Podcast Transcript
Telehealth in ADHD Diagnosis and Treatment
Summary: Figuring out what services are provided by telehealth can be confusing for patients. There are several benefits from the expansion of telehealth in recent years. It is important for providers to carefully consider each patient's needs in determining whether or not telehealth is appropriate, especially when evaluating for ADHD. There are important considerations to make when prescribing stimulant medication and providing continued treatment through telehealth. There are benefits to being able to communicate with patients using technology. Providers using a portal messaging system should communicate with patients so they know when they can expect a response, what types of issues can be handled through messaging, and what requires an in-person or telehealth visit.
Margaret Sibley, PhD
Margaret Sibley is an associate professor of psychiatry and behavioral sciences at the University of Washington School of Medicine and a clinical psychologist at Seattle Children’s Hospital. She has authored over 100 scholarly publications on ADHD in adolescence and adulthood, including a comprehensive therapist’s guide to treating ADHD in teens. Dr. Sibley’s research is funded by the National Institute of Mental Health and the Institute of Education Sciences.
Craig Bruce Hackett Surman, MD
Craig Surman is an associate professor of psychiatry at Harvard Medical School. He is the Scientific Coordinator of the Adult ADHD Research Program of the Clinical and Research Program in Pediatric Psychopharmacology and Adult ADHD at Massachusetts General Hospital. His research strives to improve the assessment and treatment of self-regulatory disorders, including ADHD, in adulthood. He completed a residency in Psychiatry at the Harvard Longwood Psychiatry Residency Training Program in Boston, as well as a fellowship in Neuropsychiatry at the Division of Cognitive and Behavioral Neurology at Brigham and Women’s Hospital, also in Boston. His work has been published in peer-reviewed journals and presented internationally. Dr. Surman has directed or facilitated over fifty studies related to ADHD in adults. He is co-author of FASTMINDS: How To Thrive If You Have ADHD (or think you might) and editor of ADHD in adults: A Practical Guide to Evaluation and Management.
Learning Objectives:
- Explain the considerations of effective ADHD medication management delivered through telehealth
- Describe the importance of interprofessional collaboration in treatment of ADHD through telehealth
- Discuss the diagnosis of ADHD in an adult
Announcer: You are listening to Pocket MD: Training on ADHD in Children and Adults.
Margaret Sibley: Welcome to another episode of the Pocket MD podcast. My name is Maggie Sibley. I'm a psychologist and researcher at the University of Washington School of Medicine. And today we're going to be having a conversation with Dr. Craig Surman about telehealth in the treatment of ADHD.
Craig Surman: Thanks for having me. As you said, I'm Dr. Craig Surman. I am currently co-chair of the professional advisory board at CHADD, Children and Adults with ADHD, and I am a neuropsychiatrist by training. I work primarily with adults, and I'm an associate professor at Harvard Medical School, where I'm affiliated also with Mass General. At Mass General I work in an adult ADHD clinic, where I do research as well, so I am happy to talk about the new world of telecare.
Margaret Sibley: So, I think we should start off with a really basic question, which is what do we mean by telehealth? What is telehealth?
Craig Surman: Telehealth is any health-related service communicated via non-face-to-face in person, really, this is the way I think it's reasonable to think about it. Telemedicine would be if you're doing clinical services, But even the scheduling that you do over a phone can be considered telehealth, even before we had an internet and other means of adding video to audio. So I think telehealth has been around for a very long time, but its expansion has been extraordinary recently.
Margaret Sibley: So, telehealth isn't just video care over the computer, it's a lot of other things, too. It's how you communicate with patients over a portal. All of these little pieces are broadly kind of part of telehealth. That's interesting. Who can deliver telehealth for ADHD?
