The Clinicians’ Guide to Treating Complex ADHD is a clinical compendium from Medscape, MDEdge, and ADDitude designed to guide health care providers through the difficult, important decisions they face when treating pediatric and adult patients for ADHD and its comorbid conditions. This guided email course will cover the following topics:

• DECISION 1: What should I consider when developing a comprehensive treatment plan for ADHD?
• DECISION 2: What medications and other approaches should I turn to as first-line treatments for ADHD?
• DECISION 3: How can I decide which ADHD medication to prescribe first?
• DECISION 4: What challenges and side effects should I anticipate from ADHD medications, and how should I address them?
• DECISION 5: How can I improve treatment outcomes for patients with ADHD and comorbid diagnoses?
• DECISION 6: What dietary, behavioral, or other complementary interventions should I recommend to patients with ADHD?
• DECISION 7: How should I follow up with patients with ADHD, and what should we discuss during these checkups?

NOTE: This resource is for personal use only.

FOLLOW-UP: How should a clinician follow up with a patient being treated for ADHD?

A: Like diabetes or hypertension, ADHD is not an illness for which one can hand the patient a prescription for pills and assume recovery is automatic… | Keep reading on Medscape »

COLLABORATIVE CARE: How can collaborative care models improve care for patients with ADHD?

A: This model – wherein primary care providers, case managers, and psychiatrists work as a team to care for and monitor patients – effectively resolves many common barriers to quality… | Keep reading on ADDitude »

DIVERSION: How can clinicians educate patients about the danger of drug diversion?

A: Doctors can provide printed or video material explaining the legal and health risks associated with sharing or selling stimulants… | Keep reading on ADDitude »

TREATMENT RELUCTANCE: Why might a child resist ADHD treatment, and how can clinicians address medication aversion?

A: When someone refuses to even consider change, your best strategy is to show him empathy and normalize the situation. Instead of driving him into an even more defensive posture… | Keep reading on ADDitude »

POSITIVE PSYCHIATRY: How does positive psychiatry benefit ADHD patients in the long run?

A: Incorporating positive psychiatry is best viewed as the creation of a supplementary toolbox that allows clinicians an expanded set of focus areas to help patients achieve a more robust and sustained response to treatment… | Keep reading on MDedge »

RELATED RESOURCES

How to Get, Afford, and Refill Your Prescriptions With Minimum Hassle

Expert Webinar with Laurie Dupar, PMHNP, RN, PCC | Listen now on ADDitude »

CBT and DBT for ADHD: How Talk Therapies Reduce Symptoms and Boost Confidence

Expert Webinar with John Mitchell, Ph.D. | Listen now on ADDitude »

7-Week Guide to Treating ADHD, from Medscape x MDedge x ADDitude:

DECISION 1: What should I consider to develop a comprehensive ADHD treatment plan?
DECISION 2: What medications and other approaches should I turn to as first-line treatments for ADHD?
DECISION 3: How can I decide which ADHD medication to prescribe first?
DECISION 4: What challenges and side effects should I anticipate from ADHD medications, and how should I address them?
DECISION 5: How can I improve treatment outcomes for patients with ADHD and comorbid diagnoses?
DECISION 6: What dietary, behavioral, or other complementary interventions should I recommend to patients with ADHD?
> DECISION 7: How should I follow up with patients with ADHD, and what should we discuss during these checkups?

COMPLEX TREATMENT: How should clinicians approach treatment for patients with ADHD and comorbid conditions?

A: As clinicians, we must expect that adults with ADHD will come to us with complex presentations… | Keep reading on ADDitude »

PEDIATRIC COMORBIDITIES: How should clinicians adjust pharmacological treatment for children with ADHD and comorbidities?

A: Though stimulant medication, paired with behavioral therapy, is the first-line treatment for ADHD in children, contraindications and side effects may limit their use. For example, depression and anxiety can worsen… | Keep reading on ADDitude »

ADHD + DEPRESSION: What is the recommended approach for treating ADHD with depression?

A: Options for patients include an array of psychological and psychopharmacological treatments, along with newer, cutting-edge approaches… | Keep reading on ADDitude »

ADHD + EATING DISORDERS: How should clinicians adjust treatment approaches for patients with ADHD and comorbid eating disorders?

A: Treat both ADHD and the eating disorder together and don’t discount the relevance of ADHD symptoms in driving the eating disorder. ADHD has to be treated in order to unlock effective ED treatment… | Keep reading on ADDitude »

ADHD + EFD: How is executive dysfunction related to ADHD, and how should it be treated?

