
- Vol 38, Issue 3
- Volume 03
Navigating New Challenges in the Management of ADHD
Multidisciplinary insights on helping patients with ADHD during the COVID-19 pandemic, medication abuse, and other factors affecting care.
VIEWPOINTS
Diagnosis and treatment of attention deficit hyperactivity disorder (ADHD) are associated with a variety of practical and clinical challenges. In a recent Psychiatric Times™
Diagnosis is Key
ADHD is the most common presenting neurobehavioral disorder that pediatricians and child psychiatrists will see in their course of practice and is second only to asthma when ranked among all chronic pediatric illnesses, Wilens explained as he opened the discussion. The prevalence of ADHD among children is between 6% to 9%, regardless of country of origin.
Diagnosis can be made as young as age 4. Behavioral interventions are the first-line treatment option. When deemed appropriate and necessary, stimulant medications are the first-line choice for pharmacotherapy, according to the
A key challenge associated with ADHD is making an accurate diagnosis, Robert L. Findling, MD, MBA, said, noting that a countless number of things may make a child appear inattentive or fidgety.
“[Diagnosis] can only be done by a careful assessment, both cross-sectionally and over time, [and] pediatricians are particularly well-equipped to do such a thing because [they] have the benefit of watching children grow up,” Findling explained. He added that comorbidities, such as oppositional defiant disorder,
Approximately 70% to 75% of kids with ADHD have a comorbid medical or psychiatric disorder or
To help manage ADHD, pediatricians and child psychiatrists would benefit through collaboration, Findling said. “Sometimes it just takes a bunch of people working together, putting the kid right in the center,” he explained.
However, Mark Wolraich, MD explained that
ADHD Management During the COVID-19 Pandemic
In addition to these challenges, the panelists discussed several downstream consequences of the
Telemedicine
For years,
“Patients can come to appointments much easier,” Wilens said. “[Parents] don’t have to drive far distances, [they] don’t have to take off a half day of work, kids don’t have to miss sports [or] school. Our no-show rates [have] dropped precipitously.”
In addition, as ADHD stimulant medications are scheduled drugs, Wilens also observed that the relaxing of regulatory oversight during the pandemic for prescribing controlled substances via telehealth visit has proven helpful.
The downside of increased
Virtual Schooling
Another challenge associated with a more virtual world in the wake of the COVID-19 pandemic, is not all children are back to in-person learning at
But it’s not just concerns over learning, children with ADHD have strengths that can’t be observed virtually, Findling said. “[So] now they have lost the chance to succeed in domains that they might have been successful at when [school] was in person and not via screen,” he explained.
Medication Access
COVID-19 has also made for supply chain issues that have created access barriers for stimulant medications. “We’re dealing with distribution problems, [and] people are having more problems finding stimulants … they may have to go to 3 or 4 different pharmacies,” Wilens said.
Because pharmacies will not always tell someone over the phone if they have a particular stimulant medication in stock over robbery concerns, a parent may drive there only to learn the medication isn’t available. “Then I have to … go back and send [the e-script] to another pharmacy, [and] it takes up a lot of time just to try and get somebody their medicine,” Childress said.
Unfortunately, COVID-19 has forced many people out of work and that has also meant loss of health insurance for families, making it difficult to afford brand-name ADHD medications that they have already been taking. “I’m having to do things that I don’t like to do, and that’s switch people to immediate-release [agents] that they can afford,” Childress said.
How to Curb ADHD Stimulant Drug Abuse
The last big challenge in the management of ADHD that the panelists discussed is the misuse of prescription stimulant drugs.
Nonmedical use of prescription stimulants—using the drug differently than was prescribed or using the drug without a prescription—has now outpaced opioid [use] among teens and young adults, Wilens explained, with the highest rates of abuse aggregating at colleges and universities.
“It turns out that about 40% of stimulant misuse is intranasal,” Wilens said. “This is a huge concern … [because] if you use [it] intranasal[ly] or intravenous[ly], you have a 20-fold [higher] likelihood of serious medical morbidity or even death.”
The panelists offered several suggestions for curbing nonmedical use of prescription stimulants: prescribe extended-release formulations, monitor pill counts, and write [scripts] for the number of tablets the patient needs. Extended-release formulations have less intranasal abuse potential versus their immediate release counterparts, while pill counting and not writing for extra tablets helps prevent stockpiling.
Several
“[It’s] really exciting to hear that we have new potential alternatives [for use in ADHD] … [and that] they are trying to make them safer,” Wilens said.
EXPERT PANEL
Timothy Wilens, MD
Chief, Division of Child and Adolescent Psychiatry
Co-Director, Center for Addiction Medicine
Director, Substance Abuse Services in Pediatric Psychopharmacology
Massachusetts General Hospital
Boston, Massachusetts
Ann Childress, MD
Clinical Associate Professor
University of Nevada School of Medicine
Las Vegas, Nevada
Robert L. Findling, MD, MBA
Chair, Department of Psychiatry
Virginia Commonwealth School of Medicine
Richmond, Virginia
Harlan R. Gephart, MD
Author of ADHD Complex: Practicing Mental Health in Primary Care
Bellevue, Washington
Mark Wolraich, MD
Professor, University of Health Sciences
Oklahoma City, Oklahoma
To watch the complete custom video program, visit
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