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The National Commission on Correctional Health Care's (NCCHC) annual awards pay tribute to leaders and innovators who have enriched the correctional health care field. This year's awards were presented November 1 during the opening ceremony of the 

National Conference on Correctional Health Care

The South Woods State Prison in New Jersey has been named the R. Scott Chavez Facility of the Year. The award is presented to one facility selected from among all NCCHC-accredited facilities for outstanding quality, innovation, and dedication. South Woods State Prison is the largest and one of the newest facilities managed by the New Jersey Department of Corrections with a capacity to house more than 3000 incarcerated individuals, including some of the most critically ill in the state system. Despite its size, NCCHC surveyors noted that close collaboration between custody, health care, and mental health care creates a positive culture focused on high-quality, personalized care, provided by Rutgers University Correctional Health Care.


recognizes programs of excellence among the thousands provided by accredited jails, prisons, and juvenile facilities. This year, the 

Hillsborough County Sheriff's Office, Falkenberg Road Jai

in Tampa, Florida, was chosen for its Veterans Resurgence Program. In August 2019, Hillsborough County Sheriff Chad Chronister launched the Veterans Resurgence Program, which focuses on providing incarcerated US military veterans with a supportive and constructive environment to help restore their dignity. In addition to receiving mental health and substance abuse treatment, participating veterans are housed together in a pod decorated with American flags and flags from each branch of the US military. Inspirational imagery painted by inmates covers the walls.

 for demonstrated excellence and service to advance the correctional health care field. For 20+ years Dr Clarke oversaw all health care at the Berkshire County Jail and House of Correction in Pittsfield, Massachusetts, guiding that facility to NCCHC accreditation and to a Program of the Year Award for its innovative long-term care and discharge planning program. Dr Clarke remains highly involved with NCCHC and with the organization’s consulting arm, NCCHC Resources. An NCCHC physician surveyor for almost 20 years, he has been an active member of the surveyor advisory committee since its inception, served on the task forces that revised the 2014 and 2018 editions of the 

 and is a regular presenter of seminars on the standards.

 pays tribute to innovative, well-executed communications that have had a positive impact on the field of correctional health care, or to individuals for bodies of work. This year the award was given to 

for excellence in communications. Ms Johnson has nearly 30 years of correctional health care legal experience with over 20 years providing legal services for Centurion Health and MHM Services, Inc, Centurion’s cofounding company. She is a nationally recognized expert in correctional health law and a frequent

Edward A. Harrison Award of Excellence in Correctional Health Care Leadership

 This award is presented to someone who leads by example, inspires others, and is committed to quality improvement in correctional health care. Dr Andrade has over 20 years of correctional and forensic health experience and is a nationally recognized mental health expert in the treatment and management of individuals with personality disorders and gender dysphoria in correctional settings. He is a published author and regular presenter/educator on the delivery of effective treatment for those populations. He is currently the senior director of behavioral health services at Centurion Health.

 recognizes new and upcoming leaders in the field of correctional health care. This year’s winner is 

attending psychiatrist at San Francisco Jail Behavioral Health Service and assistant professor of clinical psychiatry at UCSF Department of Psychiatry and Behavioral Sciences. He became inspired to pursue a career in correctional and forensic psychiatry during an elective rotation at Bellvue Hospital during medical school at Harvard University. Dr Morris has published extensively in peer-reviewed journals and popular media. He hopes to help change views and treatment of incarcerated people with mental health issues, while also continuing to provide direct patient care.

 Ms Mayne served for nearly 2 decades as health services administrator for the Fairfax County Adult Detention Center in Virginia. Between supervising 23 health professionals, establishing chronic care clinics, developing nursing protocols, and implementing a new medical records system, she also found time to participate in NCCHC accreditation surveys. She became a lead surveyor soon after retiring and has devoted herself to that vocation ever since. When COVID-19 drove surveys to a more high-tech virtual format, Ms Mayne embraced the new technology and was soon training other surveyors on the process. Throughout the pandemic, she has been a leader in the number of virtual and hybrid surveys completed.

Congratulations to all the award winners!

Articles

2021 NCCHC Conference

Check out the National Commission on Correctional Health Care's annual award winners! 

Award Winners Honored at 45th National Conference on Correctional Health Care

Napoleon B. Higgins, Jr, MD, and Rona J. Hu, MD, presented on the impact of cultural differences on health disparities and unequal access to care at the 

2021 Neuroscience Education Institute (NEI) Congress

 Friday, November 5, in Colorado Springs, Colorado.