A: The FDA does not allow prescriptions for stimulants to be phoned into a pharmacy or refills to be added to prescriptions — and this adds to the burden of treating patients who take them… | Keep reading on Medscape »

RELATED RESOURCES

Substance Use Disorder and ADHD: Safe, Effective Treatment Options

Expert Webinar with Timothy Wilens, M.D. | Listen now on ADDitude »

Current Guidelines for Treatment and Behavioral Interventions for Tourette Syndrome and Tic Disorders

Expert Webinar with John Piacentini, Ph.D., ABPP | Listen now on ADDitude »

7-Week Guide to Treating ADHD, from Medscape x MDedge x ADDitude:

DECISION 1: What should I consider to develop a comprehensive ADHD treatment plan?
DECISION 2: What medications and other approaches should I turn to as first-line treatments for ADHD?
DECISION 3: How can I decide which ADHD medication to prescribe first?
DECISION 4: What challenges and side effects should I anticipate from ADHD medications, and how should I address them?
> DECISION 5: How can I improve treatment outcomes for patients with ADHD and comorbid diagnoses?
DECISION 6: What dietary, behavioral, or other complementary interventions should I recommend to patients with ADHD?
DECISION 7: How should I follow up with patients with ADHD, and what should we discuss during these checkups?

STIMULANT + NON-STIMULANT: How can combination therapy improve symptoms with fewer side effects?

A: The term refers to using a stimulant and a non-stimulant to reduce ADHD symptoms. There were no lectures in medical school on this therapy and no studies of it when… | Keep reading on ADDitude »

SLEEP: Stimulant use is associated with an elevated risk for sleep problems. How can clinicians address this side effect?

A: Clinicians should titrate while evaluating a patient’s environmental and familial conditions, screen for primary sleep disorders, and… | Keep reading on ADDitude »

MED CHANGES: When should a patient switch to a different medication and/or dosage?

A: If a stimulant is causing excessive irritability, restlessness, or seriousness throughout the day, a dose reduction… | Keep reading on MDedge »

ADHERENCE IN CHILDREN: How can clinicians improve medication adherence in children with ADHD?

A: ADHD medication initiation and adherence are increased when patients have a strong working alliance with their clinician and trust the health care system… | Keep reading on ADDitude »

ADHERENCE IN ADULTS: How can clinicians improve medication adherence in adults and adolescents with ADHD?

A: As clinicians, we must acknowledge how difficult it is take medications every day. And we must be proactive in asking our patients, “How many times did you skip a dose, and what impact did that have… | Keep reading on ADDitude »

RELATED RESOURCES

How to Optimize ADHD Medication: Strategies for Achieving Better Symptom Management

Expert Webinar with William Dodson, M.D., LF-APA | Listen now on ADDitude »

Why Adults with ADHD Abandon Medication — and How to Improve Treatment Outcomes

Expert Webinar with William Dodson, M.D., LF-APA | Listen now on ADDitude »

How to Optimize Stimulant Treatment for Children and Adults: Better Symptom Management Without Side Effects

Expert Webinar with Thomas E. Brown, Ph.D. | Listen now on ADDitude »

7-Week Guide to Treating ADHD, from Medscape x MDedge x ADDitude:

DECISION 1: What should I consider to develop a comprehensive ADHD treatment plan?
DECISION 2: What medications and other approaches should I turn to as first-line treatments for ADHD?
DECISION 3: How can I decide which ADHD medication to prescribe first?
> DECISION 4: What challenges and side effects should I anticipate from ADHD medications, and how should I address them?
DECISION 5: How can I improve treatment outcomes for patients with ADHD and comorbid diagnoses?
DECISION 6: What dietary, behavioral, or other complementary interventions should I recommend to patients with ADHD?
DECISION 7: How should I follow up with patients with ADHD, and what should we discuss during these checkups?

ADHD medications — both stimulants and non-stimulants — do not place patients of any age at greater risk for cardiovascular events such as heart failure and hypertension. This groundbreaking finding comes from a new meta-analysis of 19 observational studies, including 3.9 million participants, that found no statistically significant association between ADHD medications and cardiovascular disease (CVD), even among middle-aged and older adults.¹

The analysis, published November 23 in JAMA Network Open, is the most comprehensive systematic review and meta-analysis of longitudinal observational studies to date on the association between ADHD medication use and the risk of CVD. It included patients from the United States, South Korea, Canada, Denmark, Spain, and Hong Kong. It found no associations between ADHD medication use and a higher incidence of CVD, however, it did recommend further research on the risk of cardiac arrest and tachyarrhythmias among female patients and patients with pre-existing CVD.

“The results of this meta-analysis suggested no statistically significant association between ADHD medication use and the risk of any cardiovascular events across age groups, although a modest risk increase could not be excluded, especially for the risk of cardiac arrest or tachyarrhythmias,” the study authors wrote. “Therefore, clinicians should discuss with their patients and families the possible cardiovascular risk of ADHD medication in light of the latest evidence, and they should rigorously follow clinical guidelines that suggest monitoring of blood pressure and heart rate at baseline and each medication review.”

Clinicians should not outright disallow ADHD medication for adult patients, according to the JAMA findings. This represents a stark change to the status quo for many medical practitioners who have ruled out stimulants and non-stimulants due to fear of cardiovascular side effects, said William Dodson, M.D.