Craig Surman: So if it's clinical care you're talking about, I think someone who is trained to use it for assessment or treatment of ADHD, there's some place for telehealth in their practice. There are some things that I think we won't be able to do the same remotely that we can do in person. In terms of what provider types in particular have taken up telehealth, I think there's a very big difference between people who are doing things that are conversational, where that's the only thing they really need to do to provide care, as that can happen with just audio, versus things that require some kind of physical presence, whether it's taking a blood pressure, because someone's on a medication that could affect blood pressure, or needs to be screened to see if they're going to have a blood pressure changed by medicine in a way that's the problem, or someone who provides testing services to try to help differentiate ADHD from other conditions or understand what's confounding ADHD, like a neuropsychologist or other psychometrician provider. And I’m not saying that you can't do those services remotely, but the vast bulk of how those things have been done historically is certainly not remote.
Margaret Sibley: So, it's really the same people that would do these jobs in person that would also then go on to be able to do them in telehealth for the most part. But there may be some pieces of ADHD assessment and treatment that have been harder to transfer into a telehealth modality than others. You were talking about that a little bit.
Craig Surman: Yes, the kinds of things that require physical presence. Some of my patients already have a blood pressure cuff. I can ask them to sit there in the comfort of their home and take their blood pressure. Some of them are wearing devices all the time that seem to be monitoring their heart rate and giving us information that's hard to interpret about their heart rate or about their sleep. In a clinic, you control your tool and know the tool you're using for assay, an assessment. I know how my blood pressure cuff works, and I'm normed against other people I've seen using it. When people using lots of different devices certainly could be useful when compared to the same tool, so changes using the same tool I think are reasonable. But it can be challenging to know how to norm it. Some folks say that you should sort of norm your blood pressure cuff against your primary care doctor's blood pressure cuff.
In my world what I tend to care about is, am I going to change somebody's physiology in a way that's problematic for them? Can I get a baseline reading? What are they able to tell me about their resting heart rate and blood pressure, for example? Are they going to be able to measure it later? And if the answer is no, and there's significant risk to that, like someone who already has hypertension that's been hard to treat and their primary care just met with them to change a new medicine, I may delay or not treat that person remotely, because I would much rather have good information about whether I'm going to potentially do harm.
Margaret Sibley: So, there might be certain patients that also would be a better fit for telehealth than other patients, just based on their individual factors, too. It may be that certain people really do benefit from being in person for care. I think that's the same for psychologists doing telehealth as well. We're doing conversational work with people. There are some families and some kids for whom it's hard to be focused over the computer, because they have too many distractions; people who are maybe trying to get care while driving or cooking dinner. Those folks may benefit from coming into a quiet environment and sitting down and working with us one-on-one in that setting. But then again, some people say it's nice to see people in their natural environment, and if you're assessing someone and you can get a little glimpse of how the household is, that could be a valuable piece of information. So it's interesting to think about telehealth as something that we have in our toolbox that as we move forward we can use to expand care when needed, and not always use it if it doesn't seem indicated.
Craig Surman: You're bringing up some of the challenges of telehealth. I think I was trained to set a frame for care, and in the physical care world, it was kind of clear some of the things that are not as clear. So you describe things that have happened, where people are say driving or in transition, while just fitting in a visit. I think that's very different than someone who's transitioned by driving to my office, waited in a waiting room, and then came and sat with me. And then there's even, I think, pre-work the people that are doing. In the case of behavioral therapy, for example, we're trying to help people with ADHD reduce overwhelm and manage organizational challenges. There's even information I get from what I see in the waiting room, that they're cramming their behavioral therapy homework in the workbook before they come in. That's like, "Okay, they didn't tell me that they're not doing their homework, but I just saw it." I mean, that's happened a bunch of times historically.
And now I have someone who can just be ahead, and I have no context, I don't see the transition in and out, and they may not really be creating a frame for the time themselves. A lot of my colleagues who do more traditional dynamic therapy, for example, or even analytic therapy, really feel that, what we call the frame, like the time and place, the ritual, the routine, creates a chance for things like reflecting on the last time and place that you met and talked about this. And one session builds on another. The way that our brains work, in part, is very spatially and time dependent, so these old studies that show that you do better on a test if you study in the same room that you take the test in. I think there is something about continuity and the amount of the borders, if you will, around care.