In their presentation, titled “Nurturing Cultural Humility in Mental Health Care,” Higgins and Hu discussed the impact of history on current mental health care outcomes; the effects of racism on mental health; the ways oppression, racism, access barriers, and other sociocultural factors lead to health disparities and mental health sequelae; and the importance of cultural humility in mental health care settings. They reported that, due to many historical incidents of racism and oppression over the years in mental health care, patients from minority communities have often been excluded from research studies; diagnostic assessments have not been sensitive for minority populations; diagnostic and treatment algorithms often pay little attention to diversity; not as much is known about the differences in the ways individuals from different cultures may express symptoms of mental illness; and, therefore, many patients from minority communities may distrust the medical system. This lack of information about—and trust from—these communities is problematic in part because there is predicted to be a 90% increase in racial and ethnic minorities by 2050, according to the United States Census Bureau.

In order to improve outcomes with patients from minority communities, Higgins and Hu suggested that practitioners recognize their privilege and the historical role of privilege in oppressive systems; recognize their own biases and stereotypes, and the ways these impact reactions to microaggressions and other cultural issues in therapeutic settings; and practice cultural humility, which Higgins and Hu defined as a willingness and lifelong dedication to learn from patients about their experiences by asking questions—rather than making assumptions—while acknowledging their own embeddedness in culture(s).

 “We don’t want to make assumptions—we always want to ask and be inquisitive,” Higgins said during the presentation. “When you show that you’re inquisitive, it shows interest, not ignorance. When you ask the question, it shows that you’re interested in that person’s story.”

Higgins is president and CEO of Bay Pointe Behavioral Health Service, Inc., and South East Houston Research Group; medical director of the Hold My Hand Residential Treatment Center; and a staff psychiatrist in the Prairie View A&M University Student Center. Hu is a clinical professor in the Stanford Medical Center Department of Psychiatry and Behavioral Sciences, and associate dean of Academic Affairs at the Stanford University School of Medicine.

1. Higgins, Jr. NB, Hu RJ. Nurturing cultural humility in mental health care. Presented at 2021 NEI Congress. November 5, 2021.

2021 NEI Congress

How can cultural humility in therapeutic settings improve patient outcomes?

Nurturing Cultural Humility in Mental Health Care

affects individuals of all ages with and without concomitant psychiatric disorders. To help foster recognition, Narmada Neerja Bhimanadham, MD, and Ornela Ali, MD, from the department of psychiatry at Bergen New Bridge Medical Center, in Paramus, New Jersey, shared a poster presentation on somatic symptom disorder at the 2021 NEI Congress.

Somatic symptom disorder is characterized by various bodily complaints that are not associated with organic changes and cannot be attributed to a disease. Although stressful life events (eg, loss of a loved one, children leaving home, financial hardships) often precipitate symptom onset, cytokines such as interferon, tumor necrosis factor, and cerebral asymmetry may also play a role, noted Bhimanadham and Ali. They reported prevalence of somatic symptom disorder tends to decrease after age 65 years, with rates range from 11% to 21% in younger patients, 10% to 20% in middle-aged patients, and 1.5% to 13% in older patients.

To illustrate the complexity of the disorder, Bhimanadham and Ali shared the case of a man aged 62 years with a history of anxiety and unspecified depression who voluntarily presented to the emergency department.

Upon presentation, the patient complained of generalized body aches, burning sensation, numbness of the forehead and face, all of which he noted began 2 years prior and after he took an herbal supplement for osteoarthritis. Based on research on the internet, the patient further believed he developed lead poisoning as a result. The patient appeared anxious, and he demanded that staff admit him and perform a number of diagnostic tests. 

Results of basic tests found complete blood count, serum chemistry, and bronchoalveolar lavage within normal limits. Urinalysis analysis and SARS-CoV-2 test were also negative. After further investigation, it was learned that the patient received a diagnosis of somatoform disorder in 2013 and was hospitalized in January 2021 with similar complaints. At that time, he underwent numerous diagnostic tests, including EEG, electromyography, spinal tap, CT of his head, and 25 MRIs of the brain, all of which were nonsignificant.

During the evaluation, the patient noted his daughter had moved out of the house, around the same time the symptoms first appeared. His demeanor changed when discussing his daughter, with sad affect noted.

In terms of treatment, trials of venlafaxine, lurasidone, paliperidone, duloxetine, mirtazapine, clomipramine, quetiapine, risperidone, and fluvoxamine were used. Unfortunately, there were issues with adherence, so the efficacy of the various regimens was unknown. However, the patient’s condition stabilized, and he was discharged after a thorough evaluation.