“Since I have been in the ADHD field, I’ve had to battle the false belief perpetuated by the FDA that the stimulant medications were somehow cardiotoxic despite not having the slightest evidence that they were toxic at all,” said Dodson, who led an ADDitude webinar in April 2022 titled, “Why Adults with ADHD Abandon Medication.” “The only effect that these medications have on the cardiovascular system is that if the dose is too high or you’ve added a stimulant on top of a finely tuned dose, it’s going to increase the blood pressure and increase the heart rate. That’s it.”

In recent correspondence with ADDitude, Dodson called the JAMA meta-analysis “the most important article in the last decade” in ADHD medicine and heralded it as a “turning point,” particularly for older adults who have been unable to treat their ADHD with medication due to fears of cardiovascular side effects.

“This is probably the single biggest false belief about ADHD medications… Taking stimulant medications does not increase your cardiovascular risk at all, zero, nothing,” Dodson said. “Cardiologists know that these medications are not dangerous and that there is lots of research to support that.”

However, in a JAMA editorial published alongside the recent finding, Roy C. Ziegelstein, M.D., advised clinicians to proceed with caution. He expressed the need for further research into elderly patients, as well as women and individuals with pre-existing CVA. He also sought data broken out by race and ethnicity, and comorbidities.

“Although the study by Zhang et al. is reassuring in many ways,” wrote Ziegelstein, a cardiovascular disease expert at Johns Hopkins University School of Medicine, “health care professionals must carefully weigh these factors when prescribing ADHD medications, especially to older adults, individuals with established CVD, and those with other comorbidities that increase CVD risk.”

Sources

¹Zhang L, Yao H, Li L, et al. (2022). Risk of Cardiovascular Diseases Associated with Medications Used in Attention-Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis. JAMA Netw Open. https://doi.org/10.1001/jamanetworkopen.2022.43597

As the youth mental health crisis escalates, so too does demand for mental health services. Supply simply can’t accommodate the new demand, so many children and teens with mental, emotional, and behavioral disorders are struggling to access care.

More than half of neurodivergent youth have sought mental health care for the first time in the last few years, according to a recent ADDitude survey wherein 62% of caregivers said it was “difficult” or “very difficult” to access mental health care due to challenges such as prohibitive wait times, scheduling conflicts, and lack of accessibility.

Barriers to Care

Two-thirds of children with ADHD are currently receiving mental health care, according to the 1,187 caregivers who completed the ADDitude survey in August and September. Many parents reported barriers to care that made it challenging to secure services for their child.

“While I have good insurance, many of the mental health practitioners are limited to talk therapy and not employing practices such as EMDR,” said Kate, parent to a young adult with ADHD, anxiety, and depression in Kansas. “Mental health care is extremely expensive. If you have acute emergency mental health care needs, you face dropping $3,000 to $5,000 to get in at the ER. The other alternative is a long waiting list. In the meantime, your child suffers. It’s a nightmare.”

Long wait lists for in-network providers lead many to pay for services out-of-pocket. Caregivers reported wait times ranging from a few months to a few years, and more than 40% reported insurance and cost barriers.

[ADDitude Directory: Find Affordable Care Near You]

“Does this insurance have these providers? What will it cost without insurance when there are none?” asked the parent of a teenager with ADHD who rated her child’s mental health as “poor.” “And trying to provide healthy, palatable foods for a sort of picky eater without a job is hard on the wallet. Getting specific prescriptions that cost a lot isn’t easy, either. At moments, it makes the mentally healthier want to lay down and die.”

Though seemingly worsened by the pandemic, long wait times existed long before March 2020. According to the American Psychological Association (APA), only 4,000 out of 100,000 U.S. clinical psychologists specialize as child and adolescent clinicians.¹ Time barriers have been, and continue to be, the norm.

“We were unable to reach our therapist once the pandemic started, and then the practice became so busy that they could no longer provide services,” wrote the mother of an 11-year-old with ADHD and anxiety in Pennsylvania. “[Our son] has not received services in three years. We have reached out to a different practice, but the wait time for a new appointment is more than 10 months long.”

One Australian parent, like 121 other respondents, said that securing access to mental health care was easy. Finding a well-equipped provider who could understand and effectively treat their child’s eating disorder, anxiety, and depression was not.

[Use This Checklist to Assess ADHD Doctors and Clinicians]

“Accessing therapy is easy but keeping therapists who don’t leave or finding one who engages well with my daughter and her temperament is difficult,” the parent wrote. “The process of telling her story again and again to new counselors is a big hurdle. Engaging with a stable, mature, and experienced counselor is the challenge, plus affordability.”

More than half of respondents encountered scheduling or appointment conflicts (55%) or a lack of accessibility (50%).

“There is no one within two hours of us who treats ADHD, treats children under 12 years old, accepts Medicaid, and has availability,” wrote Jessika, the mother of an 11-year-old boy with ADHD in Maine.

Mental Health Treatments and Interventions

Of the neurodivergent youth with access to care, more than three quarters are currently taking medication. Medication was among the most useful treatment options according to caregiver ratings, as was exercise, which was most often rated as “helpful” or “very helpful.”

