ADHD: Strategies for Developing a Further Dialogue - Episode 4
Expert physicians consider how the management of pediatrics with ADHD (attention deficit hyperactivity disorder) has changed during the COVID-19 pandemic, with special consideration to the use of telemedicine.
Tim Wilens, MD: You're talking about taking care of the kids, we’ve talked about the comorbidities, etc. Taking care of the kid, just in case you haven't looked around, everybody realizes we’re in a very special time right now, and that is we’re trying to care for, both pediatrically and from a child psychiatric standpoint, kids in the middle of COVID-19 [coronavirus disease 2019]. We’re trying to figure this out in terms of what we do.
Mark, how has the practice of pediatrics changed with diagnosing and treating ADHD [attention-deficit/hyperactivity disorder] during COVID-19? Can people follow the guidelines?
Mark Wolraich, MD: In some ways there's some improvement, particularly with the need for telemedicine that has been promoted with the COVID epidemic. One of the difficulties as you probably know, the stimulant medication, you could change doses rapidly. You don’t have to wait a month to figure out if it’s working, and we’ve tried to get pediatricians to do it on a weekly basis, not with necessarily seeing the child, but by a phone call with the parent.
The difficulty with that has been that it’s not been a reimbursable intervention for the physicians to do, so it’s been a hard sell for us to do it. With telemedicine that can happen much better, particularly if they start compensating for it. The characteristics of the child are not so much what you see in the office, which is not their typical setting, but what the parents are observing and what the teachers are observing, so getting that information. That was part of the reason I had developed the Vanderbilt [ADHD Diagnostic Rating] Scale, so that there was a more systematic collection of the ratings of the behaviors that are going on.
The guidelines do recommend that you see the child back within a month after being seen, and then monthly, and spacing it out more. But certainly, with use of telemedicine that can come pretty close to what’s needed, probably more so than some of the other conditions that you all have to deal with that need much more intimate contact with the patients themselves.
Tim Wilens, MD: That’s reassuring, and I have to say that telemedicine has become front and central. What’s interesting is telemedicine is not new to this country. Our rural colleagues have been using telemedicine for years, and I would say, rather effectively. In fact, in ADHD research, a study started almost a decade ago that was published a few years ago by Kathleen Myers [MD, MPH], showed that using telehealth, following guidelines, doing things properly, not just shooting from the hip, when you did that and you compared it to in-person treatment as usual, you had as good or better outcomes using telehealth than you did with treatment as usual. Again in that study, part of it was they were doing guidelines, they were using appropriate, best-evidence practice of medicine type of work. Nevertheless, it’s evident that telemedicine works and telehealth works.
A couple of other comments about telehealth, part of the reason it’s worked, and we do need to thank the relaxation of the regulatory oversight, as there has been a state of emergency declared, and because of that, Ryan White [health care act] and other laws were revised to allow people to use telehealth to start new prescriptions of controlled substances, licensures. There was relaxation of boundaries allowing people out of state and things of that nature. There have been changes that one would expect to see regulatory tightening at the end of COVID-19, with, I would think, most continuation of telehealth.
Other issues about telehealth that are interesting are that many of the programs, such as mine, are finding that we’re about 10% to 15% higher in the number of visits we’re doing this year compared to same time last year. We think much of that is because of the ease of using telehealth. Patients can come to appointments much easier; they don’t have to drive far distances. They’re able to dial up, dial in. Parents don’t have to take off a half day of work, kids don’t a have to miss sports, kids don’t have to miss school. They're able to do that, so we’re able to schedule people easier, we’re able to not have people miss appointments; our no-show rates dropped precipitously. Our first no-shows for evaluations have dropped precipitously. That’s been another big important thing compared to last year.
The other interesting point is you get to see people in their own environment, and it’s a huge thing to be able to look into people’s houses. Not all of it is great on the other hand, with telehealth, and we still have a lot of challenges right now. First of all, my hat goes out to pediatricians who are trying to look at vital signs and trying to evaluate rashes and everything. But for most of us, we can’t do vital signs, we can’t do physicals, we can’t look at things, if the kid has a tic, it may be hard to pick up on a screen.