“Phase of life problems could also contribute to somatic symptom disorder due to lack of coping strategies to manage stress, life changing situations, or to face the expected physiological changes and cognitive decline that are part of normal aging process,” Ali said in the poster presentation. She added, “We know that primary care physicians, psychiatrists, and neurologists encounter most of the cases, where 20% to 60% of outpatient visits constitute of medically unexplained symptoms.”

“The concept of mind-body dualism might pose a challenge in early identification of the condition and subsequently lead to frequent hospital visits, numerous diagnostic tests, and an overall increase in health care costs and patient dissatisfaction,” Ali reported. With that in mind, Ali emphasized the importance of inquiring about risk factors such as social and psychological stressors to assist in identifying somatic symptom disorder. She also suggested the use of PHQ-15 in clinical practice, especially in primary care settings, as an effective screening tool.

“Management should be focused on establishing a strong patient provider relationship, combining psychotherapy and pharmacotherapy to improve outcomes and, ultimately, patient's quality of life,” she concluded.

Exploring Somatic Symptom Disorder: A Case Report

Roger S. McIntyre, MD, FRCPC, of the University of Toronto and the University Health Network presented on inflammation in individuals with mood disorders at the 2021 Neuroscience Education Institute (NEI) Congress Friday, November 5, in Colorado Springs, Colorado.

In his presentation, titled “Inflamed in the Brain: The Role of Inflammation in Psychiatry,” McIntyre discussed the physiology of the inflammatory system and how inflammation correlates in individuals with mood disorders, as well as some common anti-inflammatory interventions for these individuals. He stated that there is a high prevalence of inflammation in individuals with mood disorders such as depression and bipolar disorder: About 25% to 30% of individuals with major depressive disorder (MDD) or bipolar disorder have a CRP of higher than 3 mg per liter, and 50% have a CRP of higher than 1. Using COVID-19 as an example, he reported that individuals with MDD or bipolar disorder were more likely to contract, be hospitalized, and die due to COVID-19. Further, one-third of outpatients and one-half of inpatients with COVID-19 have since developed a neurologic or psychiatric disorder.

McIntyre shared that some sources of pro-inflammatory balance in mood disorders include genetics, as well as environmental factors like social determinants (eg, poverty), behavior (eg, smoking cigarettes), diet, sleep disturbance/chronobiology, comorbidity (eg, obesity), microbiota, trauma, and loneliness. He also recommended several anti-inflammatory treatment methods, including mindfulness, exercise, restorative sleep, Mediterranean-like diet, and greater social network ties.

According to McIntyre, having an increased understanding of the link between inflammation and psychiatric disorders has become particularly important, given the association between COVID-19 and mood disorders.“We have a serious public health crisis right now,” he said during his presentation. “We all want to see our patients get vaccinated to protect their health … but I think we have to advocate for our patients. And we have to be very vigilant because I don’t think we know if a year from now—or 2 years from now or 3 years from now—whether the immunocompetence can be assumed to be identical. I don’t know the answer to that. It’s a really interesting hypothesis that if we can better treat them with psychotherapy, CBT, mindfulness, and good antidepressants they can tolerate, this might be the extra boost they need.”

McIntyre is a professor of psychiatry and pharmacology at the University of Toronto and head of the Mood Disorders Psychopharmacology Unit at the University Health Network in Toronto, Canada. In his research, he aims primarily to characterize the neurobiology, phenomenology, and novel therapeutics of mood disorders.

1. McIntyre RS. Inflamed in the brain: the role of inflammation in psychiatry. Presented at 2021 NEI Congress. November 5, 2021.

What is the connection between inflammation and mood disorders?

Inflamed in the Brain

“I am not here to speak on behalf of the trans community. I do not presume to know their lived experience. What I do strive to do, however, is to infuse the lived experiences that they have entrusted with me into everything that I do, as a clinician, as a teacher, and as a researcher.”

In her session, “Beyond the Binary: Affirmative Mental Health Care for Transgender and Gender Diverse People,” at the 2021 NEI Congress, Rhonda Schwindt, DNP, RN, PMHNP-BC, shared information on affirmative mental health care for transgender and gender diverse people.

