61. MEDS for ADHD + Anxiety - Q+A

Navigating Treatment for ADHD and Anxiety in Kids

Ever wondered which to treat first in kids who have both ADHD and anxiety? Dr. Elise Fallucco, child psychiatrist, tackles this common dilemma in the latest episode of Child Mental Health for Pediatric Clinicians. She shares fresh insights and data, stressing the importance of starting with stimulant medication for ADHD. Dr. Elise also discusses medication types, dosages, and the rationale behind her treatment choices, while addressing common parental concerns and considerations. Tune in to understand how to navigate this complex but crucial aspect of pediatric mental health care!

00:00 Introduction to ADHD and Anxiety in Children

01:02 Which Condition to Treat First: ADHD or Anxiety?

02:05 Why Treat ADHD with Medication?

03:47 Choosing the Right Medication for ADHD and Anxiety

04:58

08:54 Pharmacogenetic Testing for ADHD

09:22 Non-Stimulant Medication Options

10:15 Alpha Agonists for ADHD and Anxiety

11:50 Norepinephrine Reuptake Inhibitors: A Third-Line Treatment

14:49 Important Clinical Considerations and Recap

Check out our website PsychEd4Peds.com for more resources.
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Transcript

Dr. Elise Fallucco: 0:21

Welcome back to Child Mental Health for Pediatric Clinicians. I'm your host, Dr. Elise Fallucco, child psychiatrist, and mom. In this episode, I'm gonna be answering the most common questions you have about treating kids and teens with both A DHD, and anxiety. Okay, so before we even start the questions, just the little fact to share that up to half of kids with A DHD are going to develop anxiety. So these two conditions are commonly comorbid. And typically we'd see a DHD symptoms earlier. We tend to see them sometimes as early as preschool or early childhood, usually be usually in kids with prominent hyperactivity and impulsivity. But there are a lot of kids who tend to have more of the inattentive A DHD, who don't get recognized until later in life, like more like middle school, high school, or even adulthood. In which case, in which case you may actually notice or diagnose the anxiety before you see the A DHD. But this brings us to our first question. When you have a kid with both A DHD and anxiety, which do you treat first? Okay, so we have new data here. We used to hem and haw about which one goes first and say in this occasion you do that, and in that occasion you do this. Now with more data, we have a simple answer. You treat the A DHD first, why? Well, first, treating A DHD with stimulants goes pretty quickly. You can see the same day whether you're gonna get a response or not, where it's, it can take weeks, maybe four to six weeks at least, to see treatment effects with SSRIs. But probably more importantly, the second reason why you would treat A DHD first is that when you address problems with inattention, hyperactivity, and impulsivity related to A DHD that are negatively impacting school and social relationships, you may actually relieve some of the anxiety just by virtue of addressing these things that are causing stress and problems in our kids with both A DHD and anxiety. and I know we have a lot of parents and families in our practice who are reluctant to treat A DHD with medication. I commonly get asked, do we even need to treat A DHD with medication? Something that I like to remind families in answering that is that when you're a child with a DHD. If your symptoms are left untreated, it could potentially affect your view of what you are capable of doing because you're basically trying to function without treatment. Or to use an analogy that one of my attendings used to use at Wash U is, it's like somebody who needs glasses, who keeps trying to read or keeps trying to see without glasses, it's gonna be incredibly frustrating and it'll probably make you not wanna try anymore at school or with things that require sustained attention. Another reason to treat A DHD with medication is that we have really compelling data that suggests that treating A DHD with medication will reduce the future risk of awful outcomes like suicide, motor vehicle accidents, and substance misuse. So you're not just helping the child now with their developing brain and in their day-to-day life, but you're also reducing the risk of. Future morbidity and mortality. Perhaps the most compelling reason to treat A DHD with medication is that we know that the medications that we use for A DHD specifically, the stimulants are more effective than even Tylenol and Ibuprofen are for pain. The effect size for stimulants is 1.0, which is really, really high. And we know that about 70 to 85% of kids respond really well to stimulants and tolerate them. So, okay, perhaps the most common question that I get asked about treating kids with A DHD and anxiety is, are you treating the A DHD differently if you know that the kid already has anxiety? So in other words, do you avoid trying stimulants, knowing that kids in general with anxiety tend to be more sensitive to stimulant medication? So would you just avoid the stimulants and start straight off with non stimulant medication? Alright, again, we wanna go back to the effect size data. So what we know is that stimulants have a much higher effect size than the non stimulants for treating A DHD. So stimulant effects are about 