Then there are a number of kids who don’t have access. Most people think of telehealth like it’s a video, but it’s also telephone. Not all families have telephones, and not all families have bandwidth, and not all families have computers, and until we solve that, many communities are underserved using telehealth, and there needs to be continued advocacy and growth in that area. Then there are technical issues that we’ve all dealt with, and lastly, that human connection, so I think telehealth is here to stay.
Mark Wolraich, MD: Another element I think we’re seeing that makes a big difference is that some of the continuing education programs, and one that Harlan and I have been involved with the REACH Institute, set up the communication between child psychiatrists and pediatricians. A lot of times what we hear from pediatricians is if the case is difficult, they don’t have somewhere to go or who they can call. In a lot of parts of the country, we’ve been trying to set up where there is a child psychiatrist they can call to get a consult, and they’re not doing a formal consult with them, so that the really severe patients are ones we can clearly send to you, but there's a group where the pediatricians need some help but can still implement the treatment within their setting.
Tim Wilens, MD: That’s terrific, and that is something that as you rightly put, rurally, they’ve optimized that. It’s absolutely a great point.
-Dr. Findling receives or has received research support, acted as a consultant and/or has received honoraria from Acadia, Adamas, Aevi, Afecta, Akili, Alkermes, Allergan, American Academy of Child & Adolescent Psychiatry, American Psychiatric Press, Arbor, Axsome, Daiichi-Sankyo, Emelex, Gedeon Richter, Genentech, Idorsia, Intra-Cellular Therapies, Kempharm, Luminopia, Lundbeck, MedAvante-ProPhase, Merck, MJH Life Sciences,NIH, Neurim, Otsuka, PaxMedica, PCORI, Pfizer, Physicians Postgraduate Press, Q BioMed, Receptor Life Sciences, Roche, Sage, Signant Health, Sunovion, Supernus Pharmaceuticals, Syneos, Syneurx, Takeda, Teva, Tris, and Validus.
-Dr Gephart is retired from the practice of medicine. He is on the faculty of the REACH Institute for a course entitled “Patient Centered Mental Health in Primary Care.” He receives a stipend for serving as a virtual consultant to Course graduates who call in and present difficult cases. He has no other financial contracts to report.
-Dr Childress reports receipt of research or writing support, participation on advisory boards, and service as a consultant or speaker for Adlon Therapeutics, Aevi Genomic Medicine, Akili Interactive, Allergan, Arbor Pharmaceuticals, Cingulate Therapeutics, Emalex Biosciences, Ironshore Pharmaceuticals, Jazz Pharmaceuticals, KemPharm, Lundbeck, Neos Therapeutics, Neurovance, NLS Pharma, Otsuka, Pearson, Pfizer, Purdue Pharma, Rhodes Pharmaceuticals, Sunovion, Supernus Pharmaceuticals, Takeda, and Tris Pharma.
-Dr Wolraich is professor emeritus from the University of Oklahoma Health Sciences Center. He is on the steering committee and a faculty member of the REACH Institute, a non-profit organization providing CME training on mental health to primary care physicians. He has no affiliations or investments where he receives any compensation, and he is no longer in any clinical practice.
-Dr Wilens is Chief, Division of Child and Adolescent Psychiatry and Co-Director of the Center for Addiction Medicine at Massachusetts General Hospital. He receives or has received grant support from NIH(NIDA). He is or has been a consultant for Arbor, Otsuka, Ironshore, KemPharm and Vallon. He is the author of Straight Talk About Psychiatric Medications for Kids (Guilford Press). He is co-editor of ADHD in Adults and Children (Cambridge University Press), Massachusetts General Hospital Comprehensive Clinical Psychiatry (Elsevier); and Massachusetts General Hospital Psychopharmacology and Neurotherapeutics (Elsevier). He is co-owner of a copyrighted diagnostic questionnaire (Before School Functioning Questionnaire) and has a licensing agreement with Ironshore (BSFQ Questionnaire). He serves as a clinical consultant to the US National Football League (ERM Associates), U.S. Minor/Major League Baseball; Gavin Foundation and Bay Cove Human Services.