A recent randomized control trial highlighted the role for Escitalopram in helping teenagers with generalized anxiety (Strawn et al, 2020). Interestingly, the study also found that certain genetic factors may impact effectiveness of the medication. This highlights the clear role for SSRIs in anxiety management, as well as possible future directions for tailoring psychiatric treatment. Other reviews of anxiety treatment highlight that SSRIs can be effective for multiple anxiety disorders (Generalized anxiety, social anxiety, panic disorder and others), and in general can take up to 8 weeks to take full effect (Kodish et al., 2011).

A proposed dosing strategy for adolescents with anxiety

Sertraline – start at 25 mg and increase by 25 mg every 1-4 weeks, targeting symptom remission. Typically response occurs between 100 – 150 mg, but can occur at lower doses. Sometimes doses up to 200mg may be used, provided the medication is tolerated.

Fluoxetine – start at 10 and increase by 10 mg – every 1-4 weeks, targeting symptom remission. Typically response occurs between 20 – 40 mg, but can occur at lower doses. Rarely doses up to 60 mg may be used, provided the medication is tolerated.

Escitalopram – start at 5 – 10 and increase by 5 – 10 mg – every 1-4 weeks, targeting symptom remission. Maximum dose is 20 mg, higher doses are not recommended due to QTC prolonging risks.

For referrals or psychopharm guidance

• SmartCare for Families : 858-956-5900
• SmartCare for Providers : 858-880-6405
• Psychologytoday.com
• County Sevices
  • https://www.optumsandiego.com/content/dam/san-diego/documents/socdirectory/SBC_DBH-SUDRS_Provider_Directory_English.pdfIpser JC, Stein DJ, Hawkridge S, Hoppe L. Pharmacotherapy for anxiety disorders in children and adolescents. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD005170. DOI: 10.1002/14651858.CD005170.pub2.Strawn JR, Mills JA, Schroeder H, Mossman SA, Varney ST, Ramsey LB, Poweleit EA, Desta Z, Cecil K, DelBello MP. Escitalopram in Adolescents With Generalized Anxiety Disorder: A Double-Blind, Randomized, Placebo-Controlled Study. J Clin Psychiatry. 2020 Aug 25;81(5):20m13396. doi: 10.4088/JCP.20m13396. PMID: 32857933; PMCID: PMC7504974.
  • Kodish, I., Rockhill, C., & Varley, C. (2011). Pharmacotherapy for anxiety disorders in children and adolescents. Dialogues in clinical neuroscience, 13(4), 439–452.

Decreased appetite:
If your patient’s appetite decreases after taking ADHD medicine, advise the parent to give the morning dose after breakfast so that the youth will eat better in the morning. Also advise them to serve a large dinner in the evening when the medication is beginning to wear off. Have them keep healthy, high-calorie, protein snacks on hand for whenever a child asks for food, even if it is before bedtime. Discuss with parents that it is more important to monitor the child’s weight than his day-to-day appetite. Advise them to let you know if the child’s poor appetite lasts for a long period, and consider reducing the dose or stopping the drug on weekends or summer breaks to allow appetite and food intake to return to normal.

Stomach pain or upset:
Advise parents not to give the medication on an empty stomach. Taking the medication with or immediately after food can be helpful for this side effect.

Sleep problems:
Parents should set up a regular bedtime routine that includes calming activities, such as bathing or reading.  Makes sure that a long-acting stimulant is only given in the mornings, typically no later than 10am, and an afternoon dose of a short-acting stimulant should typically not be given later than 3pm. If the sleep disturbance persists, the provider could consider switching from a long-acting to a shorter-acting form or reducing the dose or stopping an afternoon dose.

Daytime drowsiness:
If a child is taking atomoxetine (Strattera) or guanfacine (Tenex/Intuniv) or clonidine (Catapres/Kapvay) and experiences daytime sleepiness, consider giving the medication at bedtime instead of in the morning.  The provider could also consider lowering the dose or dividing the dose and giving it twice a day. 

Rebounding effects:
When an ADHD medication wears off in the afternoon or evening, some children have a period of more ADHD symptoms or irritability and moodiness.  This is more common with the stimulant medications than the non-stimulant medications. To prevent this “rebounding” consider using a longer-lasting medication or prescribing a small dose of fast-acting stimulant later in the day.

Mood Changes:
Make sure the parents are keeping an eye out for changes in the child’s mood and anxiety.  Stimulant medications can negatively affect mood symptoms and anxiety. If that does occur, consider using a non-stimulant medication instead to address the ADHD symptoms.