“Trans people have the right to determine who they are. And they have the right to expect that you will believe them. Now, in order to do that, we have to be willing to challenge that social construct that tells us gender can only exist within the binary, male female,” said Schwindt, who is an associate professor and Director of the Psychiatric-Mental Health Nurse Practitioner Program at George Washington University School of Nursing in Ashburn, Virginia.

Schwindt went on to use the example of “Michael.” Michael is a 25-year-old who identifies as a transgender male. About 6 months ago, Michael finally got a well-deserved and desired promotion; however, with that promotion came a new office in a new building with new coworkers. And almost immediately after he assumed that new position, he became the target of daily harassment, bullying, and discrimination. Michael began mapping out the nearest public restrooms, places where his coworkers could not judge him, but when realized those bathroom trips were not sustainable, he began limited his fluid intake. He then needed medical intervention for severe dehydration and constipation.

“What Michael needed was for me to be an affirming mental health care provider and to ask him about his lived experience,” said Schwindt. “When I finally did that, then we were able to bring in a team of people and work with Michael. You can't medicate away discrimination.”

Schwindt also brought up the discouraging suicide rate in the trans community: suicide attempt rates amongst transgender patients is about 40%. She stressed how assessing for specific gender identity conversion efforts is important, as it may be contributing to a trans patient’s suicidal ideation.

Overall, Schwindt reminded the audience that, “affirmative mental health care requires a holistic, client centered approach to care,” especially in the case of transgender and gender diverse patients.

How can you provide affirmative mental health care for transgender and gender diverse patients? 

Infusing Lived Experiences for Trans and Gender Diverse Patients

“Benzodiazepines. Is there any class of medications probably other than opiates that evokes that same visceral reaction? I don't think so,” said Jeffrey R. Strawn, MD, in his session “The When, Why, and How of Using Benzodiazepines” at the 2021 NEI Congress.

Strawn playfully asked the audience, “How many of your viewers are like me you have that love hate relationship with the benzodiazepines?” About 90% of the in-person audience raised their hands.

Strawn began with discussing the varied advantages and disadvantages of benzodiazepines use. Advantages include rapid onset, reasonable tolerability, useful for breakthrough symptoms, and may be useful for acute and chronic anxiety. Disadvantages include initial sedation, memory impairment, falls, possible increased risk of fracture, and possibility of abuse dependence and withdrawal.

According to Strawn, recent research shows approximately 7.4% of patients seen in psychiatric care are receiving benzodiazepines.

 Unfortunately, 5.2 million adults misuse benzodiazepines. Of those, 0.5 million adults had benzodiazepines use disorder and 0.3 million had benzodiazepines dependence.

 Factors that increase risk for benzodiazepines misuse, use disorders, and harms include younger age, male gender, socioeconomically disadvantage, substance use disorders, and divorced or separated or never married.

Overall, Strawn said, “Benzodiazepines have a role in treating anxiety disorders, but they require monitoring and consideration of risks/benefits.”

Tolerance data are mixed, although benzodiazepines should be used carefully in patients with a history of substance use. They could be potentially beneficial when patients have breakthrough symptoms, when rapid onset is needed (panic attacks), or when the patient is experiencing acute expected anxiety (phobias). However, patients who are older, children, and those concurrently using opioids, have a history of substance use disorder, are at risk of falling, or operate heavy machinery should be carefully monitored, as they have a lower likelihood of benefit.

Patterns in outpatient benzodiazepine prescribing in the United States

Prevalence and correlates of benzodiazepine use, misuse, and use disorders among adults in the United States.

Benzodiazepines: a class of medications that evokes that a visceral reaction.

The Love-Hate Relationship with Benzodiazepines

Andrew J. Cutler, MD, of SUNY Upstate Medical University and the Neuroscience Education Institute (NEI) presented on the management of the most common adverse effects of 

In his presentation, titled “Safety First: A Comparison of the Safety and Tolerability of Antipsychotics,” Cutler discussed the 4 most common adverse effects of antipsychotics that can negatively affect treatment adherence—metabolic problems, movement disorders, sedation, and sexual dysfunction

—as well as some treatment strategies medical providers can use to optimize the management of these adverse effects according to individual patient needs.

