1.
Thoughtful Child
Psychopharmacology in
the Summertime
Stephen Grcevich, MD
Family Center by the Falls, Chagrin Falls OH
Associate Professor of Psychiatry, NEOMED
Stark MHAR Lunch and Learn Series
May 19, 2021

2.
Learning
objectives
• Participants will…
• Explore a model for medical decision-
making in adjusting medication
regimens in children and teens being
treated for common mental health
conditions during the summertime.
• Identify issues and concerns unique to
summer that may impact prescribing
decisions.
• Discuss the rationale for “structured
treatment interruptions” of
pharmacotherapy during the summer,
with a focus on medication for ADHD.

3.
What are we treating?
• Emotional distress and functional impairment
across at least one of four major life domains
• School
• Peer relationships
• Family relationships/functioning
• Age-appropriate community activities
• How do the relative importance of major life
domains shift during the summer?

4.
Impacts of the
environments
where kids
spend their
time
• “Structure” – the extent to which the environment
promotes ability to focus on what’s most important
in the moment.
• Rules, expectations
• Demands upon decision-making
• Sensory stimulation
• Mental stimulation – extent to which activities
taking place occupy the consciousness of
participants
• Culture: expectation for how people will act – and
interact with one another

5.
How treatment
considerations
change in
summer
• Relative importance of life domains and
functional impairment shifts
• Capacity for academic tasks – less
important
• Interpersonal functioning at home grows
in importance
• Environments that help to promote or hinder
positive mental health differ relative to the
school year

6.
A mental model
for addressing
summer
treatment needs
• What treatment needs
are likely to require
more attention during
the summer?
• Are there advantages to
initiating, discontinuing
specific medications in
the summer?
• Are there medications
for which the risk-benefit
ratio is less favorable in
the summer?

7.
Which patients are likely to get worse over
the summer?

8.
Patients who get worse in
summer
• Patients with internalizing disorders who rely upon
cognitive stimulation for relief.
• OCD
• Anxiety Disorders
• DMDD
• Some kids on the high end of autism spectrum
• Patients who depend upon structure available
outside their families to maintain self control.
• Autism
• Disruptive behavior disorders
• Patients from homes where they experience
ongoing trauma, neglect

9.
How can we help them?

10.
How can we help them?
• Busy is better!
• Direct families to activities that afford
necessary cognitive stimulation, structure
• Utilize school-based counselors, case
managers to assist parents in creating more
favorable home environments
• Shifting pharmacotherapy priorities

11.
When might a summer trial of new
medication be advantageous?
• Kids with lots of impulsive, aggressive behavior
at home, in less structured environments
• When feedback from teachers is less important
in medical decision-making
• Kids who might benefit from an SSRI, but
concerns exist re: behavior activation,
motivation in school

12.
When medications
shouldn’t be stopped in
summer
• Anxiety medication when anxiety
in school is a key consideration
• Depression medication when
school stressors are a major
contributor to mood.
• Immediately prior to major life
stressors
• High school-college transition
• Substantial changes in school
demands anticipated in fall
• Family relocation

13.
Structured Treatment Interruptions
(“drug holidays”)
• The conscious, deliberate suspension of
medication, usually for a short time.
• May include any combination of weekends, week-
long, monthly, school vacations or any combination
• Used to:
• Demonstrate the clinical need for medication
• Temporarily remove side effects to medication
(sleep delay, appetite suppression, perceived or
real tolerance)
• Satisfy notion of caregivers that medication should
not be used if it can be avoided.
Manos MJ. Opinions on Drug Holidays in Pediatric ADHD, Medscape Psychiatry 2005;10(2)

14.
When are
structured
treatment
interruptions
indicated?
• Functional impairment necessitating
medication is substantially reduced or absent
• Tradeoff between benefits, drawbacks of
medication becomes unfavorable
• Appetite suppression, sleep issues
• Medication for school causes significant
issues in peer relations
• Parent preference

15.
What’s the evidence basis for
ADHD medication holidays?
• No clear consensus on benefits
• Presumed reasons for medication holidays
• Compensate for appetite suppression, failure to
gain weight in school year
• Mitigates impacts of ADHD meds on growth, stature
• Mitigates any “tolerance” that may occur
• Most “thought leaders” recommend treatment
seven days/week, 365 days/year
• Possible protective effects against substance abuse
in adolescents
NICE guideline NG87, National Institute for Health and Care Excellence (NICE) 2018

16.
Summer challenges may call for different
treatment approaches

17.
ADHD medication needs
during summer
• Kids may benefit from different…
• Drug
• Dose timing
• Duration of action
• Activities necessitating medication in summer
• Summer school, tutoring
• Sports/extracurricular activities
• Special activities requiring greater than usual self-
control
• Driving in older patients

18.
Conclusions
• Differences in environment, expectations and
functional demands faced by our patients in
summer may call for different medication
regimens.
• More, less or different medication may be
indicated.
• Goal: Help patients and families achieve optimal
functioning in summer across all environments
• On as few medications as possible
• In as small a dose as possible
• For as short a period of time as possible

19.
Contact
information
• sgrcevich@neomed.edu
• https://www.linkedin.com/in
/stephen-grcevich-md/
• Twitter: @drgrcevich