“The things [our son is] doing now, like exercise and mindfulness, are things he’s doing on his own to improve himself,” said one parent of a young adult with ADHD in New York. “This is a result of individual and family therapy he received in the past, which he resented at the time, but which he now says saved his life. He uses what he learned then to apply himself now. To us, this is miraculous.”

Previous research suggests sedentary behavior is associated with an increased risk of depression as children age.² While exercise can help lessen the risk of depressive symptoms, the pandemic’s social distancing, increased screen time, and remote learning environments have not promoted physical activity.

Individual therapy was the most popular treatment option among respondents. More than 90% of youth with access to care are currently receiving individual therapy or have in the past two to three years. Sleep changes and family therapy were rated least helpful by caregivers.

Numerous respondents said getting their child to follow through with treatments or interventions was admittedly difficult. It’s not uncommon for adolescents to refuse help due to feelings of embarrassment and shame.

“[Our daughter] is dead set against medications, counseling, and actually anything that could be beneficial for her mental health,” said the mother of a teenager with anxiety and depression. “She tends to be stubborn and obstinate about any of it. She seems to withdraw more instead of being open to help of any kind.”

A System That Needs Fixing

Many parents feel hopeless in the face of a crisis they’re not equipped to solve on their own. This includes Breanne, who says the mental health system is “quite broken” for her daughter with an eating disorder, oppositional defiant disorder, and ADHD.

“There are too many barriers: waitlists, personal opinions… Real help only kicks in when your child is actively suicidal.”

When children can’t access proper treatment interventions, the consequences extend well into adulthood.

“My child is affected because her mom was terminated from her 20-year career for asking for accommodations due to her ADHD,” wrote the parent of an 8-year-old child with ADHD, anxiety, and learning disabilities. “Now, her mom has lost everything and can’t afford many things. Just getting basic needs is difficult enough, so doctor appointments take a backseat to the basic needs like food, job, utilities.”

“Another barrier is lack of trust. I don’t see that parents have sufficient assistance when dealing with their own disability… They need all kinds of mental, social, and financial assistance, and there is none.”

Youth Mental Health Care and ADHD: Next Steps

• Join Us! Mental Health Out Loud Event on Eating Disorders in Teens
• Read: Special 2022 Mental Health Report from ADDitude
• Read: Two Years Inside a Pandemic: A COVID Timeline of ADHD Brains in Distress

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Sources

¹Abramson, A. (2022, January 1). Children’s mental health is in crisis. Monitor on Psychology, 53(1). https://www.apa.org/monitor/2022/01/special-childrens-mental-health

²Kandola, A., et al. (2020). Depressive symptoms and objectively measured physical activity and sedentary behaviour throughout adolescence: a prospective cohort study. The Lancet Psychiatry, 7(3), 262 – 271. https://doi.org/10.1016/S2215-0366(20)30034-1

Attention deficit hyperactivity disorder (ADHD) is highly treatable, yet systemic barriers — from cost and lack of pediatric services to fragmented care systems — often hinder identification of ADHD in children and/or prevent them from receiving optimal care. According to the American Academy of Pediatrics (AAP), primary care providers often view ADHD as distinct from other pediatric conditions and outside the scope of primary care.¹ What’s more, only one-third of school-aged children diagnosed with ADHD receive both medication and behavioral therapy to treat the condition, as recommended by the AAP.²

Fragmented, unreliable care is ineffective care for children with ADHD — and most providers and caregivers feel powerless to affect change.

Enter integrated care — a collaborative health-care model wherein primary care and behavioral health professionals work seamlessly together (and with families) to provide patient-centered, systematic, and cost-effective care.³ Collaborative care is a type of integrated care model meant to treat persistent, broadly impactful conditions that require systematic follow-up, like ADHD.⁴

Integrated care eliminates common barriers to health-care, and evidence also links collaborative care approaches to increased engagement and adherence to ADHD treatment plans.^{5 6 7 8} Here, we’ll demonstrate how this model could benefit a fictitious pediatric patient with ADHD (“Sarah”), plus her family, and health care team.

Collaborative Care for ADHD: Framework and Features

Integrated care aims to reduce the silos that notoriously appear in traditional health care settings and impede quality care by connecting the following vital roles and responsibilities, all within one physical setting and system:

• Primary Care Provider
• Behavioral Health Care Manager
• Psychiatric Consultant

[Get This Free Download: Choosing the Right Professional to Treat ADHD]

Primary Care Provider (PCP)

Primary care is the ideal setting for integrated care for the following reasons:

• Patient-provider trust is often already established.
• Pediatric patients already have regular and frequent contact with PCPs.
• PCPs are one of few medical professionals who look at patients holistically.
• PCPs commonly refer patients to specialized services and care when needed.

