Podcast Transcript
ADHD Medication Management
Summary:
ADHD medications can provide significant benefits for youth, including improving attention and self-regulation and reducing risks such as depression, anxiety, and accidents. This podcast provides an overview of the different categories of ADHD medications, how they work, their effects on ADHD symptoms, and considerations around side effects, comorbidities like anxiety, and the risk of substance abuse. Discussed also are strategies for starting and titrating ADHD medications, including the importance of not undertreating, medication's role as part of a comprehensive treatment plan, and the importance of getting feedback from teachers and others involved in the individual's life to optimize treatment. The speakers emphasize the importance of an individualized, multimodal approach to managing ADHD, with medications playing a key role in helping the individual function better but not being the sole solution. They also emphasize the need to closely monitor individuals on ADHD medications and to make adjustments as needed.
Max Wiznitzer, MD
Max Wiznitzer, MD, is a pediatric neurologist at Rainbow Babies & Children’s Hospital in Cleveland, Ohio. He is a professor of pediatrics and neurology at Case Western Reserve University. He has a longstanding interest in neurodevelopmental disabilities, especially ADHD and autism, and has been involved in local, state, and national committees and initiatives, including autism treatment research, Ohio autism service guidelines, autism screening, and early identification of developmental disabilities. He is on the editorial board of Lancet Neurology and the Journal of Child Neurology and lectures nationally and internationally about various neurodevelopmental disabilities.
Carolyn Lentzsch-Parcells, MD
Carolyn Lentzsch-Parcells, MD, is a board-certified pediatrician and an assistant professor of pediatrics at the TCU Burnett School of Medicine. As a physician with ADHD herself, she has a special interest in caring for patients and families with ADHD and learning issues. Dr. Lentzsch-Parcells regularly speaks to parent, student, and professional audiences on subjects such as parenting, ADHD, depression, anxiety and stress, adolescent development, sexuality, and preparing for college.
Learning Objectives for this podcast:
- Explain the benefits of ADHD medication as part of ADHD management.
- Learn about the main categories of ADHD medications and their efficacy.
- Understand the need for individualized ADHD medication management.
- Identify the professionals involved in a multimodal intervention for a child's ADHD.
Learning Objectives for CHADD Podcast Series PD4969:
- Identify ADHD symptoms throughout the lifespan to improve diagnosis and treatment precision.
- Describe common coexisting conditions in people with ADHD to enhance care strategies.
- Explain effective principles of ADHD medication management for better outcomes.
- Discuss the importance of integrating behavioral and other interventions in managing ADHD for comprehensive care.
- Describe the role of interprofessional collaboration in delivering effective ADHD treatment.
The following transcript has been edited for clarity.
Announcer (00:00): You are listening to Pocket MD training on ADHD in children and adults.
Dr. Max Wiznitzer (00:07): Welcome to the Pocket MD podcast on ADHD medications. I'm Dr. Max Wiznitzer, co-chair of the professional advisory board at CHADD, the national advocacy group for ADHD. And today our guest is Dr. Carolyn Lentzsch-Parcells. Dr. Lentzsch-Parcells, would you please introduce yourself?
Dr. Carolyn Lentzsch-Parcells (00:25): I would love to. Thank you so much. I'm a board-certified pediatrician who has ADHD, and I also take care of children, teens, and young adults who have ADHD. I'm also the committee chair for the development committee for CHADD.
Dr. Max Wiznitzer (00:42): Thank you, and thank you for all your service. Today's topic is about medication. We recognize that medication is part of the triad of medication, behavioral intervention, and educational and work environment intervention that is necessary for the appropriate and optimal management of ADHD. And while we acknowledge that medication is only part of it, which basically gets you to the starting line so that you can utilize all the other skills, it's still important to get to that starting line and therefore that's what we're going to be focusing on today. Dr. Lentzsch-Parcells, tell us, people know what ADHD is, but what are the benefits of using ADHD medications?