So, it's felt to me that at times I get less done in sessions with people. And with folks with ADHD, as you mentioned with children running around the house, they're not corralled in a room, my adult patients I know are doing other tasks while they're talking to me. I can see their eyes moving. There's a divided attention that's very hard to escape for some of them. It may improve as they're treated. I prefer a hybrid, because of that, between in-person and remote, because the commitment to the work is just more intense, when someone's held to it in presence. But it's so inconvenient to have to come in. There are interesting regulatory issues for some of our work in ADHD, where people are supposed to come in once a year in-person under some of the laws that exist for controlled substance treatment.
And so you end up in a situation where, in the near future as the public health emergency may end and some of those laws come back into effect, treatment choices may be different for some of these patients, where a provider is hopefully thinking judiciously about it, but they may be preferring to maintain a tele-environment and not try to figure out how to bring people in. So they may steer towards non-controlled substances more. Certain clinics need to be set up to have in-person presence to keep prescribing controlled substances. At least that's the way things are looking now in November of 2022.
Margaret Sibley: It's an interesting thought that the convenience of telehealth, especially to practitioners, could end up influencing their prescribing patterns, and so that they're picking something not based on the best choice for that person's profile, but maybe what they are capable of giving within the modality that they prefer to use to deliver treatment.
Craig Surman: And we have no clinical trials that are based on telehealth that led to FDA indication. There may be lots of other intangibles that somehow impact how effective these treatments are. On the face of it, you'd think a measurement done remotely should be the same as a measurement done in person, and there's evidence for that. We've been part of a small project looking at the correlation between in-person ratings and remote ratings. And it's not much different than between rater ratings in-person. At face value, these assessments and tools that have been done in person are probably as good remotely. I don't mean to say that my colleagues would intentionally withhold care, but I like the way you put it, that some people will be set up better to deliver certain kinds of care for the medically ill who need blood pressure checks, for the folks that need stimulant consultation once a year in person for example.
Margaret Sibley: If we think about why we're having this conversation about telehealth now, versus a few years ago, I think the public consciousness is higher for telehealth, obviously because of the pandemic. But from your perspective, what do you think are the major factors that have led this to be such a surging modality right now?
Craig Surman: Well, that everyone moved to sort of video platforms for everything that they could do video platform on during the COVID pandemic just meant it was acceptable and normed. We had telehealth options, for example, at my institution, that people were choosing to do or not do. And then suddenly, everyone had to do remote. So it's just it's suddenly doing that. It's just a huge factor. There are interesting business models that emerged, of trying to deliver a care remotely, especially under the sort of pandemic less-limited-sort-of-environment healthcare regulation which also have been a big factor, where people can over the internet find a provider. People could do that before through matching services, almost like a dating app if you will, but you're finding a therapist. But you really were rarely finding a prescriber that way.
And certainly insurance-based care was not being done that way very often. Insurance wouldn't pay for it. With the pandemic, insurers started to say, "We're going to continue our subscribers’ care under insurance." So this just opened the floodgates for, I think, people both to find providers and providers being willing to do it, because otherwise it was, I think, private pay primarily, where people were doing some kind of hybrid, and at least in my part of the world.
Margaret Sibley: You mentioned, a second ago, the loosening of restrictions. Can you talk a little bit more about that? You mentioned it with the insurance companies, but also I think there was some sort of federal legislation also that came into play with that.
Craig Surman: The understanding I have is that there's sort of parity of pay between teleclinical care and regular clinical care. And that's a big deal, that insurers could otherwise just not pay providers. They would say, "Hey, it's like you had a phone call with someone. It wasn't a real visit." I think this is a moving target, where it needs to be solidified and can stay tuned about what the latest regulations are when people are listening to this, but understanding that particular insurance provisions may cover care and others won't. Typically, how Medicare goes, so too everyone else has to go. And that's really, I think, the place to look, if people are curious about the state of things as they're listening to this.