The PCP retains the same responsibilities under this model as they would in a traditional setting, which include but are not limited to the following:

• identifying conditions using clinical interviews, screeners, exams, history, etc.
• treating conditions; prescribing medications; developing and adjusting treatment plans
• monitoring patient health over time; adjusting diagnoses as necessary

Consider Sarah, an 8-year-old girl who presents for a checkup. Through routine, universal behavioral health screening, Sarah’s parents indicate that is not doing well in school and is struggling socially. Could Sarah be exhibiting symptoms of ADHD, and/or something else?

Outside an integrated care model, Sarah’s parents might have been limited to discussing these concerns in a follow-up appointment. The PCP would have likely provided Sarah’s parents with ADHD screening tools for themselves and Sarah’s teachers to complete before the next appointment. A referral — and a long wait — to see an ADHD specialist were likely next steps.

[Read: Your Complete ADHD Diagnosis and Testing Guide]

In this scenario, much of the burden falls on Sarah’s family to make connections and pursue next steps with the PCP, who is essentially working in isolation on the case.

But it’s a different story under collaborative care, wherein the PCP collaborates with a behavioral health care manager (BHCM) and a psychiatric consultant to build out a patient’s profile in a time-efficient manner.

Sarah’s PCP identifies her as a great candidate for this collaborative approach, explains the process to her family, and obtains consent to start before introducing them to the BHCM.

Behavioral Health Care Manager

The BHCM plays a pivotal role in collaborative care. BHCMs are counselors, social workers, psychologists, nurses, and other behavioral health professionals who act as a linchpin between patients, the primary care facility, and other systems like school.

The BHCM will do all of the following in Sarah’s case:

• Connect with Sarah’s family, listen to their needs, field concerns, and further explain the collaborative care model.
• Communicate with Sarah’s school and her other health care providers; build partnerships.
• Review medical and school records; help gather additional information on Sarah (academic and behavioral challenges, family circumstances, prior treatments and supports provided, barriers to care, etc.).
• Provide brief evidence-based psychotherapeutic interventions as needed.
• Monitor Sarah’s progress through a registry and advocate for her across multiple settings.

BHCMs work to paint and share an ongoing, accurate picture of a patient — a process that often takes considerably longer in traditional systems (and likely with gaps at that).

In doing this work, the BHCM learns that Sarah is possibly showing signs of anxiety — critical information that was not revealed during the initial PCP appointment. The BHCM updates Sarah’s shared file, and flags the team’s psychiatric consultant, who will evaluate Sarah for ADHD and anxiety — conditions that are often confused for one another but can also co-occur — with these factors in mind. Ahead of the evaluation, the BHCM provides Sarah and her family with an anxiety screener to complete, and ensures follow-through.

Psychiatric Consultant

The psychiatric consultant supports the BHCM and PCP in treating patients with behavioral health issues. They may suggest treatment modifications, perform evaluations, and otherwise lend their psychiatric expertise — a scarce resource — to a great number of patients.

Prior to meeting with and evaluating Sarah, the psychiatric consultant will access her shared file for key information gathered by the BHCM and PCP. Merging that information with new details gathered during evaluation, the psychiatric consultant learns the following and initiates additional steps:

• Sarah meets criteria for inattentive ADHD. ADHD screeners and other data collected by the BHCM show that Sarah has exhibited symptoms of inattention since kindergarten. The consultant recommends a stimulant trial, and reviews with Sarah’s family what that would entail.
• Sarah’s worries are mostly related to her school performance, especially activities around numbers, so suspicion for a separate anxiety disorder is lessened. Teachers told the BHCM that Sarah is at grade level in most areas, but she exhibits significant impairment in math concepts. Her difficulties in math merit follow-up psychoeducational testing to determine if she has a specific learning disorder like dyscalculia. (After all, up to 45% of children with ADHD also have a learning disability.⁹)
• Sarah’s problems around school have created tension between her and her mother. Sarah’s father also has ADHD, and there is evidence of multigenerational trauma and dysfunction. A referral for parent behavioral therapy could benefit the family.
• Sarah is having trouble falling and staying asleep. The consultant discusses the association between ADHD and sleep problems, and emphasizes lifestyle factors including sleep hygiene, proper nutrition and regular physical exercise.

Collaborative Care: Putting It All Together

Sarah’s family will eventually meet again with the PCP, who now has access to a wealth of additional information gathered by the BHCM and psychiatric consultant to aid in her role. If the family agrees to the stimulant trial, the PCP will write the prescription and collaborate with the team to observe Sarah over time and adjust her diagnosis and/or treatment plan as needed.

The BHCM continues to work with the family on the following:

• outlining goals and developing a treatment plan for Sarah, which may include connecting to a behavioral parent training provider
• connecting with Sarah’s school on psychoeducational testing and communicating results to the team
• advocating for Sarah in school, including attending Individualized Education Plan (IEP) meetings and informing parents of their legal rights
• connecting the family to additional community services as needed
• monitoring Sarah’s progress, which includes school (especially math) performance
• maintaining connections with the team (meeting monthly with the PCP) and outside partners

The psychiatric consultant will also provide case guidance on an ongoing basis, especially if Sarah is not improving on a treatment plan.