1.0, and the non-stimulant effect size is like 0.6 or 0.7. Or maybe as low as 0.5 if we're talking about the norepinephrine reuptake inhibitors. So stimulants are much more likely to work than non stimulants are for treating A DHD. And again,, 70 to 85% of kids respond well to stimulants and tolerate them. So the short answer is We still start with stimulants even in kids who have both A DHD and anxiety and need treatment for their A DHD with stimulants. A big caveat regardless of whatever medication you end up starting in a kid with a DHD and anxiety to treat the A DHD, remember that kids tend to be really sensitive to stimulants. Stimulant side effects. So you wanna start low. And sometimes if you've got a kid that's not quite a teenager and even in very young teenagers, instead of starting with a long acting drug sometimes I like to start with a really short acting stimulant. Because they come in incredibly low doses and I'm suspecting that these kids may be sensitive to meds because they have both A DH, D and anxiety. And so I'll start at a short acting, really low dose, try it, twice a day or so and then titrate up until we get a level that I'm comfortable with and then switch over to a long acting. A lot of my colleagues will just start with long actings and that's fine. It's certainly so much simpler for families. But the thing that I worry about is that the lowest dose for some lock acting drugs may be too strong for some of our kids. So just something to keep in mind. Alright, onto the next question. Is there a stimulant that you like best for kids with both A, D, H, D and anxiety? Now if you wanna learn about my approach to A DHD treatment in general, check out episode 17, A DHD. Meds as easy as 1, 2, 3. But when we're talking about medication for A DHD and anxiety, I'm really going to use the very similar algorithm where I like to try all three different subclasses of stimulants before going to a non-stimulant med, where the first class would be methylphenidate. The second would be the amphetamines, and the third would be the dexmethylphenidates So I would first start with the methylphenidate class, and these would be meds like your Ritalins, Daytrana, Concerta, things like that. In kids with a DHD and anxiety, it may not worsen anxiety and in some kids it actually may help. It's gonna cause less appetite suppression than the amphetamine products based on meta-analyses. And your dosing range would be between 0.5 milligrams to 1.5 milligrams per kilogram per day as the doses that you'd be looking at for methylphenidate. Okay, so first step number one would be methylphenidate for a DH, D and anxiety. Step number two, if that doesn't work, would be the amphetamine. These would be the ones like Adderall, Vyvanse. The amphetamines may cause more irritability than the methylphenidate products for kids with A DHD in general. And if you've got a kid with a DHD and anxiety, you definitely do not need more irritability. So that's why these are the second choice. And the dose range would be about 0.25 to one milligram per kilogram per day. Step three in treatment of A DHD with stimulants would be the, dexmethylphenidate products. So the ones like Focalin ir or Focalin xr. These tend to be better tolerated than even the regular methylphenidates, but typically they're not as long acting, which is why I've put them as number three. Side note, there is a new medication called, AzSTARys, that addresses the issues that we used to have with Focalin being not long acting enough. AzSTARys combines immediate release dexmethylphenidate. So you get quick acting with a pro-drug ser dexmethylphenidate that allows for extended efficacy and could be potentially a once daily dose that would last throughout the whole day. I personally do not have a ton of use with this med, but just wanted to make you aware of it because you may have drug reps or other people talking to you about it. So I wanted you to know where it fits. Okay. So we've talked about the 1, 2, 3 approach for treatment of A DHD with anxiety, with meds, one methylphenidate, two amphetamines, and three maybe the Dexmethylphenidate products. Next question. Is there some test, like some pharmacogenetic test that we can take that would tell us which medication would be best for our child with A-D-H-D-I? Can we save a few trials and steps by just doing a gene site test for A DHD? This one's a real quick answer. No, as of now, 2025. December when this will be released. Genetic testing for A DHD is still not very helpful. Alright, next question In which kids with A DHD and anxiety would you try non-stimulants? Alright, so about 15 to 30% of kids don't respond well to stimulant medication. And so let's say you've tried the 1, 2, 3 steps with stimulants, or maybe you've decided it's really not worth belaboring the process and you try one stimulant or maybe two and say, we're good. Let's move to non-stimulants. Again, the thing to remember is the effect size for non-stimulants is not as high as it is for stimulants. The good news about non-stimulants is that really the most common adverse effects you're looking at are sedation, making them feel a little bit tired. you don't tend to see as many of the emotional or appetite effects as you see with stimulants. Alright. So what would be next question? What would be your first choice for a non stimulant medication? If