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

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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

Episode Transcript

Dr. Elise Fallucco (00:21):
Welcome back to PsychEd4Peds.
I'm your host, Dr.
Elise Fallucco.
Child psychiatrist and mom.
So we are continuing theconversation with Dr.
Jeffrey Strawn about medicationtreatment for ADHD and anxiety.
We hope you've enjoyed part oneand part two of this series in
the previous two episodes.
And now we're wrapping up ADHDwith anxiety, with an advanced,

(00:45):
rapid fire Q and a.
And before we close, we're goingto share an amazing clinical
resource hot off the press tohelp us, as we treat kids with
ADHD, anxiety, and even allsorts of other child mental
health problems..
So thanks for tuning in.
And here we go.
You mentioned before that thetimes where we would consider

(01:06):
using non stimulants for kidswith ADHD plus or minus anxiety
are largely when they've notbeen able to tolerate stimulant
medication.
Then you would think aboutmedications like Viloxazine or
less preferentially atomoxetineor potentially the alpha 2
agonists.
Let's say you have a kid who'snot tolerated trials of multiple
different stimulants.

(01:27):
And you have a choice between analpha 2 agonist like guanfacine
extended release or viloxazine.
How do you think through whichdirection to go?

Dr. Jeffrey Strawn (01:37):
So for me, in many of those situations,
particularly if I have a lot ofimpulsivity symptoms related to
the ADHD, I'm often thinkingabout an alpha 2 and
specifically there is, as wetalked about earlier I'm really
going to guanfacine extendedrelease.
I think the other issue is,let's go back to that patient,
maybe with ADHD and some anxietysymptoms who's treated with a

(01:59):
stimulant.
I may use the Alpha 2 agonistadjunctively in that patient as
well.
And certainly we know patientswith anxiety disorders may be
more likely to experience sideeffects.
And this is where I think theliterature is really interesting
when we look at thesecombination treatments of the
Alpha 2 plus the stimulant.

(02:20):
What we see is that in many ofthose studies, the kids that are
in the combination treatmentactually have fewer side effects
than do the kids who are in thestimulant monotherapy or the
alpha 2 agonist monotherapy.
And so really what you'relooking at is probably a
cancelling of the side effectsor it's really a peanut butter
and jelly, or if you're aReese's fan, maybe a peanut

(02:42):
butter and chocolate type ofcombination.

Dr. Elise Fallucco (02:45):
Delicious.
Yes.
so instead of abandoning thestimulant medication, you would
think first, especially if achild has high problems with
impulsivity of, using an alpha 2agonist as adjunctive I do the
same thing I try not to abandonthe stimulants and maybe to the
frustration of some of thefamilies that I take care of,
because.
I really try to give them a tryof the methylphenidate and then

(03:07):
an amphetamine salt.
And even sometimes I'll go backas a third one and talk about
dexmethylphenidate, some of thefocalin preparations, cause they
tend to be a little bit bettertolerated.
and I'll try those threepermutations before I'll
consider abandoning stimulants.
And going to something like, anorepinephrine reuptake
inhibitor, like Viloxazine.

(03:28):
And of course, when we're in thestimulants adding an alpha
agonist to improve tolerabilityto do the peanut butter and
jelly or the peanut butter andchocolate, which sounds
delicious too The other thingwhen I'm talking to families
about the NRIs, norepinephrinereactive inhibitors, at this
point in the game, they've triedother medicines that haven't
worked and it's hardpsychologically to tell them it

(03:50):
may take a couple of weeks untilwe see an effect.
It's not like the stimulantswhere we know the day you take
it, whether it's going to beeffective.
So that makes it a little bitmore challenging.
Is there a magical medicine thattreats ADHD and anxiety without
any side effects and works

Dr. Jeffrey Strawn (04:05):
immediately?
Not that I know of.
But I want to maybe jump fromthat question to something else.
I think, probably about 10 yearsago, there was a lot of buzz in
terms of using atomoxetine forboth ADHD and anxiety.
And there was a study publishedby Geller and colleagues that
actually looked at that.
And so the idea was, could weuse one medicine and really

