Review of: Wang SM et al, J Psychiatr Res 2017;84:292–300.

Modafinil (Provigil) is FDA-approved for narcolepsy, obstructive sleep apnea, and shift work sleep disorder, but not for ADHD. Given that it has some of the same stimulating properties of psychostimulants, it should theoretically be effective. Wang and colleagues identified five randomized placebo-controlled trials testing modafinil for the treatment of ADHD in children and adolescents, and performed a meta-analysis of this data.

Of the 927 participants in these studies, 640 were randomly assigned to modafinil (doses ranged from 170–425 mg/day), and 287 were assigned to placebo. All five RCTs were short-term studies (all < 9 weeks). Patients on modafinil showed more improvement on ADHD scores than patients on placebo, with a standard mean difference vs placebo of -0.77 and -0.71 for the ADHD-RS-IV home and school versions, respectively. The standard mean difference is also known as the effect size, and this effect size is moderate to large. (For perspective, in previous meta-analyses, effect sizes for stimulants have been in the 0.6–0.8 range.) Modafinil patients experienced more insomnia and decreased appetite. Only four cases of serious adverse events (Stevens-Johnson syndrome, duodenitis, and two cases of dehydration) were reported in the modafinil group.

CCPR’s take
Modafinil appears to work about as well as stimulants for children and adolescents with ADHD. It is a good off-label option for kids who don’t respond or don’t tolerate stimulants. Just be aware that there is a small (likely very small) risk of Stevens-Johnson syndrome.