To manage metabolic problems, Cutler recommended monitoring metabolic parameters, weight gain, and appetite changes; encouraging a healthy diet and active lifestyle; choosing agents with lower incidents of weight gain when possible (eg, aripiprazole, lurasidone); considering the incorporation of metformin when initiating treatment with olanzapine or clozapine; or using olanzapine with samidorphan instead of olanzapine alone. For movement disorders, he suggested some specific strategies for drug-induced parkinsonism (DIP) and akathisia, which both may be mitigated by reducing dosage or switching to medications with lower risk (eg, clozapine, iloperidone, lumateperone) when possible. Introducing adjunctive medications (eg, beta-adrenergic blockers, benzodiazepines) may also be helpful in cases of akathisia. For sedation, he recommended consolidating antipsychotic medication doses into once-daily doses; identifying any potential interactions between the antipsychotics and other medications the patient may be taking; ruling out comorbid disorders that may be contributing to the sedation; and switching to antipsychotics with a lower risk of sedation (eg, lumateperone, pimavanserin) when possible. Finally, for sexual dysfunction, he suggested selecting an antipsychotic agent with lower likelihood of elevating prolactin (eg, lurasidone, quetiapine) or lowering prolactin (eg, brexpiprazole, cariprazine); considering adding low doses of aripiprazole to another antipsychotic that is causing sexual dysfunction and hyperprolactinemia; and incorporating psychosocial strategies such as relationship counseling and psychoeducation.

“Medications used to treat psychosis may be the single most powerful tool in a clinician’s armamentarium for reducing antipsychotic-induced adverse effects,” Cutler said in his presentation. Cutler is a clinical associate professor in the SUNY Upstate Medical University Department of Psychiatry, and chief medical officer for NEI. He is board certified in internal medicine by the American Board of Internal Medicine and in psychiatry by the American Board of Psychiatry and Neurology.

1. Cutler AJ. Safety first: a comparison of the safety and tolerability of antipsychotics. Presented at 2021 NEI Congress. November 5, 2021.

How do you manage the 4 most common adverse effects of antipsychotic medications?

Safety First

Parul Kumar, MD, and colleagues from Westchester Medical Center, 

, Department of Psychiatry, reported on an unusual encounter as part of the 2021 Neuroscience Education Institute Poster Presentation. The patient, aged 38, was a White female with a history of schizoaffective disorder. She presented to the emergency department with reports of racing thoughts, distractibility, increased energy, decreased need for sleep, and hyper-talkativeness.

The patient reported delusions of her father invisibly raping her. She also reported hypoguesia and 

 1-2 days prior to her visit to the emergency department, but now was hallucinating smells of blood and flesh. She denied head trauma, seizures, as well as previous emotional, physical, and sexual trauma. The patient noted a remote history of migraines.

Neurological examination was within normal limits, as were brain computed tomography, chest X-ray, and various laboratory studies. However, the patient tested positive for SARS-CoV-2.

Following admission and treatment for 2 days that included aripiprazole, haloperidol, topiramate, and fluoxetine, the patient reported resolution of the hallucinations and was discharged to follow-up outpatient care.

Research has indicated that patients with schizophrenia have an increased risk for acquiring COVID-19, with an adjusted odds ratio of 7.34,

 along with increased risk for hospitalization (27.4% vs 18.6%) and mortality (8.5% vs 4.7%) compared with individuals with no psychiatric disorders, respectively. Kumar et al noted the olfactory symptoms were the only presenting symptoms associated with COVID-19 in their patient. Thus, they recommended testing for SARS-CoV-2 in patients with psychosis or other psychiatric illness who present with olfactory symptoms as part of the differential diagnosis.

Increased risk of COVID -19 infection and mortality in people with mental

disorders: analysis from electronic health records in the United States

This case presented as part of the Poster Presentations at the 2021 NEI Congress is a good reminder of the importance of taking a thorough history.   

Case Report Poster: A Smelly Situation 

Are treatments delivering what they should be and what patients need? That’s the question 

2021 Neuroscience Education Institute Congress

. “I've been a psychiatrist now for over 2 decades, and it’s an incredible privilege that I've been given to meet people, meet families. And I've heard narrative, after narrative, after narrative that the treatments are not delivering what I had hoped they could deliver,” McIntyre said. “And it's encouraged me to not just rethink, but also to refocus on what are the therapeutic objectives.”

McIntyre shared results from a study looking at the differences between issues in depression recovery that are important to patients versus issues that are deemed indicators of recovery by clinicians.

 Investigators found that there is a disconnect between the goals of treatment, with health care providers looking for resolution of symptoms like blue mood, despair, anxiety, and depression while patients were more interested in issues regarding quality of life, like finding meaning and enjoying oneself. “This is part of a larger recognition that there's a bit of a disconnect between what the consumer is prioritizing, and what we prioritize. I don't think we're completely on different pages, but we are not prioritizing this in a way that is entirely aligned,” noted McIntyre, who is a professor in the departments of psychiatry and pharmacology and head of the Mood Disorders Psychopharmacology Unit at the University Health Network in the University of Toronto. To better align the priorities, McIntyre suggested clinicians take the new approach of not just “taketh away of mental illness but to giveth mental health and well-being.”

