainly suggested a benefit. If we look at what the study actually showed, it showed a medication that really was not as effective as a stimulant for ADHD and not as effective as an SSRI for anxiety. So really, for me, this was not a good option. Because what we were saying is, let's settle on something that's a little bit less effective for both conditions, as opposed to using the most effective treatment for both the anxiety and the ADHD. And, if this were something I were dealing with one of my kids or myself I would rather have the most effective treatment that I could, even if that meant taking two capsules or two pills.

Dr. Elise Fallucco:

Exactly. We would love to kill birds, two birds, not kill birds, just kill two birds with one stone.

Dr. Jeffrey Strawn:

That also has implications when we're thinking about therapy. One of my, one of my favorite findings is actually a secondary analysis from the child and adolescent multimodal study. And what they found was that the kids who had ADHD didn't do as well in psychotherapy, which I think is not an effect of ADHD per se. I think it reflected where we were with the treatments. And in many ways, I worry that we're undermining our efforts in therapy by not adequately treating ADHD, so we give one of these longer acting stimulant medications, and that's enough to get the high school student through sixth period algebra, but then we send them to therapy at 4 30 or five o'clock with essentially no stimulant on board, and we asked them to learn, we asked them to process new information to shift attention to focus. Yep. And they don't necessarily have their ADHD treated at that time because the stimulant is

Dr. Elise Fallucco:

long gone. Another powerful reason to make sure that we're covering ADHD and treating it throughout the day, not just the social implications that we talked about before, but the big picture of if they're in therapy for anxiety, for whatever reason, they need to be able to concentrate to be able to lay down the new knowledge and apply it. Absolutely. Another question for you. Let's say you've got a preschooler who'd you're treating with pretty significant ADHD and real poor impulse control. In addition to referring them to therapy, would you consider starting a stimulant or would you start with an alpha agonist?

Dr. Jeffrey Strawn:

This is actually still a situation where I do start with a stimulant because we do get significant improvement in terms of the impulsivity symptoms, the hyperactivity with that stimulant medication.

Dr. Elise Fallucco:

Yeah. I think that's counter to what people are actually doing. I think there's, for some reason, there's a myth floating around that the alpha agonists are safer in the five and six year olds than the stimulants are. Okay. The other question is, you want to add an alpha two agonist onto their stimulant medication, but they have trouble swallowing pills. The packaging will say that guanfacin IR and ER cannot be crushed. Do you ever run into this situation?

Dr. Jeffrey Strawn:

Yeah. So those are situations where depending on the pharmacies that you have access to. There are some compounding instructions for the immediate release clonidine and guanfacine, although in many situations that requires a specialty pharmacy that's able to compound these medications. The other issue to be careful with is in terms of the recipes for compounding the clonidine there, there are several out there. And that's a situation where I, Really need to have an extra layer of caution. I'll generally talk to the pharmacist when I'm calling in the medication as well.

Dr. Elise Fallucco:

So the correct approach would be to try to find a compounding pharmacy and also monitoring closely, particularly with clonidine because of its more more potent effects on blood pressure to make sure that you've got the right concentration and Absolutely. You trust the compounding pharmacy. Okay. And then shifting gears a little bit, I want to talk about your new book. We have all known that you're a psychopharm guru tell us a little bit about this book and how we can access it.

Dr. Jeffrey Strawn:

Certainly. So the book is called Case Studies, Children and Adolescents, and it's one of the Stahl's Essential Psychopharmacology texts. So it is a book that includes 18 or 20 cases or so and really follows the patient through the experience. And in essence, what it typically uses is almost the choose your own adventure type format. So starting with the presentation, giving a little bit of information, And then looking at some dilemma, what treatment should I use, or what should I do now that a side effect has emerged, or now that I have a new comorbidity, or now that I've encountered treatment resistance, or now that I have this drug interaction that's giving rise to another side effect. So really walking through that process and certainly sprinkling in the evidence where we have it

Dr. Elise Fallucco:

I love that it's case based because that's how we think. I have a patient in my office. What am I doing about this? Or I keep running into the dilemma of. Things like we talked about, like wanting to treat both ADHD and anxiety and pulling my hair out.

Dr. Jeffrey Strawn:

And so we have that ADHD anxiety overlap. We have the anxiety that's not getting better with the first or second FSRI. We have what to do with ticks when they're occurring with co occurring OCD. It's not just the straightforward, what do you do as your first line treatment for disorder X or disorder Y.

Dr. Elise Fallucco:

This sounds like an excellent resource. How can we get a hold of this resource? So I think

Dr. Jeffrey Strawn:

you can find it on Amazon or through Cambridge University Publishing. All of those are probably good options to get it.

Dr. Elise Fallucco:

Excellent. We will, for our Psyched for Peds listeners, we will include a link to where you can purchase this fantastic Psychopharm case studies book by Dr. Strawn on our website, psyched4peds. com. And before we wrap up, do you have any take home message that you want to share with pediatricians or pediatric clinicians on choosing medication treatment for kids with ADHD and anxiety?

Dr. Jeffrey Strawn:

So I'd really go back to where we started in terms of before we think about the medication, we have to really make sure that we've gotten the diagnosis right. And it's so critical to figure out if those symptoms that are presenting in the office with that child are driven primarily by anxiety or if they're driven by ADHD. And oftentimes because we do a much better job of screening for ADHD than we do for anxiety, I think in the primary pediatric care setting, we may be biased towards seeing those symptoms as related to the ADHD. So really, as I said earlier, smoking out what is primary. And then I think for me probably starting with the ADHD treatment.

Dr. Elise Fallucco:

Very helpful. Excellent. Thank you so much, Dr. Strawn for your time and for your expertise. I'm really excited about this resource that you've put out and we will link to it on our website because I think this will be really helpful for all of our pediatric colleagues as we navigate this challenging field of psychopharm. Thank

Dr. Jeffrey Strawn:

you for inviting me. This has been a lot of fun.

Dr. Elise Fallucco:

To recap, we talked about how alpha agonists can be used as adjunctive treatment for kids who are having trouble tolerating stimulants, and or who have residual impulsivity when they're being treated with stimulants. We've talked about the possibility of using compounding pharmacies to help create liquid formulations of certain short acting alpha agonists for kids who have trouble swallowing pills. And we've reviewed the importance of starting with stimulant medication when you're considering medication treatment for ADHD, regardless of how old the child is. So for preschool aged children with ADHD for whom you're considering medication treatment, start with stimulant medication as opposed to non-stimulant medication. We've lamented, how Atomoxetine or Straterra. Tara has turned out to be somewhat disappointing as it is not effective. As our first-line treatments for ADHD, nor is it as effective as our first-line treatments for anxiety. And finally we covered the amazing resource of the case studies. In child and adolescent psychopharmacology written by Dr. Jeff Strawn. And if you want to check out this resource and other resources, Check out our website at psyched, the number four peds.com thanks again for tuning in. Please make sure that you follow or subscribe to this podcast in apple podcasts, spotify or wherever you listen. Thanks again and see you next week.