BHIPP Bulletin

Volume 10, Issue 5

November 2024

This month's BHIPP Bulletin is a contribution from

Rheanna Platt, MD, Associate Professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins University School of Medicine and BHIPP Consultant.

A medication holiday is defined as “deliberate interruption of pharmacotherapy for a defined period and for a specific clinical purpose".¹ Common clinical purposes include to minimize or decrease potential adverse effects as well as to assess the need for ongoing pharmacotherapy, particularly for treatment of ADHD. Reassessment of the need for ongoing ADHD treatment is important, given that a proportion of individuals with ADHD experience remission of symptoms over time (likely due to brain maturation). Common times where “holidays” are considered include weekends during the school year (short ‘holidays’) and breaks from school in the winter and summer (longer ‘holidays’), when academic demands might be less. In this newsletter we will review what is known about medication holidays, including evidence around rebound of ADHD symptoms when stimulants are stopped as well as evidence around whether stimulant side effects are lessened with medication holidays.  

Re-emergence of ADHD Symptoms with Medication Discontinuation:

A recent systematic review conducted in partnership with the American Academy of Child and Adolescent Psychiatry examined the evidence around intentional discontinuation of stimulants.² Encompassing multiple types of studies (e.g., observational, studies tapering stimulants and studies in which stimulants were withdrawn/discontinued), they found that while most individuals experienced a re-emergence of ADHD symptoms (and/or impairment) with stimulants, a proportion (around 30% in several studies) did not experience either a deterioration or relapse of symptoms after stimulant discontinuation. Additional findings of this review included the importance of obtaining multiple informants (e.g., parents, teachers) about symptoms after discontinuation; one study found greater report of symptoms with discontinuation by teacher as compared to parent report.³ They also noted that in studies testing whether psychotherapy/behavioral therapy attenuated worsening symptoms when stimulants are discontinued, there was no evidence of attenuation. Finally, this review noted that in most cases, symptoms should re-emerge quickly (e.g., within 2 weeks or less). 

Mitigation of Stimulant Side Effects with Drug Holidays:

The aforementioned review also examined common stimulant side effects (e.g., effects on weight and height) and found mixed evidence about whether adverse effects were mitigated by drug holidays.² There was some evidence for short-term weight gain with stimulant discontinuation. For example, some studies describe weight gain amongst those randomized to placebo (discontinuation) of stimulant compared to those continuing stimulant treatment,⁴ while another study found no statistically significant differences in weight change between those who discontinued stimulants over the course of two summers. However, a difference in height (with the ‘summer holiday’ group being 1.5cm taller than the group which did not discontinue stimulants for the summer) was observed.⁵ A study examining whether stimulant discontinuation affected tics among those with premorbid disorder found no significant difference with discontinuation.⁶  

Effects of Weekend Holidays:

Patients/families may also ask whether there is evidence that not taking stimulants during the weekend can cause worse, or ‘rebound’ ADHD symptoms early the following week when stimulants are resumed. A study randomizing individuals to placebo or methylphenidate on the weekends did not find rebound ADHD symptoms on Mondays after weekend holidays, and the placebo group also had reduction in insomnia symptoms after weekend holidays.⁷ 

Decisions around Whether to take 'Medication Holidays':

It is important to note that the decision to take a holiday may depend somewhat on the severity of symptoms and the demands placed on an individual during a potential holiday period. For example, if a child has a weekend that may be demanding academically or socially (where hyperactivity/impulsivity may interfere with social relationships) or upcoming significant demands (e.g., state testing), the demands and potential ‘risk’ of a holiday may outweigh potential benefits. Shared decision-making (considering patient and family preference, benefits and adverse effects of the medication, and the potential impact of stopping the medication on education and functioning) is important in considering medication holidays. It is also important to understand the reason for desired discontinuation (e.g., are there concerns about stigma of taking medications at school that could be addressed with a different formulation? Are there concerns about particular side effects?)