(04:28):
address both disorders versususing a stimulant plus an SSRI
or some other combination ofthese medicines that we've been
talking about?
And for me while the datacertainly suggested a benefit.
If we look at what the studyactually showed, it showed a
medication that really was notas effective as a stimulant for

(04:50):
ADHD and not as effective as anSSRI for anxiety.
So really, for me, this was nota good option.
Because what we were saying is,let's settle on something that's
a little bit less effective forboth conditions, as opposed to
using the most effectivetreatment for both the anxiety

(05:11):
and the ADHD.
And, if this were something Iwere dealing with one of my kids
or myself I would rather havethe most effective treatment
that I could, even if that meanttaking two capsules or two
pills.

Dr. Elise Fallucco (05:24):
Exactly.
We would love to kill birds, twobirds, not kill birds, just kill
two birds with one stone.

Dr. Jeffrey Strawn (05:32):
That also has implications when we're
thinking about therapy.
One of my, one of my favoritefindings is actually a secondary
analysis from the child andadolescent multimodal study.
And what they found was that thekids who had ADHD didn't do as
well in psychotherapy, which Ithink is not an effect of ADHD
per se.

(05:52):
I think it reflected where wewere with the treatments.
And in many ways, I worry thatwe're undermining our efforts in
therapy by not adequatelytreating ADHD, so we give one of
these longer acting stimulantmedications, and that's enough
to get the high school studentthrough sixth period algebra,
but then we send them to therapyat 4 30 or five o'clock with

(06:15):
essentially no stimulant onboard, and we asked them to
learn, we asked them to processnew information to shift
attention to focus.
Yep.
And they don't necessarily havetheir ADHD treated at that time
because the stimulant is

Dr. Elise Fallucco (06:29):
long gone.
Another powerful reason to makesure that we're covering ADHD
and treating it throughout theday, not just the social
implications that we talkedabout before, but the big
picture of if they're in therapyfor anxiety, for whatever
reason, they need to be able toconcentrate to be able to lay
down the new knowledge and applyit.
Absolutely.
Another question for you.

(06:50):
Let's say you've got apreschooler who'd you're
treating with pretty significantADHD and real poor impulse
control.
In addition to referring them totherapy, would you consider
starting a stimulant or wouldyou start with an alpha agonist?

Dr. Jeffrey Strawn (07:03):
This is actually still a situation where
I do start with a stimulantbecause we do get significant
improvement in terms of theimpulsivity symptoms, the
hyperactivity with thatstimulant medication.

Dr. Elise Fallucco (07:14):
Yeah.
I think that's counter to whatpeople are actually doing.
I think there's, for somereason, there's a myth floating
around that the alpha agonistsare safer in the five and six
year olds than the stimulantsare.
Okay.
The other question is, you wantto add an alpha two agonist onto
their stimulant medication, butthey have trouble swallowing
pills.

(07:35):
The packaging will say thatguanfacin IR and ER cannot be
crushed.
Do you ever run into thissituation?

Dr. Jeffrey Strawn (07:43):
Yeah.
So those are situations wheredepending on the pharmacies that
you have access to.
There are some compoundinginstructions for the immediate
release clonidine andguanfacine, although in many
situations that requires aspecialty pharmacy that's able
to compound these medications.
The other issue to be carefulwith is in terms of the recipes

(08:03):
for compounding the clonidinethere, 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 thepharmacist when I'm calling in
the medication as well.

Dr. Elise Fallucco (08:18):
So the correct approach would be to try
to find a compounding pharmacyand also monitoring closely,
particularly with clonidinebecause of its more more potent
effects on blood pressure tomake sure that you've got the
right concentration andAbsolutely.
You trust the compoundingpharmacy.
Okay.
And then shifting gears a littlebit, I want to talk about your

(08:40):
new book.
We have all known that you're apsychopharm guru tell us a
little bit about this book andhow we can access it.