Dr. Carolyn Lentzsch-Parcells (01:22): Oh, thank you so much for asking that. There's so much. We have reams and reams of data now showing us all kinds of benefits, short term and long term. But I think some of the most important things that people don't always recognize, like you said, I love how you said it, it's getting us to the starting line because medication does absolutely help us to learn the skills we need and apply the skills we need. For one, I've always said pills don't build skills, but as I've practiced over the years, I've changed to saying pills don't build skills, but they sure as heck help us use them. So, I think that's a really important part of ADHD medications. But the research also shows us on a bigger scale that optimal treatment of our ADHD, which does often include the use of medication, decreases risk for depression, anxiety, substance abuse, accidents, it improves school performance, work performance, relationship performance. And with Dr. Russell Barkley's work, and then the work that came out of England not that long ago, we also have data to show that treating our ADHD optimally may even extend our lifespan. So, there's now evidence to suggest that taking care of our ADHD also helps us. The way I put it to people is, it helps us take care of us overall and take care of our overall health and wellness.
Dr. Max Wiznitzer (02:42): What are the basic or core categories of ADHD medications and how does each one seem to work in order to advance the functioning of these individuals?
Dr. Carolyn Lentzsch-Parcells (02:52): The way I like to describe it is [that] I start with, there's two big families of ADHD medications. There's stimulants and, and then within each of those big families, there's smaller families. So, we have our stimulant medications that we can then break down into the methylphenidates and the amphetamines. Methylphenidates are things like people might've heard of—Concerta, Ritalin, Focalin. There's a whole bunch of other ones now, too. And then of course the amphetamines, things like Adderall, Vyvanse, and again, there's a whole bunch of other ones there too. And then we have the nonstimulant medications; those are things like atomoxetine, also known as Strattera, newer ones like Qelbree, Intuniv, also known as guanfacine. So, there's multiple categories of medications. Sometimes they're used individually, sometimes they're actually used in combination with each other for better efficacy, depending on the patient and what they need.
Dr. Max Wiznitzer (03:45): When we're talking about the modes or mechanisms by which these medicines work, is there a difference between the stimulant and the nonstimulants?
Dr. Carolyn Lentzsch-Parcells (03:53): Yes. Vastly simplifying, stimulant medications primarily work by increasing available dopamine in the brain or increasing available dopamine and norepinephrine available in the brain. Whereas the nonstimulants, it depends on the nonstimulant; guanfacine and clonidine are what we call alpha-adrenergic agonists. Technically speaking, we still don't totally understand how they work in ADHD, but it makes sense to me why they work in ADHD because overall the primary use of those is helping with impulsivity, hyperactivity, emotional regulation, possibly rejection sensitivity dysphoria. And what we do know about these medicines, because they were previously or still are used as centrally acting blood pressure medications, is they decrease sympathetic outflow—or, as I like to call them, the literal chill pill. They kind of tamp down that sympathetic nervous system response, which to me then makes sense if you look at what they do for folks with ADHD. Now the other ones, atomoxetine or Strattera and Qelbree, are known as selective norepinephrine reuptake inhibitors. So, for the most part, they work by increasing available norepinephrine in the brain. Although with Qelbree, there's evidence that it also increases available serotonin in the brain, I believe some dopamine as well.
Dr. Max Wiznitzer (05:16): People have said that there are some mild differences in some of the medications. So, for instance, if you're on a methylphenidate, Ritalin-type product, it can improve your attention span, but it also can also blunt your affect and do things like this, whether you're using an amphetamine or an Adderall-type medication. It also has an effect on impulsivity, but not as much effect on your own overall personality. Have you seen that pattern?
Dr. Carolyn Lentzsch-Parcells (05:44): You know what, no, actually, I don't think I have. And maybe that's just mainly because of the patient population that I see; well, I say that it's funny, because I see younger kids. I do see adults or young adults and adolescents, but because my patient population skews younger, I use more methylphenidates in general. So, I think some of that is selection bias for me. But in general, so much of the response to ADHD medications—both side effects and efficacy in my experience—it's just so individualized. But again, it's funny, now that you asked that question, I'm kind of thinking through it and going, do I see more of it? Because I do see blunting of affect for some of my kids. I just don't know, statistically speaking, do I see more of it in the methylphenidates than the amphetamines? I'm not sure, to be totally honest.
Dr. Max Wiznitzer (06:34): That's all right. Now, as you mentioned that these medications either enhance dopamine or affect norepinephrine or impact the sympathetic system. What specific ADHD symptoms do they impact in order to help the individuals function better?