we're talking about classes, I would say alpha two agonists for sure. These are the meds like guanine and clonidine. They directly modulate the pre and post-synaptic alpha two adrenergic receptors. Why is that so hard to say? Adrenergic. Okay. And honestly, clonidine is more of a dirtier med, meaning that it has effects not just at the alpha two receptors, but also at other receptors. And so it tends to have more side effects, causes a lot more sedation. So that's a great one for kids who are having trouble falling asleep to use as a sleep aid at night. However, I use Guan Faine much more commonly than I use Clonidine because it's a cleaner medication. More selective for alpha two, does not have as much sedation, and the extended release form can be dosed once a day. So if we're thinking Guanfacine xr, which is Intuniv, your target dose would be about 0.1 milligrams per kilogram per day for the full effect. And as a side note, while you know the Guan Faine is really gonna target the hyperactivity and the impulsivity, it may not be as good at addressing the inattention as the stimulant medications are. But a potential bonus is that we have some preliminary data from a 2017 study in the Journal of Child and Adolescent Psychopharmacology that Dr. Strawn and his colleagues did that shows that guanine may actually help with anxiety in kids with a DHD. All right, so we've talked about stimulants, we've talked about alpha agonists. So next question would be, what about Qelbree? What about these norepinephrine reuptake inhibitors? Like the atomoxetine when do we use those? Which patients are these meds good for? Okay, so there's a reason why we start with stimulants and then we think alpha agonists and then. These NRIs or selective norepinephrine reuptake inhibitors are more of a third line of treatment. And the big reason is that their effect size is closer to 0.5, which is lower than the alpha agonist and the stimulants. 50% of people who try these meds experience a positive response, So I am really gonna talk more about Viloxazine or Qelbree, which is a newer selective norepinephrine reuptake inhibitor. That also has serotonin receptor modulating effects that is FDA approved and effective for A DHD in children six years and older. And unlike the stimulants, which tend to work the day you take them and you can see whether it's gonna be effective or not. The N MRIs, like Atomoxetine and Viloxazine can sometimes take a couple of weeks to work. And Qelbree tends to work within about a week. You see a difference from placebo whereas Atomoxetine or Strattera takes a little bit longer. Qelbree comes in a sprinkle capsule, which is good for kids who have trouble swallowing pills. And the most common side effects with kere are really similar to the ones that you see in the stimulants with a decreased appetite a little bit of nausea, and then some sedation and maybe headaches. And also like the stimulants, they tend to have the heart rate and blood pressure elevation. So of course you'd wanna monitor vitals regularly in your kids and teens who are on these meds. The potential bonus of the Viloxazine is the serotonin receptor modulating effects which potentially could affect mood. And in fact, this medicine was actually used in Europe for a while to treat major depression in adults. So this tells us that in theory, this could be helpful for kids with A DHD and moodiness. Important things clinically to tell families. The one thing to note about Qelbree and to remember is that it's a really potent inhibitor of Cytochrome 1A2. So what that means for those of you who are not as. Psychopharm nerdy as I am is that this med. Inhibits the cytochrome that metabolizes caffeine. it really increases the effects of caffeine. So you really wanna tell your patients, especially if they're teenagers or older, to be really thoughtful about coffee and energy drinks. Because basically, when you have one cup of coffee, it feels like six cups of coffee. So make sure to let them know that. As far as dosing for Qelbree, if you've got a kid six to 11 years old, you'd start at about a hundred milligrams a day. That may be their final dose, but after a week, you may wanna increase it to 200 milligrams daily. Your 12 and older kids, you could just go ahead and start at 200 daily. Before doing a quick recap. I just wanna thank two of the really prominent child psychiatrists who talk about medication, treatment of A DHD and anxiety, Dr. Jeff Strawn and Dr. Jim Waxmonsky. A lot of what I'm sharing has come from discussions with them and a lot of their advice. So I wanna give them a shout out for influencing part of the content, whether they know it or not. Finally, to recap the things you need to know about A DHD and anxiety treatment in kids one. Start with stimulants using the 1, 2, 3 approach. Two, if stimulants don't work, then consider alpha agonist, particularly guanfacine XR with a target dose of around 0.1 milligrams per kilogram per day. And then third line if the alpha combination of stimulants and alpha agonists or just. Monotherapy with either doesn't tend to be very helpful. Then you would consider the N MRIs, like Viloxazine or Qelbree Alright, please keep sending your questions letting me know anything that you wanna learn about and look forward to talking to you next episode on the pod. Thanks for listening. See you next time.