Dr. Jeffrey Strawn (08:47):
Certainly.
So the book is called CaseStudies, Children and
Adolescents, and it's one of theStahl's Essential
Psychopharmacology texts.
So it is a book that includes 18or 20 cases or so and really
follows the patient through theexperience.
And in essence, what ittypically uses is almost the

(09:11):
choose your own adventure typeformat.
So starting with thepresentation, giving a little
bit of information, And thenlooking at some dilemma, what
treatment should I use, or whatshould I do now that a side
effect has emerged, or now thatI have a new comorbidity, or now
that I've encountered treatmentresistance, or now that I have
this drug interaction that'sgiving rise to another side

(09:33):
effect.
So really walking through thatprocess and certainly sprinkling
in the evidence where we have it

Dr. Elise Fallucco (09:40):
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 thedilemma of.
Things like we talked about,like wanting to treat both ADHD
and anxiety and pulling my hairout.

Dr. Jeffrey Strawn (09:54):
And so we have that ADHD anxiety overlap.
We have the anxiety that's notgetting better with the first or
second FSRI.
We have what to do with tickswhen they're occurring with co
occurring OCD.
It's not just thestraightforward, what do you do
as your first line treatment fordisorder X or disorder Y.

Dr. Elise Fallucco (10:15):
This sounds like an excellent resource.
How can we get a hold of thisresource?
So I think

Dr. Jeffrey Strawn (10:20):
you can find it on Amazon or through
Cambridge University Publishing.
All of those are probably goodoptions to get it.

Dr. Elise Fallucco (10:28):
Excellent.
We will, for our Psyched forPeds listeners, we will include
a link to where you can purchasethis fantastic Psychopharm case
studies book by Dr.
Strawn on our website,psyched4peds.
com.
And before we wrap up, do youhave any take home message that
you want to share withpediatricians or pediatric
clinicians on choosingmedication treatment for kids

(10:51):
with ADHD and anxiety?

Dr. Jeffrey Strawn (10:53):
So I'd really go back to where we
started in terms of before wethink about the medication, we
have to really make sure thatwe've gotten the diagnosis
right.
And it's so critical to figureout if those symptoms that are
presenting in the office withthat child are driven primarily
by anxiety or if they're drivenby ADHD.

(11:14):
And oftentimes because we do amuch better job of screening for
ADHD than we do for anxiety, Ithink in the primary pediatric
care setting, we may be biasedtowards 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 probablystarting with the ADHD

(11:36):
treatment.

Dr. Elise Fallucco (11:37):
Very helpful.
Excellent.
Thank you so much, Dr.
Strawn for your time and foryour expertise.
I'm really excited about thisresource that you've put out and
we will link to it on ourwebsite because I think this
will be really helpful for allof our pediatric colleagues as
we navigate this challengingfield of psychopharm.
Thank

Dr. Jeffrey Strawn (11:56):
you for inviting me.
This has been a lot of fun.

Dr. Elise Fallucco (11:58):
To recap, we talked about how alpha agonists
can be used as adjunctivetreatment for kids who are
having trouble toleratingstimulants, and or who have
residual impulsivity whenthey're being treated with
stimulants.
We've talked about thepossibility of using compounding
pharmacies to help create liquidformulations of certain short
acting alpha agonists for kidswho have trouble swallowing

(12:21):
pills.
And we've reviewed theimportance of starting with
stimulant medication when you'reconsidering medication treatment
for ADHD, regardless of how oldthe child is.
So for preschool aged childrenwith ADHD for whom you're
considering medicationtreatment, start with stimulant
medication as opposed tonon-stimulant medication.

(12:41):
We've lamented, how Atomoxetineor Straterra.
Tara has turned out to besomewhat disappointing as it is
not effective.
As our first-line treatments forADHD, nor is it as effective as
our first-line treatments foranxiety.
And finally we covered theamazing resource of the case
studies.

(13:02):
In child and adolescentpsychopharmacology written by
Dr.
Jeff Strawn.
And if you want to check outthis resource and other
resources, Check out our websiteat psyched, the number four
peds.com thanks again for tuningin.
Please make sure that you followor subscribe to this podcast in
apple podcasts, spotify orwherever you listen.

(13:22):
Thanks again and see you nextweek.