Dr. Carolyn Lentzsch-Parcells (06:50): The stimulant medications at least have the potential to have a positive effect on all of the core symptoms of ADHD, meaning impulsivity and hyperactivity symptoms and the symptoms associated with attention and focus. So, attention, focus, initiating tasks, hyperactivity side of things, fidgeting, sitting still, being able to self-regulate, really. Because I know there's a lot of talk out there about this, but it's one of the things that I think is so important to understand about ADHD and therefore about ADHD medications again, is that it's not just about hyperactivity, impulsivity, focus, and attention, it's overall self-regulation. And so, what we're hoping for with the medications, and in particular with, as I'm talking about the stimulants, is overall improvement in ability to self-regulate across the board. Now with the stimulant medications, though, both really any of them, the evidence suggests that they don't necessarily help as much with the executive functioning side of things, the executive functioning symptoms directly.
But here's what I tell patients. While the medicines don't necessarily affect or help with executive functioning directly—I come back to the pills do not build skills, but they sure as heck help us use them—the medicine, if it helps us with our focus and attention and our impulsivity and all of those things, it helps us to learn the strategies better that we need to help with our executive functioning. It helps us to store those strategies better and it helps us with the impulse control we need in the moment to go, hold on a second. Well, how do I want to handle this? Let me grab that skill and use that skill. So, I kind of feel like, secondarily, some people might feel like they see an improvement in their executive functioning skills. It's just not directly from the medication. With the nonstimulant medications, same kind of thing.
Strattera and the Qelbree are supposedly able to—and I'll tell you why I said supposedly in a minute—help with overall both the inattentive and attention symptoms as well as the impulsivity and hyperactivity symptoms, but they haven't been shown to be as effective as the stimulants. That's why I say supposedly, because they certainly do help some people, and as I tell everybody, if your medicine is working for you, then great. It's just for most people, they haven't been shown to be as effective as stimulant medications. The alpha-adrenergic agonists guanfacine and clonidine may help a little bit with attention and focus, but really they primarily help with the impulsivity and hyperactivity symptoms as well as the emotional regulation side of things.
Dr. Max Wiznitzer (09:26): Now, you've talked about the benefits of the medications, but what about any potential drawbacks or complications or side effects that people may get from medications?
Dr. Carolyn Lentzsch-Parcells (09:37): So, obviously, I tell folks all the time, everything we do in medicine, there's a potential upside and a potential downside, right? There's potential side effects. So, for any of the stimulants, and it varies by person, varies by age group, et cetera, but the kind of common side effects we see are things like headache, stomachache, decreased appetite, feeling irritated, agitated, revved up, not in a good way or the opposite, feeling like blunted out, blah. Again, I take care of teenagers and kids and young adults, so I use terms like meh and blah because those are the medical terms that we understand and appreciate and can identify with. So, those are of course always a possibility. But I also tell patients, just because you have side effects with one medication doesn't mean you're going to have those same side effects or that same severity of side effect with other medications.
And in fact, you might not even have those same side effects or intensity of side effects with another medicine even within the same family. And I set that expectation early on because so many of my patients, by the time they come to me, have tried maybe one medicine or one dose of one medicine or maybe two doses of one medicine or two medicines, but they were like, Nope, not for me. And they gave up and said, Nope, this is not for me. I don't like these medicines, which I completely understand, but I like to set the expectation that it might take us some time to find the right thing or the right combination of things. So, that's the stimulant medications. And then of course, each of the non-stimulant medications has their own independent potential side effect profile.
The other thing I like to talk to people about though, when we're talking about side effects, we always talk about the side effects of medicine, but we don't always talk about the side effects of not taking medicine. And I think that's something very important for us to think about and talk about, especially in the context of ADHD. And again, not saying that medication is going to be the right choice for everybody, we know it's not. We also know that at least, I think, 85% of people with ADHD will have a positive response to at least one ADHD medication, stimulants in particular. So, it's important for us to at least consider it, and it's important for us to consider not only the potential benefits and risk of the medicine, but the potential benefits and risks of not taking the medicine.