Sarah’s case helps illustrate the positive impact a collaborative care model can have on children with ADHD, their families, and other partners:

• Families have a medical home where they can receive collaborative support without fear of gaps or inefficient communication lapses.
• Families receive evidence-based care and information earlier in children’s lives, improving patient satisfaction.
• Job satisfaction improves as the PCP, BHCM, and psychiatric consultant learn from one another.

Collaborative Care: Making It the Norm

Many academic medical centers within larger cities offer integrated care models for a variety of conditions, but the approach is not yet standard.

Clinical practices can learn more about the collaborative care model through the University of Washington, which developed the approach. The university’s AIMS Center provides the following resources:

• Overview
• Implementation Guide
• Training (CEUs) and Support
• Billing and Financing

The American Psychiatric Association (APA) also offers information and resources on the collaborative care model, including examples of successful implementation across the U.S.

Even outside a collaborative care model, there is plenty that clinical practices can do to implement an integrated care approach:

• Develop concise, efficient workflows. Partnership reduces duplicated work and takes the burden off parents as intermediaries.
• Engage in outreach and affirm the desire to collaborate. Get to know external medical professionals and partners, including personnel at local schools and community programs. Encourage all medical staff to do the same.
• Commit to ongoing education about IEPs, 504 Plans, and other programs and services patients often use that are implicated in their care.
• Research and incorporate available integrated care services. The Partnership Access Line, for example, connects PCPs in Washington, Alaska, and Wyoming to on-call pediatric psychiatrists for telephone consultations.

Collaborative Care for ADHD: Next Steps

• Free Download: How Is ADHD Diagnosed?
• Read: What Does an Effective, Efficient Treatment Team Look Like?
• Read: It Takes a Village (and a Plan) to Stay the ADHD Treatment Course

The Clinicians’ Guide to Treating Complex ADHD from Medscape, MDedge, and ADDitude

• What should I consider when developing a comprehensive treatment plan for ADHD?
• What medications and other approaches should I turn to as first-line treatments for ADHD?
• How can I decide which ADHD medication to prescribe first?
• What challenges and side effects should I anticipate from ADHD medications, and how should I address them?
• How can I improve treatment outcomes for patients with ADHD and comorbid diagnoses?
• What dietary, behavioral, or other complementary interventions should I recommend to patients with ADHD?
• How should I follow up with patients with ADHD, and what should we discuss during these checkups?
  • How should a clinician follow up with a patient being treated for ADHD?
  • How can collaborative care models improve care for patients with ADHD?
  • How can clinicians educate patients about the danger of drug diversion?
  • Why might a child resist ADHD treatment, and how can clinicians address medication aversion?
  • How does positive psychiatry benefit ADHD patients in the long run?
  • Free webinar: How to Get, Afford, and Refill Your Prescriptions With Minimum Hassle
  • Free webinar: CBT and DBT for ADHD: How Talk Therapies Reduce Symptoms and Boost Confidence

The content for this article was derived, in part, from the ADDitude ADHD Experts webinar titled, “Integrated Care for Children with ADHD: How to Form a Cross-Functional Care Team“ [Video Replay & Podcast #411],” with Sheryl Morelli, M.D., Leslie F. Graham, MSW, and Douglas Russell, M.D. which was broadcast on July 12, 2022.

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Sources

¹ Wolraich, M. L., Hagan, J. F., Jr, Allan, C. et al (2019). Systemic barriers to the care of children and adolescents with ADHD. In Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics, 144(4), e20192528. https://doi.org/10.1542/peds.2019-2528

² Danielson, M. L., Bitsko, R. H., Ghandour, R. M., Holbrook, J. R., Kogan, M. D., & Blumberg, S. J. (2018). Prevalence of Parent-Reported ADHD Diagnosis and Associated Treatment Among U.S. Children and Adolescents, 2016. Journal of Clinical Child and Adolescent Psychology, 47(2), 199–212. https://doi.org/10.1080/15374416.2017.1417860

³ Peek CJ and the National Integration Academy Council. Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus. AHRQ Publication No.13-IP001-EF. Rockville, MD: Agency for Healthcare Research and Quality. 2013. Available at: http://integrationacademy.ahrq.gov/sites/default/files/Lexicon.pdf

⁴ University of Washington. (n.d.) Collaborative care. Retrieved from https://aims.uw.edu/collaborative-care

⁵ Silverstein, M., Hironaka, L. K., Walter, H. J., Feinberg, E., Sandler, J., Pellicer, M., Chen, N., & Cabral, H. (2015). Collaborative care for children with ADHD symptoms: a randomized comparative effectiveness trial. Pediatrics, 135(4), e858–e867. https://doi.org/10.1542/peds.2014-3221

⁶ Kolko, D. J., Hart, J. A., Campo, J., Sakolsky, D., Rounds, J., Wolraich, M. L., & Wisniewski, S. R. (2020). Effects of Collaborative Care for Comorbid Attention Deficit Hyperactivity Disorder Among Children With Behavior Problems in Pediatric Primary Care. Clinical pediatrics, 59(8), 787–800. https://doi.org/10.1177/0009922820920013

