In children with Attention Deficit Hyperactivity Disorder (ADHD) who are not responding to their current stimulant medication and are experiencing anxiety, should the stimulant be stopped and a Selective Serotonin Reuptake Inhibitor (SSRI) be started?

From the Guidelines

For children with ADHD who are not responding to stimulant medication and experiencing anxiety, completely stopping the stimulant and switching directly to an SSRI alone is not typically recommended as a first approach. Instead, a more appropriate strategy would be to optimize the current stimulant treatment first by adjusting the dose or trying a different stimulant medication (such as switching from methylphenidate to amphetamine-based medications or vice versa) 1. If anxiety persists despite optimized stimulant therapy, adding an SSRI (such as fluoxetine 10-20mg daily or sertraline 25-50mg daily) to the treatment regimen may be beneficial while maintaining the stimulant, as supported by the most recent clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders 1. This combination approach addresses both the ADHD symptoms and anxiety. In some cases where the stimulant clearly worsens anxiety, a non-stimulant ADHD medication like atomoxetine (18-100mg daily based on weight) or guanfacine (1-4mg daily) might be considered as an alternative before adding an SSRI. The rationale for this approach is that untreated ADHD symptoms can themselves contribute to anxiety, and SSRIs alone do not effectively treat core ADHD symptoms. Treatment decisions should be individualized based on symptom severity, medication side effects, and the child's overall functioning, with regular monitoring for effectiveness and side effects. Key considerations include the potential benefits of combining stimulants with SSRIs, as well as the importance of addressing both ADHD and anxiety symptoms to improve overall quality of life.

Some key points to consider in this approach include:

• Optimizing stimulant treatment before considering alternative medications
• Adding an SSRI to the treatment regimen if anxiety persists despite optimized stimulant therapy
• Considering non-stimulant ADHD medications as an alternative in cases where stimulants worsen anxiety
• Individualizing treatment decisions based on symptom severity, medication side effects, and the child's overall functioning
• Regular monitoring for effectiveness and side effects to ensure the best possible outcomes for the child.

From the FDA Drug Label

Patients with comorbid depressive symptoms should be adequately screened to determine if they are at risk for bipolar disorder; such screening should include a detailed psychiatric history, including a family history of suicide, bipolar disorder, and depression. If such symptoms occur, consideration should be given to a possible causal role of the stimulant, and discontinuation of treatment may be appropriate

The decision to stop the stimulant and start an SSRI in children with ADHD who are not responding to their current stimulant medication and are experiencing anxiety is not directly addressed in the provided drug label.

• Key considerations include the potential for stimulants to exacerbate symptoms of anxiety, bipolar disorder, or other psychiatric conditions.
• No conclusion can be drawn from the provided information regarding the use of SSRIs in this context, as the label does not explicitly address this topic 2.

From the Research

Treatment Approach for Children with ADHD and Anxiety

• In children with Attention Deficit Hyperactivity Disorder (ADHD) who are not responding to their current stimulant medication and are experiencing anxiety, the approach to treatment involves several considerations 3, 4, 5, 6.
• Stimulant treatment is generally considered the first-line treatment for ADHD, and it can also alleviate symptoms of comorbid anxiety disorders in many cases 3, 4, 5, 6.
• However, if the stimulant administration does not attenuate the severity of the comorbid anxiety disorder, a treatment that targets specifically the anxiety disorder should be added 3.
• Selective serotonin reuptake inhibitors (SSRIs) can be added to stimulants in moderate and severe cases of comorbid anxiety disorders, with the required caution 3, 6.
• Atomoxetine is another option that has demonstrated efficacy in treating both ADHD and anxiety symptoms, and it may be considered as an alternative or adjunctive treatment 5, 7.
• Cognitive-behavioral therapy (CBT) is also an important treatment to improve anxiety symptoms, and it is recommended as an adjunctive treatment for anxiety disorders 3, 6.

Considerations for Stopping Stimulant Medication

• The decision to stop stimulant medication in children with ADHD who are not responding to treatment and are experiencing anxiety should be made on a case-by-case basis, taking into account the individual child's symptoms and treatment history 3, 4, 5, 6.
• Stimulant treatment is generally considered safe and well-tolerated in children with ADHD and comorbid anxiety disorders, and it may be continued in conjunction with other treatments for anxiety 3, 4, 5, 6.
• However, if the child is experiencing significant side effects or if the stimulant medication is not effective in managing ADHD symptoms, alternative treatments may be considered 3, 4, 5, 6.

Adjunctive Treatments for Anxiety

• SSRIs can be used as adjunctive treatment for anxiety disorders in children with ADHD, but they require careful monitoring of side effects 3, 6.
• CBT is an effective treatment for anxiety symptoms, and it can be used in conjunction with medication or as a standalone treatment 3, 6.
• Other psychosocial interventions, such as behavioral therapy and family therapy, may also be beneficial in improving outcomes for children with ADHD and comorbid anxiety disorders 6.