Another thing, though, that was very interesting about the pandemic times in clinical care, was a bit of a loosening around state versus federal sort of rules. There was a wish, as I understand it, for providers to come to states and help where states needed help with the pandemic. And the fact that care could be provided across state lines with brief process of approval for that was very new. Psychologists and medical doctors could get approvals to practice in states that they hadn't been licensed in more rapidly. And while people certainly are very migratory, it depends on the state, the actual rules for a physician or a psychologist. But where the individual resides and is permanently living, and where they see you from, where they are when you're seeing them, are factors. So we have odd situations, like people driving across the border and parking and parking lots to do teleclinical care in our state, where our catchment area, for example, at our hospital historically has been all of New England, and it was never even a question, because they were coming physically to the hospital. It's like, "Yeah, hi you're here." No question, right? So the state licensure-based aspect of provider care is really interesting.
And another interesting thing has been the way that, basically with people being migratory and with “tele provision” of prescriptions through e-prescribing, electronic prescribing, it's quite easy for people to send a prescription to another state or pick up a prescription in another state. There are some states which have reacted to this by saying—for example, Florida recently—that someone has to have been seen in person by an out-of-state provider within a 90-day period, for that person to still be their provider. For example, in that state, as I understand it, for controlled substances like stimulants, it's not based upon residence or licensure. It's, "Did you see this person in person? And has it been within 90 days?"
Some of that, as I understand it, was in reaction to online clinical services that people could access, some of which still exist. In one fairly well known case, there's a clinical ADHD assessment that was being done online, and prescriptions were happening, including controlled-substance prescriptions for people, that ceased its operations. That is a complex story in and of itself. But what makes sense to a business, and what is possible through teleclinical care, is certainly not always one-to-one overlapping with what's right for the patient. And that left patients scrambling for care, and, "Where am I going to get my next prescription from?" So, there's this trade-off, obviously, between convenience and actually providing real psychological support for medicine.
Margaret Sibley: As I understand it, there was also an opportunity to prescribe controlled substances over telehealth that was allowed during the pandemic temporarily. And maybe there's a question mark as to the future of that. I don't know if you have more of an understanding of that than I do, or you want to share anything about that as well.
Craig Surman: The prescription recording is mandated in some states, so that functionality, just that piece of it, is quite common, and probably the way things will and should go, because it helps, especially if there's a common database, that all prescriptions are recorded with basically accounting for what people have filled, when they've filled it. Are they shopping around different places? Because we intersect with issues of substance misuse and diversion often. So e-prescribing has been possible for a while.
E-prescribing across state lines has not necessarily, I think, had a clear regulatory environment it operates in. But the practice of medicine itself does have clear, typically state-based rules and some federal rules. So I really encourage anybody listening to this to be up on what their local board of medicine of their prescriber or a psychological society advises, because it's tricky.
And it can be a different environment you're operating in, if the rules in the other state involved are different. So, I can operate under our Massachusetts rules fine, but, in an adjoining state, I'm actually not practicing medicine correctly from their perspective. And this gets to be odd. But there was this period of relaxation in various ways of basically the provision of care, under medical licenses, across state lines. You're completely right about that.
Margaret Sibley: I think one thing that we've started touching on, but maybe you have some additional comments on, is what you see as the main challenges and benefits of using telehealth modality for delivering care for ADHD.
Craig Surman: Yes, I think whether it's in person or not, you want to do this the right way. You want to know the criteria for ADHD. You want to actually do a full differential diagnosis for ADHD, if you're doing assessment. If you're doing treatment, you should first of all make sure you're doing no harm. You should know the potential risks and monitor them. A lot of these things I'm talking about can happen in person or remotely, but it does take a bit of thinking ahead. And it can be a very real-time, like each day thinking ahead, "How am I going to do assessment and treatment right for this particular patient?" And it can depend now on how you worked with them last. So there are patients, for example, that I have still never met, that I'm working with, and if the public health emergency ends, I may have to terminate care with, because of the way rules are.