⁷ Kolko, D. J., Campo, J., Kilbourne, A. M., Hart, J., Sakolsky, D., & Wisniewski, S. (2014). Collaborative care outcomes for pediatric behavioral health problems: a cluster randomized trial. Pediatrics, 133(4), e981–e992. https://doi.org/10.1542/peds.2013-2516

⁸ Kolko, D. J., Campo, J. V., Kilbourne, A. M., & Kelleher, K. (2012). Doctor-office collaborative care for pediatric behavioral problems: a preliminary clinical trial. Archives of pediatrics & adolescent medicine, 166(3), 224–231. https://doi.org/10.1001/archpediatrics.2011.201

⁹ DuPaul, G. J., Gormley, M. J., & Laracy, S. D. (2013). Comorbidity of LD and ADHD: implications of DSM-5 for assessment and treatment. Journal of learning disabilities, 46(1), 43–51. https://doi.org/10.1177/0022219412464351

Barriers to mental health treatment impacted more than 4 in 10 U.S. adults who needed care for substance use or mental health in the past 12 months but were unable to receive it. This unmet demand for mental health care is more than double that for primary health care, according to an online survey of 2,053 U.S. adults conducted by The Harris Poll on behalf of the National Council for Mental Wellbeing.¹ Of the 43% of participants unable to access mental health or substance use services, 42% said they needed and unsuccessfully pursued mental health care and 24% said they needed substance use care.

Even those who ultimately did access care reported significant barriers to treatment. Among those who received substance use care, 81% reported trouble accessing care. Among those who received mental health care, 67% reported trouble accessing care but eventually met with a provider. Cost, location, preferred meeting format (virtual or in-person), and wait time were common contributing factors to lack of treatment.

In addition, a lack of culturally diverse services was reported by 13% of those with unmet mental health needs and by 17% of those with unmet substance use needs. Those percentages were slightly higher among those who did receive care. Most participants reported feeling as though there weren’t enough providers prepared to address issues related to race, ethnicity, sexual orientation, or socioeconomic status.

“Recruiting more mental health and substance use professionals must be a top priority – and that workforce must reflect the rich diversity of our nation,” wrote Chuck Ingoglia, President and CEO of the National Council for Mental Wellbeing. “We won’t be able to increase access to care or meet the historic demand for mental health and substance use care with an inadequate number of people employed to provide treatment.”¹

Of the adults who lacked access to mental health care, 44% reported a decline in mental wellbeing, 45% reported problems at work, and 50% reported relationships issues. Slightly lower statistics were found among adults seeking substance use care.

Many adults believe paying out-of-pocket is easier than going through an insurance provider. In fact, 59% believe it is easier or faster to pay on their own. Seventy-one percent believe that it would be more convenient to receive mental healthcare through a primary care doctor. Furthermore, 67% think it’s much harder to find a mental healthcare provider than it is a primary care provider.

According to survey results, men were more likely to report a need for substance use care in the past year (30% of males vs. 17% of females). Adults ages 18 to 41 were most likely to report needing both substance use and mental health services.

“The pandemic led to increased substance use and mental health challenges for people of all ages and all backgrounds, yet too many people are not getting the care they need,” Ingoglia said. “It is not enough to acknowledge the problem. We must break down these barriers.”

Sources

¹National Council for Mental Wellbeing. (2022, May 31). More than 4 in 10 U.S. Adults Who Needed Substance Use and Mental Health Care Did Not Get Treatment. https://www.thenationalcouncil.org/news/more-than-4-in-10-us-adults-who-needed-substance-use-and-mental-health-care-did-not-get-treatment/

It took just 30 minutes for Allison, 31, to receive a dual diagnosis of ADHD and anxiety from a psychotherapist on Cerebral. She joined the mental health subscription platform during the pandemic because the wait time to see an in-person clinician for an ADHD evaluation was long — too long for the mother of three children, two preschoolers and one 10-year-old with ADHD. Within one week of her diagnosis, a prescription for the antidepressant Wellbutrin was mailed directly to her home in Illinois. What followed was alarming.

“I began having suicidal ideations,” she told ADDitude. “I let the provider know. They wanted me to keep taking [Wellbutrin] for the three months until my next appointment with them. I found a new psychiatrist right away and quit trusting them with my care.”

Jessica began to suspect she had ADHD during the pandemic and likewise signed up for Cerebral after seeing it advertised on Reddit. She, too, received an ADHD diagnosis following a 30-minute interview with a nurse practitioner. Shortly after that, a prescription for Wellbutrin arrived in her mailbox in Maryland. Jessica said her primary care physician was never notified of her new diagnosis or medication.

“I was told I had obvious depression. I’ve been in therapy for years; I have no signs of depression,” she said. “When I asked about something more specific to treat the ADHD, I was sent Strattera, which caused sudden depression, extreme apathy, and uncontrollable crying. I then went through the drawn-out cancellation process, got confirmation my Cerebral subscription was cancelled, and I was still billed for the next month. I had to fight for a refund.”