Dr. Max Wiznitzer (11:55): One of the things, patterns that I've noticed, is in the children and adults who are put on stimulant medications or sometimes also nonstimulants who get irritable or nasty or more temperamental, explosive, we have to look check to see if those are a comorbidity of an anxiety disorder.
Dr. Carolyn Lentzsch-Parcells (12:12): Agreed.
Dr. Max Wiznitzer (12:13): And that's much more common than, for instance, they're bipolar or anything like that.
Dr. Carolyn Lentzsch-Parcells (12:18): Correct. Agreed.
Dr. Max Wiznitzer (12:19): And anxiety disorder tends to be something that is vastly underidentified and overlooked.
Dr. Carolyn Lentzsch-Parcells (12:24): Could not agree more, sir.
Dr. Max Wiznitzer (12:26): It's a little pearl for our listeners to recognize that it may be something as simple as that, and then either go to a nonstimulant medication or then treat the anxiety and go back and explore. And one more little thing, as long as we're talking about anxieties. In my clinical experience, there have been certain stimulant medications that seem to be better tolerated with the anxiety population. It's been a dexmethylphenidate product because it's a more concentrated form of methylphenidate or Ritalin, and therefore there's less potential for side effects. And also, it's based on the delivery system, so that the methylphenidate patches which put the medicine into the body at a much slower rate seem to be better tolerated than if you take an oral medication, which has a much faster route or rate of medication absorption and therefore blood level achievement.
Dr. Carolyn Lentzsch-Parcells (13:15): Yes. Well, Dr. Wiznitzer, since you brought that up, because I think that is such an important point because I've had that happen too, where patients come to me and they think it's side effect of the medicine, and really what we're seeing is an increasing of the anxiety, and we need to manage that. Do you see, I feel like I've seen this in my patient population, but again, there may be some selection bias there. Do you see more issues with increased anxiety with lisdexamphetamine, Vyvanse?
Dr. Max Wiznitzer (13:44): We see it more with amphetamine products in general.
Dr. Carolyn Lentzsch-Parcells (13:46): In general, okay. Same.
Dr. Max Wiznitzer (13:48): In general; in fact, there are data to support that statement that methylphenidate products are better tolerated than amphetamine products when it comes to the anxiety comorbidity.
Dr. Carolyn Lentzsch-Parcells (13:57): I agree, and that's what I've seen. Obviously, like you said, there's research, but that's also what I see clinically, which is the other reason why I feel like in my patient population, I skew more toward the methylphenidates. Not that I have anything against the amphetamines, but so much of my patient population has anxiety that I think that's the other thing that skews me more toward the methylphenidates.
Dr. Max Wiznitzer (14:21): Well, and since we're talking about comorbidities and concerns and worries, there are several other concerns that people raise when it comes to, especially to the stimulant medications, but ADHD medications, the risk of addiction to the medication, the risk of tics, tic exacerbation or production, things of that level. What do you say to parents when they raise this point?
Dr. Carolyn Lentzsch-Parcells (14:43): Oh, I'm so glad you asked because this is one that I get on a massive soap box about. So, first, the substance abuse question, I want to be so exceedingly clear on this because unfortunately, this is still an area that I think there is so much misunderstanding or misinformation in the public, but also in the professional world. So, to be very, very, very, very, very clear, the research—reams and reams of research—shows us that utilizing stimulant medications in the proper dosages under the guidance of a medical professional significantly decreases the risk of substance abuse, use, dependence, and addiction. Not only that, but there is research that shows that early diagnosis and treatment are what significantly decreases that risk. And in at least one particular study that I saw that I found very, very interesting, they showed that kids who were diagnosed early and treated early had decreased risk of addiction. Kids who were diagnosed early but not treated until much later had the same elevated risk as those who weren't diagnosed or treated until later. So, it wasn't just about the diagnosis, it was about diagnosis and treatment.
Dr. Max Wiznitzer (16:04): In a timely manner.
Dr. Carolyn Lentzsch-Parcells (16:06): Yes.
Dr. Max Wiznitzer (16:06): In a timely manner.
Dr. Carolyn Lentzsch-Parcells (16:07): Exactly. Now, I also want to be clear, I'm not saying these medications cannot be misused or abused. They can. We have to be very clear about that. We have to educate our patients and our parents about that. But the use of ADHD medications properly has a very, very low risk of abuse or dependence. And I would add, just as a little side note: if they were addictive, you wouldn't have to remind us to take our medicine. Okay. I just want to put that there.