So that's a big challenge, that suddenly I'm no longer their provider, because they can't then fulfill the in-person requirement. And there may be changes to these rules. There's legislation afoot to relax some of these things. I think the complexity of the case really informs my comfort with remote care, and by comorbid risk. And it's not necessarily what we used to call Axis I conditions, the major mental health conditions; it's probably things like people's ability to be self-aware and communicate and let me know what they need to tell me, that they're going to be in touch when there's a problem. There's all these sort of intangibles that help a clinician sleep well at night. Do I really know what's going on with that person?
What's fascinating to me is that, in telehealth, I've had more third-party input and triangulation on patients than ever. "Would you like my spouse to chime in as we do this rating scale?" "Yes, please." And like, "Oh, come on in, honey." That couldn't happen before, that people have been able to be even in other countries participating as third-party informants, when I'm trying to understand. Ask someone, "Do you feel that this person's trending healthier and more adjusted in their life? Or are we going the wrong direction? Has there been any change in your years of experience as a baseline with this new treatment we started?" So I think that third-party perspective is amazing. I've had people where I just get the sense I don't have a clear picture of them, even if the spouse popped in. And there's something about the nonverbals, about the presence.
It's been quite an odd experience just to mis-assess body mass index, because all I saw was their head. It's not a huge issue for a lot of our ADHD medications, but it might affect the ceiling dose we go to. And you can ask people, "What's your weight?" But it has a lot of implication, I think, sometimes, for trends in this population, where they may be losing weight because they're on medication. They may have, unconsciously or consciously, other reasons for wanting to be on stimulants. And physically seeing how someone's habit is, it's not good or bad what they look like. It's just information. And I've been surprised. I don't know that it's affected my clinical care necessarily, that, "Wow, the picture I had in my head was of someone who was much more active," as they walked slowly into the office, because they were quick in their talking and they seemed energetic. And I'm like, "There's a question I think to ask them just based on that." I think about a case two weeks ago, when I said, "You've got an Apple watch. How many steps do you get in?" "Oh, I don't really move all day. I'm just a couch potato."
Well, as a physician, if my goal is health, if I treat ADHD, I want someone to be working on something like that, that they're getting cardiovascular fitness as part of their life. These other health determinants are part of a successful treatment. So, it's very strange sometimes these little things that come up, but very specifically blood pressure, physical exam of the heart, should be done at some point in someone's life before you give them a stimulant. There are some people you want to weigh, and maybe it's because of a comorbid issue. These things can be managed, though, by collaboration. So, there are some patients, for example, that I would not see in a telehealth environment, unless they had a physical exam by primary care. You should generally only prescribe certain medications, psychostimulants for example, to people who've had a cardiovascular exam at some point at that stage of development, so you know that they don't have structural heart abnormalities that you might somehow interact with or cause a problem with.
So, those collaborations have been very helpful. And there are some colleagues who will only see people, for example, that are referred from that kind of a setting, because they just know that they've got backup on the medical side of things, and there's someone to send them to for a physical exam.
Margaret Sibley: Yes, I think that's really important that you've been highlighting the physical health piece, because I do think that, when we're having conversations about differential diagnosis, and getting it right with ADHD in adults who are coming for first-time evaluation, a lot of the talk is about differential diagnosis with other mental health conditions. But we are forgetting how many physical health conditions also have overlapping symptoms or can contribute to ADHD. And if they're true comorbidities, they complicate the treatment picture as well.
Craig Surman: Absolutely.
Margaret Sibley: Another question is, as we move past the pandemic, how can in-person and telehealth care become complementary? How do you see that looking? How could that play a role in somebody's sort of comprehensive care plan?