To do so, McIntyre told attendees to carefully check the diagnosis, identify both physical and psychiatric comorbidities, including hypothyroidism, Cushing’s syndrome, Parkinsonism, malignancy, anemia, viral infections, vitamin and dietary deficiencies, substance misuse, anxiety disorders, eating disorders, personality disorders, posttraumatic stress disorders, and bipolar disorder.

If the diagnosis was accurate and treatment is still not effectively improving symptoms, McIntyre noted there are a few options to consider. Although adjunctive antipsychotics can result in adverse effects, he noted they can prove useful. In addition, the events can be mitigated. Similarly, neuromodulators and psychotherapy can and should be considered, he said.

Currently, a number of psychopharmacological avenues are being studied, he added. Opportunistic molecular targets for mood disorders include orexins, opioids, GABA, metabolism, glutamate, monoamines, and immune inflammatory systems.

“We now know that 35 to 45% of people with depression, especially treatment resistant depression, have elevated CRPs, elevated inflammation,” McIntyre noted. “There are data showing that NSAIDs, omega-3s, statins, minocycline—an antibiotic—are antidepressants in clinical trials. Should we all be going to our office tomorrow and prescribing NSAIDs, omega-3, statins, and minocycline? I would say hold your horses, hold your horses. There are limitations to this. It works. But the studies are small, with a lot of heterogeneity in the studies.” Ultimately, he noted, more work is needed. 

Ultimately, McIntyre reminded attendees to consider the patient perspective. Although there are newer molecular targets and promising treatments on the horizon, listening to patients and determining the underlying reasons for treatment resistance in major depression (ie, comorbidities, childhood trauma, residual symptoms) can help guide treatment and lead to more successful outcomes.

1. Demyttenaere K, Donneau AF, Albert A, et al. 

What is important in being cured from depression? Discordance between physicians and patients

2. McIntyre RS, Berk M, Brietzke E, et al. 

How can we improve treatment response? Look to the patient. 

Not Good Enough

“It’s important that from day 1 we see the patient, we are looking for comorbidities,” said Napoleon B. Higgins, Jr, MD, at the 2021 NEI Congress in his talk “There’s More to It: ADHD and Comorbidities.” Higgins is President and CEO of Bay Pointe Behavioral Health Services and South East Houston Research Group, Medical Director at Hold My Hand Residential Treatment Center, and executive director of Black Psychiatrists of America.

Higgins recommends considering the common comorbidities that often occur in the context of attention-deficit/hyperactivity disorder (ADHD) when planning treatment, and integrating treatment strategies that address both ADHD and comorbid conditions.

More than 50% of individuals with ADHD have comorbid disorders. Comorbid conditions include learning and language disabilities, mood disorders like depression and mania, anxiety, anger and impulse control disorders, and tic disorders.

Child nutrition, Higgins stressed, is key: “When you have a child's brain being developed on poor nutrition, you are going to have poor outcomes. You cannot have a Cheeto-derived brain.”

Nutritional interventions may be necessary when deciding when to treat or not to treat. “Whatever helps the heart, helps the mind,” Higgins said of dietary behavioral interventions, parallel training, and making sure expectations are clear.

Higgins also stated he focuses on “the trump cards,” or things that must be in control before the ADHD can be treated. These include mania, psychosis, depression, or learning disabilities.

Bipolar disorder and ADHD may be difficult to differentiate, Higgins noted. “I will say that the most common diagnosis that an adult with bipolar disorder will have if they were seen as a child is ADHD. Why is that? Mood issues tend to show up in later adolescence.”

When transitioning to adulthood, according to Higgins, children with ADHD must:

1. Take ownership of their treatment and direct the interview

2. Assist in finding a mental health provider

3. Transition from a child to an adult psychiatrist

5. Schedule follow-ups during breaks in college

Beyond medications, Higgins offered the following treatment options as part of ADHD coaching: decreased distractions, time management, self-motivation or self-monitoring, setting goals for the day, prioritizing tasks, breaking things down to pieces, setting a place for work, using a planning system, understanding emotions, and prayer and meditation.

Here’s how to integrate treatment strategies that address both ADHD and comorbid conditions.

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