Dr. Max Wiznitzer (16:41): That's a very good observation.
Dr. Carolyn Lentzsch-Parcells (16:42): Just saying.
Dr. Max Wiznitzer (16:43): Now, in my experience with tics, for the most part, most of the time the medications, the stimulant medicines, don't either bring on or exacerbate tics unless the individual has a coexisting anxiety disorder. And very rarely do you see tic activity increase, but most of the time it's in concert with increased anxiety.
Dr. Carolyn Lentzsch-Parcells (17:02): Agreed.
Dr. Max Wiznitzer (17:02): In your observation.
Dr. Carolyn Lentzsch-Parcells (17:03): Yep. No, I agree with that, too. And I'm also very clear with parents that the stimulant medications don't cause tics. They decrease the brain's ability to suppress them, basically, is kind of how I explain it. And I'll oftentimes—even if there is a little uptick in them—for a lot of my patients, it's not bothersome enough to change the medicine. I have had situations though, so guanfacine, guanfacine ER, one of those nonstimulant medications we were talking about, can help with tics and with tic exacerbation. So, certainly if the tics are cranking up with the medication, like you said, first of all, we ask about anxiety and we look into what's going on there. If we need to change medicines or try a different formulation, I will do that. But also sometimes, especially if the medicine's working really well for the patient, we will bring on guanfacine to help with that.
The other reason I like bringing in guanfacine too, though, is even though it's not an anti-anxiety medicine, technically, as I said, it decreases sympathetic output, which is what? It's our fight or flight system. So, for my kids with ADHD who also have anxiety, I find that oftentimes it's a really nice complement with the stimulant because it helps kind of with that overstimulation, with that hyperarousal, with that anxiety, can help with those tics. And sometimes too, if it's a kiddo who can't, or I say kiddo because that's my patient population, but this also goes for adolescents and adults, if they are not able to reach a dose of stimulant that's optimal for their symptom control without side effects that aren't tolerable, sometimes adding in that guanfacine can help get you to that spot of optimization that you can't get to with the stimulant alone.
Dr. Max Wiznitzer (18:48): Exactly, and that basically brings up the point as you've started it, that sometimes combining a stimulant and a nonstimulant medication, and there are data to support those conclusions, whether it's an alpha-adrenergic agent or whether it's a selective norepinephrine reuptake inhibitor, but mixing them with a stimulant medication can give you that extra oomph and benefit, especially when one dose, one of them isn't enough and you really maximize the amount that you're giving. I think that's for our listeners, it's important to realize that mixing and matching appropriately can be very helpful.
Dr. Carolyn Lentzsch-Parcells (19:20): It can be very helpful.
Dr. Max Wiznitzer (19:21): Let me move on. When you're starting medication, basically, my principle has always been start low, go slow. How do you approach?
Dr. Carolyn Lentzsch-Parcells (19:31): So, you know what, I've changed this in various ways over the years, and I, for the most part, I agree with you, especially if they are naive to the medication. But even if we're changing medicines, you start with the lowest or one of the lowest doses and you titrate up in a stepwise fashion until you reach the best tolerated, most optimal dose, because you don't know. It's not necessarily related to severity of ADHD or age or size or those kinds of things. So, you just don't know until you try, which is one of the things that can be, of course, really frustrating for patients and families. As far as how quickly I go, it largely depends on the patient and the family, if the family's involved, if it's a younger kiddo, and what their comfort level is. And the reason I say that is because we can, especially with the stimulant medications, we can titrate them or adjust them relatively quickly, right?
Three to five days, I usually say a week, just because it's easy for people to remember and also then they can start it on a weekend where parents can see how it's going, see if there's any side effects, or if it's an adult, they can try it on a non-work day and make sure that they're tolerating it. I do think it's important, though, I wouldn't say necessarily fast, but briskly and purposefully, to make our way toward an optimal dose and not undertreat. So, I know there's different theories and different ways of titrating or deciding when we're kind of at an optimal dose, but I do think it's really important that we do our best not to undertreat. And I'm curious, Dr. Wiznitzer, how do you do it?