Craig Surman: I think you can take care of people and do assessment and treatment as long as you triage or filter the right patient for the right context. And I think it's good for people to have, and I try to, sort of a list, and I usually do it in my evaluation note itself, of what I need to know about my patient in order to assess and treat them right. For example, to be concrete about it, change in heart rate and blood pressure while on stimulant. That's something I track. I can do that. I can use a 15-second timer, for example, and have them count their pulse in front of me on telehealth. Or I could actually take their pulse in the office. Drug testing, some places in some settings, you want to do that observed with people. There are other settings where basically it's not a part of the clinical practice at all.
So if there's a provision, though, for the assessment you need in your evaluation, and as monitoring ongoing care, you can do it, but you want to be real about how specific to the patient that is, and not just say, "Oh, I'm doing everything just because I did what I could do." There's a difference between what you can do and doing the whole assessment. There are some people where, maybe in the middle of an evaluation, I might say, "Wow, I didn't realize this person has no primary care. They live far away." I'm playing this in my mind, "How am I going to monitor something I need to?", because this person seems to have a medical condition or a substance use disorder or whatever that you might be able to manage in a clinic setting or with another provider involved. I don't know that it's specific to telehealth versus in-person, but just being real about what are the resources I need to really do my assessment and really do my treatment monitoring, I think, is the general organizing principle.
Margaret Sibley: That people should be open-minded about the range of options that they may have to be able to do that, essentially.
Craig Surman: There are some very creative ways of tracking information with technology. You can send people questionnaires ahead of time, ahead of visits. I think one of the things that I miss about being in-clinic is having a stack of forms and infographics to hand people. So my workflow has to be different now, where I send people things ahead of time. And that needs to be done in a way that doesn't violate HIPAA, so it has to be encrypted. So this is where people having a portal-based care system, for example, may be very important, or at least access to a secure email system may be very important. And how do you protect yourself in a HIPAA in that environment? Typically, you need it in writing that it's okay to not be communicating encrypted, for example. There are little things we have to think about to say, "Am I operating in within the way I'm supposed to?"
Have there been fewer questionnaires or more questionnaires since I started doing all telehealth during periods of the pandemic that I've sent out? No, I don't think it's about more or less. It's just how it fits into my workflow. So I have to now protect time to send some more emails. I think that providers have felt a lot of screen burden of doing telehealth. Back in the days with paper and paper charts, there wasn't as much screen. And if you set up your practice for telehealth, you want to think, "What's the incoming going to be like?" People are going to reach me on the portal. They're going to be messaging me. And you want that access to care. But if it's easier for people to reach me, how do I manage expectations up-front about that? What is appropriate between sessions and what's not appropriate between sessions?
For those of us trained in risk management approaches and in safety evaluations, you know that there's a difference between listening to a voicemail and having a back-and-forth conversation with somebody. When people send you messages, it's now a record of what they sent you and what you replied. So, how do you manage outgoing messages? If someone says, "I'm going to kill myself now," there's no bot to filter that message and bring it to you faster. Maybe in the future, there'll be something like that. But up front, having policies and procedures nice and tight, where you're saying, "Do you have any questions about my policies and procedures? Do you know how to reach me for emergencies? Do you understand I'll be most useful to you in sessions, but that if you need help you can go to emergency room? Or if there's something that I can answer that'll help you in a short time, that I need to get to within the day, page me." I mean, there are many different providers that have different rules about these things. It's a bit interesting that people can send stuff our way inbound easily now. And some clinics are really set up to filter that and manage that, but you want to have contingency for it.
Margaret Sibley: It sounds like that could particularly create challenges for smaller providers, who don't have a risk-management team in place essentially. Because you're right, with all these expanding possibilities, we have to be coming up behind them and thinking about compliance and thinking about risk and thinking about how we manage the new potential challenges that could arise because of the new modalities that we're using. So that's an interesting perspective. I have a couple more questions, one that I think people might be interested in. Whether it's telehealth or not, what should somebody do if they are referred a patient who's had a previous ADHD diagnosis, and when you meet them, you feel like it's questionable, and you're not sure if it's a valid diagnosis? How do you handle that?