Practice guidelines (e.g., American Academy of Pediatrics Clinical Practice Guidelines) suggest that on a case-by-case basis, periodic (e.g., annual) trials of stopping medication should be considered in order to determine whether there is ongoing need. One clinical sign that a trial of stopping medication may be warranted is if the patient has been symptom-free, with no recent need for an increased dose, for a 1-year period. Similarly, if there is lack of deterioration with missed doses or planned holidays, a trial of stopping the medication could be considered. 

As always, if you have questions about the behavioral health needs of your patients, we encourage you to call the BHIPP consultation line at 

855-MD-BHIPP (632-4477), open 9am-5pm Monday-Friday, for resource/referral networking or consultation support.

We will keep you informed about all our services and training events through our website (www.mdbhipp.org) and monthly e-newsletters. Additionally, BHIPP is on LinkedIn, X, and Facebook. We invite you to follow us there to stay up-to-date on upcoming training events, pediatric mental health research, and resources for providers, families and children.

BHIPP Announcements

New BHIPP ECHO: Enhanced Behavioral Health Training for PMHNPs

Register for the new BHIPP PMHNP ECHO series! The next session will be held on December 3rd from 11:00am-12:00pm. Join our multidisciplinary team of child behavioral health experts every month between November 2024 and April 2025 for virtual case-based learning and didactic presentations. This series is designed for Maryland Psychiatric-Mental Health Nurse Practitioners (PMHNPs) who want to deepen their knowledge of child and adolescent mental health. Free CEU credit is available for participation.

Register for the upcoming BHIPP Webinar!

Register for an upcoming BHIPP Webinar on December 4th at 12:00pm! BHIPP Webinars are a series of interactive, web-based learning sessions that are a virtual space for pediatric primary care, emergency medicine, and behavioral health providers to connect, learn and share about strategies, practices and resources to promote mental health and resilience among children and families as well as providers. Free CME and CEU credit is available for participation.

Register for the BHIPP ECHO Beyond the Basics Series!

Register for the BHIPP ECHO Beyond the Basics series! The next session will be held on December 12th from 12:00-1:00pm. Join our multidisciplinary team of child behavioral health experts on the second Thursday of every month between October 2024 and May 2025 for virtual case-based learning and didactic presentations. This series is great for providers who have already participated in BHIPP ECHO, or who feel like they are experienced in treating behavioral health in their practice and are looking to explore advanced topics. Free CME and CEU credit is available for participation.

Join the BHIPP ECHO Core Foundations Series Learning Collaborative!

Register for the BHIPP ECHO Core Foundations series! The next session will be held on December 19th from 12:00-1:00pm. Join our multidisciplinary team of child behavioral health experts every month between October 2024 and May 2025 for virtual case-based learning and didactic presentations. This series is great for providers who want to improve their knowledge of child mental health and develop foundational skills. Free CME and CEU credit is available for participation.

How has BHIPP helped you provide behavioral health care to your pediatric patients?

Thank you for your participation in BHIPP. We want to hear from you! Tell us about your experiences and how BHIPP has helped improve your practice in the Health Professional Impact Survey. Help programs like ours continue to serve health professionals like you in the future by sharing your feedback!

Haven’t connected with us yet? Please reach out for support and resources to help you address your pediatric patients’ behavioral health concerns: 855-MD-BHIPP (632-4477)

Complete this survey on Tourette Syndrome to receive a

$50 e-gift card!

The Tourette Syndrome Center of Excellence at Johns Hopkins Medicine and Kennedy Krieger Institute in collaboration with Maryland Behavioral Health Integration in Pediatric Primary Care (BHIPP) is conducting a brief survey to better understand pediatric primary care providers (PCPs) knowledge about Tourette Syndrome and related tic disorders (collectively TS) and to identify current practices of PCPs when encountering children and adolescents with TS. We will use this information to inform development of clinical tools to assist PCPs when encountering youth with TS in their everyday practice. PCPs will receive a $50 e-gift card upon completion of this 20-minute survey.