Dr. Max Wiznitzer (21:13): Basically, it all depends what comorbidities are present. I know we have discussed things like anxiety, tic disorder, but there's also the potential comorbidities of growth, appetite, and things of this nature. You have to balance all those things.
Dr. Carolyn Lentzsch-Parcells (21:28): Absolutely.
Dr. Max Wiznitzer (21:28): You stated you do it now. I tend to start my medications using an immediate-release product because I figure if it’s a child or a young adult, it's going to have a side effect. It's going to be short-lived because you're only on a short-lasting medicine compared to long-lasting. And then I will shift over to the long lasting and titrate to the appropriate dose there. But I agree, I maximize it to the point the individuals are giving us feedback with the recognition you're never going to, it's rare that you're going to make it a hundred percent.
Dr. Carolyn Lentzsch-Parcells (21:57): Absolutely.
Dr. Max Wiznitzer (21:58): That's what the behavioral educational/work environment interventions are for in order to get you those last few days, let's say, to make the touch.
Dr. Carolyn Lentzsch-Parcells (22:06): Okay. So, to use your analogy from earlier, medicine gets you the starting line, the skills and the strategies help you cross the finish line.
Dr. Max Wiznitzer (22:14): Exactly. But for people who have the expectation, I put you on medicine, it's going to fix everything and all you need is a little bit of a dose, we find out that's not necessarily true. One of my experiences also has been, especially as the individuals get a bit older, and we're talking about mainly the stimulant medications, that the dose is not based as much on weight, and we have to recognize in the adolescent and in the adult years that the dosing can be from a very low dose to a maximized dose depending on how the body handles the medication on the individual size. I mean, if you're 300 pounds, you may need a different dose than if you're 150 pounds. And those are things that we have to put into consideration. Now, let me ask you a question. When you start a medicine, what is the expectation, stimulant and nonstimulants, how long—if it's going to work—how long should it take for us to see the results?
Dr. Carolyn Lentzsch-Parcells (23:05): Well, to be totally honest, that's part of why I think the stimulants are still the gold standard for ADHD, besides the fact, just the research that they're the most effective, but stimulant medications work within 30 to 45 minutes of taking them, except for, there's a couple of formulations that are a little differently, but for the most part, so we see efficacy immediately, which for ADHD people is very helpful. And so, we see efficacy very quickly. It might take more time for side effects to resolve if we are having side effects, but as a result, we can really get going on medication very, very quickly. With the nonstimulants, it depends on the nonstimulant. Strattera, one of the biggest atomoxetine, is that it takes so long to take full effect, so eight to twelve weeks, right? Qelbree is less time than that, but it does still take, I want to say up to four weeks to take full effect. And for guanfacine, I feel like most of my patients report seeing something relatively quickly, but technically you don't see efficacy for a week, and it takes two to three weeks to get full efficacy. So, that's one of the downsides of the nonstimulant medications versus stimulant medications. And we do like our immediate gratification.
Dr. Max Wiznitzer (24:18): What should you monitor? You're starting somebody on a medication for ADHD. What should you monitor and how often should you monitor?
Dr. Carolyn Lentzsch-Parcells (24:25): That's a great question. So, I typically see them once a month when we're titrating medications, when we're adjusting the medication, and depending on the medication we're using, depending on the family, depending on their comfort level, comorbidities, all those things, if everybody's comfortable with it, I will allow them to adjust the dose themselves if it's being well tolerated once or twice in that timeframe. But I'm seeing them at least once a month, and some of them, honestly, I'm touching base with even more than that until we reach the optimal dose. Once we think we're on the optimal dose, I personally like to see them another month later just to make sure we weren't having a honeymoon period. And then once we're stable, I see them every three months; in part because these are control, they're on a stimulant, but even if they're not, honestly, all of my patients on any ADHD or mental health medication, I see every three months.
And again, part of that's because of the medications themselves, but it's also because my population is kids, teenagers, and young adults. Their brains are changing constantly and they may or may not know, even though we talk about it, when to call or when to reach out if they're struggling or having a problem, they may not totally realize that their challenge that they're facing is because their medication isn't optimized or they're having a side effect from their medication. I keep a pretty tight rein, if you will. I monitor my kiddos pretty closely, but again, I think that's both the nature of the medications, but also just the nature of brain development.