Finally, it is often advisable to schedule medication initiation or dosage changes to occur on weekends when parents can better monitor for side effect emergence

It is our hope that this practical primer on addressing the common side effects for ADHD medications is helpful to address problems that may arise in the primary care office. And remember providers can contact is at SmartCare for real-time consultation on particular cases.

It is a somewhat complicated question and answer because there are multiple factors to look at: is this ADHD alone or co-morbid with something else; stimulant and non-stimulant choices; short-acting and long-acting formulations; dose and side effect considerations; an assortment of preparations available; and insurance considerations. If we start with the position of using a stimulant medication first, unless there is a reason not to (previously failed stimulant trial, significant co-morbid anxiety, substance abuse concerns, weight concerns), the first decision really is whether to start with a short-acting or long-acting formulation. Unless the child is very young, in most circumstances it would be appropriate to start with a long-acting formulation. If a child is unable to swallow a pill, there are long-acting versions that can still be used: Adderall XR capsules can be opened, Quillivant XR is a long-acting liquid methylphenidate preparation, and the Daytrana patch to name a few.

In terms of making the decision whether to start with a methylphenidate-based preparation or an amphetamine-based preparation, it mostly depends on provider preference. For children under the age of 6, it is slightly easier to get insurance approval for an amphetamine-based preparation because there is better research on the use of that class of stimulants in young children. If planning to prescribe a stimulant medication to a young child under the age of 6, it is best to start with an immediate release preparation, typically Ritalin or Adderall, and then to consider changing to a long-acting preparation over time if needed.

At this point there are so many preparations of long-acting stimulants, which can be confusing for providers. They are available in capsules, tablets, sprinkles, liquid, and patch forms. They mostly don’t vary much in terms of length of effect and side effect profile. Some vary in terms of how the active medication is released throughout the day. In general, if a patient does not do well on a long acting preparation from one class of stimulant, for example if s/he was started on Concerta, it probably does not make sense to try another long acting methylphenidate medication, but it makes more sense to try one from the amphetamine class instead.

Unfortunately many medication decisions are made based on what is covered by a patient’s health insurance. In the case of prescribing stimulant medications, this limitation can be seen as helpful to narrow down the choices available to the provider.

Given the seemingly never-ending list of stimulant options, providers might find it helpful to develop a list of stimulant medications they are comfortable prescribing, making sure to cover the basic insurances and the basic preparations and both short-acting and long-acting preparations. It might also be a good idea to develop a comfort level with some of the non-stimulant medication options, like Strattera, Tenex, and Clonidine. These have been discussed in previous e-Weekly newsletters and will be reviewed again soon in a future e-Weekly newsletter.

While medication for ADHD is often the first line treatment for older children and adolescents with ADHD, it is not the recommended first line treatment for young children with ADHD symptoms. Both the CDC and AAP urges healthcare providers to refer parents of young children with ADHD for behavioral therapy training before prescribing medication to treat the symptoms. Research shows that behavioral therapy can be as effective as medication, being 70-80% effective for treating the core symptoms of ADHD in young children. Where the problem lies is that less than 50% of young children are referred to parent behavioral therapy training. While behavior therapy can take more time, effort, and resources than medication, the effects last much longer past when the treatment ends, unlike medication. Another concern is that stimulant medication in young children can have problematic side effects, including irritability, increased agitation, appetite suppression, growth delay, and sleep disturbance. In clinical practice, psychotropic medication for ADHD symptoms has been shown to not work as reliably and robustly in younger children as they do in older children. This could occur when ADHD is not the correct diagnosis, as children with trauma or anxiety or sensory challenges can also present with hyperactivity and impulsivity, but would respond poorly to a stimulant medication. The other major reason is that the commonly seen side effects with stimulant medications (sleep and appetite disturbance, moodiness) can have more impact on young children, who are physically growing at a faster pace and are still developing core social/emotional and behavioral processes, as compared to older children, who are typically more mature in all of these areas.

In summary, when considering the diagnosis of ADHD in a young child, it is important to conduct a careful assessment, looking for other mood/anxiety, developmental, and medical symptoms, prior to confirming the diagnosis and considering treatment. If a young child does meet criteria for ADHD, the first-line recommended treatment is parent training for behavioral therapy, before considering medication. Because we know it is hard to help families find resources, parents can be referred to the SmartCare Parent Line to help find an appropriate program to meet their needs.