Craig Surman: First, I always prefer, and in fact would require in some cases, to speak to a previous provider. In cases of taking over prescribing, I want a clear transition or handoff. It's not always possible, but I think that actually helps a lot, because what the patient tells you happened may not be what the professional tells you happened. Each provider needs to come up with their own criteria for what is a good assessment and what is good treatment monitoring. And that's up to the individual. I think it should be grounded in DSM criteria. That's the ecosystem rules that I live. In Europe, the ICD criteria have been more prominent. With ICD-11, it's much more aligned with DSM now, but previously, for example, inattention wasn't something that really got you as much of a diagnosis as hyperactivity impulsivity in the ICD system.
And it kind of comes down to doing the diagnostic process. One of the things that I hear a lot from people is that they were asked a lot of questions about, by previous providers, the current presentation, like how they are now, but not the longitudinal story. Because what you want to hear is pervasive challenges ever since before the age of 12 of at least some inattentive or some impulsive-hyperactive traits, that cause functional impairment in two or more settings. And people slice this different ways. You can certainly decide that someone is subthreshold and still needs to be treated.
But the second thing I would say that's really a big deal is the disentangling from other challenges. And often people may not have given much focus on the contribution of learning disabilities, the contribution of personality, of environmental context, of major other mental health conditions. The hardest for me to entangle often is generalized anxiety disorder from inattention, because it's so preoccupying for people, and people have just lived that way for a long time, that they really can have a hard time being present. My go-to usually is to try and understand, "Okay, what did the previous provider have to work with that was different?," and try to explain to the patient how I feel my process was appropriate. I think it often sometimes, where I'm disagreeing with the previous provider, leads to more third-party perspective, getting a spouse involved, trying to get old school records, or trying to understand that there's some other condition that explains it.
In my research, I found that sleep apnea is a real exacerbator of any mental health condition. You can have people who have dyslexia, and that's really what they're talking about when they say, "I really just can't participate in writing and language-based things. And it's a big part of my life. And I really have trouble getting too stick with and finishing these things." Over-reliance on rating scales, over-reliance on the current presentation and not accounting for how long this has been an issue and what other factors might explain the particular pattern.
One of the biggest tells for me also is the context, so I like to ask people about mundane activities and how they govern themselves during them. If someone says to me that they get distracted while putting away groceries, and they're off watering flowers, and then in the other room doing the laundry, and then coming back, it helps me disentangle from what they just told me about their academic experience, where they just couldn't focus in class and had made a lot of errors in writing and thinking, "Well, it's a learning disability." I don't think it's just the learning disability. I think it depends upon the case. But people really should have their approach to diagnosis that involves taking enough time and getting enough information. And the same comes with treatment monitoring, too. It shouldn't take risks and change treatments unless you know that you'll have a measure for them, that they'll be measurable if there is change.
Margaret Sibley: I think another piece of this same conversation is something that we're seeing recently, which is the increased spread of information online about ADHD. And then there's a lot of people in the social media world, who are sharing their experiences of ADHD in a very relatable way. So, you have a lot of people who are self-diagnosing now with ADHD, and so they may come to a provider, and they may advocate for their own identity as a person with ADHD. And you may have questions in certain situations, as a provider, about whether that's a valid conclusion that they've made about themselves. So, how do you handle that? What's your advice to other providers who may feel uncomfortable with a person's take on their self?