Dr. Max Wiznitzer (25:53): I have them touch base with us. They may call us. I also do virtual visits, which makes it very easy and depending on the individual; you are correct, anywhere between three and six months. I'll have my college students check in with me at the end of every semester just to see how they're doing. So, I agree. Now, there are two more points. One is what happens if you're traveling with the medication?
Dr. Carolyn Lentzsch-Parcells (26:15): Yes.
Dr. Max Wiznitzer (26:16): What issues should we consider for that both in the country and outside the country?
Dr. Carolyn Lentzsch-Parcells (26:20): First of all, whenever you're traveling with your medication, if it's a stimulant medication in particular, but I recommend this for all medications, make sure you are traveling with it in a properly labeled pharmacy bottle. End of story. No matter where you're traveling, if you are traveling out of this country, you need to go to, usually it's the consulate page, but actually, if you go to our government page, I want to say, is it the CDC page? I just looked this up the other day, I apologize. But even if you just Google stimulant medication in the country, it'll typically bring you to our government page for travel. Then you click on the country that you are going to, scroll down, and there'll be a health and medicine section. You click on that and basically you want to double check with the country you are going to or any country you are touching down in, even if it's just to connect to another flight.
What are their requirements? What do they need? And is your medication even legal in that country? Most countries, in my experience, because I do travel quite a bit, and I have a lot of patients that do too, most countries will require the medicine to be in the labeled bottle. They typically have a limit on how much you can bring into the country, and they typically want a letter of some sort from your physician documenting your diagnosis, what you're taking, why you're taking it, where you're going to be, and when you're going to be there. But again, it varies by country, and it is very, very important that you look at that before you leave the country and give yourself enough time if you need something from your doctor.
Dr. Max Wiznitzer (27:54): Correct. Correct. Now, we've gone through potential side effects as we've mentioned, the questions about growth and appetite and everything else, but then integrating the medication within the entire management plan. We have the management plan. Who should be the other individuals besides the families who give you feedback so you can optimize the use of the medication within the multimodal intervention that is being done for that individual?
Dr. Carolyn Lentzsch-Parcells (28:21): Absolutely. Ideally, if they're still in school, teachers; I know sometimes it can be difficult to get those forms or that input back. For college students, it can be a little trickier. I still like to get that feedback if they've got folks that they feel like they can be open with and trust with that information. But it depends on the person. I do think counseling is fabulous, even though it doesn't necessarily address the symptoms of ADHD. Counseling is a great way for us to develop positive coping strategies, so if there's a counselor involved, I always get a release of information so that we can coordinate care and give each other feedback. Obviously, if they're utilizing a coach, we want to involve [them]. I always get releases for really anybody and everybody who's involved. What do you do, sir?
Dr. Max Wiznitzer (29:06): Basically the same thing. I ask for feedback from the school. If the employment setting—because we have our adolescents and young adults who are working—is such that we have sympathetic individuals with that who understand ADHD, we get feedback about are they functioning well or are there little things that we can tweak, whether we tweak it with medication use or we tweak with learning, with addressing skills that have to be done.
Dr. Carolyn Lentzsch-Parcells (29:30): Absolutely.
Dr. Max Wiznitzer (29:30): And obviously, while they may be at home, remember, especially for children, there's feedback from relatives, there's feedback from neighbors, there's feedback from family friends that we can get, all of which can be very valuable in order to put together a plan.
Dr. Carolyn Lentzsch-Parcells (29:46): Coaches, like for athletics, I was talking about ADHD coaches, but athletic coaches, other folks, other adults who are involved in their extracurriculars, that can be helpful as well.
Dr. Max Wiznitzer (29:56): Well, I thank you very much for this insightful and helpful review of ADHD medication in the population. Our speaker today was Dr. Carolyn Lentzsch-Parcells, a member of the CHADD board of directors as well as various committees. I am Dr. Max Wiznitzer, and I thank you again for listening to our Pocket MD podcast on ADHD medication.
Announcer (30:19): Pocket MD is brought to you by CHADD with funding from the US Centers for Disease Control and Prevention, and in partnership with the Rainbow Center at Rainbow Babies and Children's Hospital.