ADHD - Should my child have a drug holiday?

Is it necessary to put your child on medication for ADHD? Is it necessary to put your child on medication for ADHD?

Your child has ADHD but you feel he/she needs a break from meds. What's your options?

Drug therapy generally requires regular administration for the indicated condition to be managed.  Whether it be a poorly functioning thyroid gland, high blood pressure or a pancreas which is not secreting insulin appropriately. However, all too often it would seem that a combination of arrogance and the stigma attached to mental illness results in people feeling that drugs acting on the brain are subject to different rules.

And in some instances this is true, but in many cases this rule-bending and breaking is due to a lack of understanding of the condition and the way the drugs work. Attention-Deficit/Hyperactivity Disorder is a prime example of a condition which is subject to personal perception when it comes to the way drug therapy should be used.

What is a drug holiday?

Many parents choose to not give their child methylphenidate (Ritalin® or Concerta®) over weekends or school holiday periods. Reasons for this can vary from the misguided assumption that ADHD is a “school problem” to the child (or teenager) deciding that he/she does not want to take it when they are not in settings where a greater level of focus or attention is required.

The technical definition of a drug holiday (or structured treatment interruption) is a period of time over which drugs are withdrawn, usually as part of a structured treatment plan to reverse ineffectiveness of a drug due to receptor desensitisation or to assess therapeutic outcomes. In conditions where drug holidays are recommended, such as Parkinson’s Disease, these treatment interruptions are to allow for assessment of therapy efficacy.

What are the reasons for observing drug holidays in ADHD?

Many drugs which act on the central nervous system accumulate in the body, with the result being that treatment with these agents cannot be abruptly withdrawn to allow for a drug holiday. Methylphenidate, however, does not accumulate and is washed out on a daily basis, thus making it a drug which allows for the observation of drug holidays. As previously stated, the reasons for observing these treatment free periods are varied and may not always in the best interests of the child.

Whether the prevailing school of thought surrounding this phenomenon is as a result of the stigma attached to use of methylphenidate or due to misinformation regarding the condition is unclear. In my personal experience, from interactions with parents and from my own Masters investigation, many people feel that “the system needs a break”. The meaning of that statement probably depends a lot on your perspective – is it a break from this horrible drug that the teachers say my child has to take? Is it a break because the drug is poisonous and should not be given continuously for fear of toxicity? Is the child asking to skip doses because he or she doesn’t tolerate some side effects very well and would prefer to minimise experiencing them when possible? Of the three possibilities provided, the last one is a reason that should not be ignored and, in my opinion, one that should be respected whenever possible. Another aspect which is considered by many is that of cost; long acting forms of methylphenidate are especially expensive. Although one would hope that a caring parent would not allow such a factor to influence this treatment decision, one can also appreciate that financial difficulties may result in one being in a situation where that is the best solution.

The specialist recommendation is to avoid removing the drug as consideration regarding the negative effect on learning, socialisation and self-image associated with removal of the drug should be given. It is possible that removal of methylphenidate will negatively affect non-pharmacological behavioural interventions due to the lack of long-term treatment effects of the drug following its removal.

What is the way forward?

The best way to change misperceptions is to provide the relevant information and encourage people to explore different perspectives to better understand the problem as a whole. As a pharmacist, I am biased towards using drugs where I feel that they are appropriate, but I would not be someone worth taking advice from if I failed to recognise situations where drug therapy is not appropriate or should be modified based on tolerability.

From my knowledge of ADHD, my recommendation is aligned with that of psychiatrists in that I do not encourage the use of drug holidays. An analogy to explain this perspective would be akin to a toddler learning to transition from nappies to using the toilet: if your toddler is encouraged to use the toilet instead of wearing nappies during the week, but over the weekend (for whatever reason) you decide to put him or her into nappies and be unconcerned regarding toilet use, it will probably be very confusing for that child. This “disconnect” is part of the problem with drug holidays, especially in young children where the brain is thought to be more plastic (able to adapt and change). Keeping to routine and implementing behavioural therapies which are aided by the use of methylphenidate is thought to assist developing and strengthening neural pathways to help your ADHD child function and cope better. Whether or not this results in permanent change as a long term therapeutic outcome is unknown and will require further research, but consistency is a very important factor for any child and is even more necessary for one with ADHD.

If you feel that ADHD is a “school problem” and can be ignored over weekends, I strongly encourage you to pay more attention to your child’s social behaviours with and without methylphenidate. That being said, if your child suffers from the “rebound effect” (irritability following the drug being washed out of the system) and you would prefer to save him or her (and yourself) from the frustration of this over weekends due to poor outcomes associated with it, this would be an understandable reason. If your child feels unhappy about taking it over weekends or during holidays, try to understand the reasoning behind this (wanting to have an unimpaired appetite, wanting to sleep-in) and discuss the benefits or risks associated with this with him or her.

The take-home message from this is: if you choose to use drug holidays, evaluate the reasoning behind this decision and whether or not it is in your child’s best interest based on therapeutic goals. – Judith Regnart {jcomments on}


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