Craig Surman: I think there's a difference between someone who comes and wants your opinion and wants to know what is best practice, and someone who comes and wants to just be validated from what they already think is true. And those things can be hard to tell. But I always give people the benefit of the doubt. And so someone who's tried to up the ante a little bit, their own self-treatment and borrowed a friend's stimulants, is very common, and says, "Oh, I know that I have ADHD because the stimulant worked for me," which is not a diagnostic criteria on the DSM. Stimulants would change lots of people, like lots of drugs do and help them get to stick with and finish things that maybe they didn't want to.
I think being mutually oriented with the patient towards a common goal and being real about what their question is. And I'll be frank with people about it. I'll say, "How curious are you about how different your brain is from other people's brains? Or you want to know if you really fall solidly in the ADHD category or do you have another particular concern today?" Because sometimes the reason they're in is not, "My whole life I've had ADHD. I'm curious about that question." It can be any number of other things. “I'm worried about if this explains my failing marriage." "I'm worried about this explains the arguments I had with my boss yesterday, where he is calling me on the carpet for something." There's just so many other things. And if you can help people understand what you can provide as a second follow-on to that, I think it really helps. People may not get it, unless they're used to therapy, unless they're used to assessment. But in the end, it is the provider's expertise that they should rely on to decide, "Is this a mutual relationship that you can make a good assessment and move on to safe treatment?"
There are plenty of people who are self-identified as ADHD, because of research that they've done, and they're 100%. And then there's a whole bunch of people who self-identify as ADHD, and they're right that there's something different about how they operate, but it's not ADHD. And then there's other people in between, where it's that plus something else that may be way more important clinically to address. "Why are you here today?" is a classic question we're trained to ask. But the follow-on to that, that you have to think about in your head, is, "Is that really what I can help them with?"
Margaret Sibley: I think one kind-of final question here is, for providers listening, if they want to educate themselves on the best way to diagnose ADHD, the best way to treat ADHD, what the best practices are, whether it's telehealth or not, what resources would you direct them to? How should they do that?
Craig Surman: CHADD, Children and Adults with ADHD, has lots of really good information that's curated by experts on its website, www.chadd.org, that is about ADHD diagnosis and that's focused more towards consumer experience, what we know about interventions and supports and treatment options. So all of that is, I think, very valuable and something to share with patients. For professionals, there are societies in some regions of the world, like APSARD, the American Professional Society of ADHD and Related Disorders, and there are trainings that are offered through APSARD. In Canada, CADDRA has developed treatment guidelines for ADHD, which are fairly comprehensive and help people understand how to operationalize differential diagnosis and treatment. I think what I'm pointing to is that there's sort of a subset of people who've sat with the question "How do you do this well?" and are a resource. They may not be people that you're going to physically see, but you can telehealth-encounter them. You can contact them. I think that's been an amazing benefit of this larger telehealth environment, that clinicians themselves can do postgraduate education that they probably didn't get very much of during their training.
Margaret Sibley: Continuing education is a really good way for people to make sure that they are staying up-to-date, things are always changing, and seeking out specific opportunities to learn about ADHD, as a part of that. That's important.
Craig Surman: For people working with adult patients, I think if you can identify a child provider that works in this space a lot, if you can, if you're in the same clinical system, try to sit in. Try to understand how does that person think about the diagnosis. There's a lot of benefit in asking patients about the effort they make to get through their day, as opposed to just looking at the symptoms. This compensatory effort you hear being basically part of why people ask what they ask when they talk to ADHD patients, because what people want is to get through their day easier, be on top of things more with less effort, I think, often. That's a core chief complaint of ADHD. But how do you understand what someone's life is like? How do you walk in their shoes? What does that interview look like? It's nice, if you can find it, to sit in with someone who's doing it.
Margaret Sibley: That peer-to-peer kind of communication of information is something that I agree is critical, especially with our not yet having really clear guidelines of how to diagnose and treat ADHD in adults, which hopefully is something that we'll all see forthcoming. Thank you so much, Dr. Surman, for participating in this conversation. This has been great. And we're really, I think, all a lot more thoughtful about telehealth as a result of it.
Announcer: 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.