Susan* stuck with Cerebral a bit longer, but not much. Following her ADHD diagnosis by a nurse practitioner, the 56-year-old struggled to achieve the continuity of care needed to fine-tune her new prescription for Adderall XR.

“I had a revolving door of care providers — three in the three months that I used the service. It was unsettling every time I was transferred to a new provider and had to basically start over,” she said. “No one seemed willing to adjust my medication or to try a different medication option. Their motto seemed to be: Take one Adderall a day and call me never.”

[Dr. Thomas E. Brown on the Building Blocks of a Good ADHD Diagnosis]

Allison, Jessica, and Susan were among the 872 ADDitude readers who recently shared their experiences with telehealth services in an ADDitude survey about ADHD treatment during the pandemic. Of the 484 American adults who answered the survey regarding their own personal care, 57% reported using telehealth services and/or mental health apps in the last two years. Among those individuals, the most popular diagnosing and/or prescribing telehealth services included Teladoc (18%), Cerebral (16%), and ADHD Online (10.5%).

Telehealth and the Promise of Mental Health Care Access for All

Telehealth services surged in popularity during the pandemic due to lockdowns, extended waiting periods with providers, and relaxed federal regulations for prescribing stimulant and other medications remotely. A recent analysis of U.S. Census data shows that 22 percent of Americans have used telehealth services recently. Before the pandemic, telehealth visits accounted for less than 1 percent of all outpatient visits.

ADDitude readers reported subscribing to telehealth services to access three primary services: evaluation of symptoms, prescription of new medication, and renewal or adjustment of existing medication. On the first count, some ADDitude survey respondents reported questionable, confusing, or troubling diagnostic experiences.

“I had a 30-minute interview with a psychiatrist that was sloppy, short, and only consisted of a dozen or so questions. I was then offhandedly thrown a diagnosis of bipolar disorder, a serious disorder that has never, in my 30 years of off-and-on therapy and different SSRIs, been considered. This felt like malpractice,” wrote one woman in Connecticut who did not specify the telehealth service she used. “I sought another opinion and was given three days of in-person, comprehensive, and thorough neuropsychological testing, evaluations, questionnaires, and interviews and then discussed the resulting clinical diagnosis of ADHD.”

[Free Guide: What Every Thorough ADHD Diagnosis Includes]

A thorough ADHD evaluation typically lasts several hours and begins with a clinical interview to understand the patient’s daily symptoms and medical history, including any diagnoses of ADHD and/or its comorbidities in the family, according to leading ADHD expert William Dodson, M.D. The Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-V), stipulates that ADHD may be diagnosed only if an adult patient demonstrates at least five out of nine symptoms of predominantly inattentive ADHD and/or five out of nine separate symptoms of predominantly hyperactive-impulsive ADHD, and only if those symptoms are consistent, persistent, and impair functioning in two or more settings — for example, at work and at home. To make this determination, clinicians often interview loved ones, colleagues, teachers, and friends as well as the patient.

But complaints of cursory evaluations and knee-jerk prescriptions were common among users of Cerebral, Done, and other prescribing services, according to the ADDitude survey. Only 52% of all telehealth users said their evaluation included “taking down the patient’s family medical history.” Two-thirds of respondents said their evaluation lasted less than an hour, and just 17% said information about their new diagnoses or prescriptions were transmitted by the telehealth service to their in-person doctor.

“My evaluation was impersonal, and my diagnosis was based on an online survey,” said a mother of two in California, who was prescribed Adderall following a 30-minute evaluation on Done. “While I answered honestly and trust the results, I can imagine how easy it might be for someone to abuse the system to get controlled prescription meds.”

Some users of Cerebral said they simply completed a questionnaire and then participated in a 30-minute clinician interview before receiving their diagnosis, which happened within one week of joining Cerebral for 72.5% of ADDitude survey respondents. Of those Cerebral users, 83% were diagnosed with ADHD, 51% were diagnosed with anxiety, and 29% were diagnosed with depression.

Telehealth and the Danger of Shallow Diagnoses

A rushed, and potentially incomplete, diagnostic evaluation can carry serious consequences. As many as 80% of adults with ADHD have at least one co-existing psychiatric disorder, making it critical that providers screen patients for symptoms of anxiety, depression, learning disorders, and more. “Even if a patient does exhibit symptoms of ADHD, clinicians should still rule out alternative explanations as part of the evaluation. Changes to the patient’s home environment and circumstances, for example, could influence symptom severity and presentation,” said Theresa Cerulli, M.D., in an ADDitude webinar in June 2021.

Though rare, ADDitude reader reports of telehealth providers who disregarded or failed to seek information regarding patients’ existing conditions and medication red flags were disturbing.

“Even though I told the prescribing nurse practitioner that I had high blood pressure, she prescribed a stimulant,” wrote one woman diagnosed with ADHD and prescribed Adderall on ADHD Online. “My pressure spiked, and I had to have it managed by my primary care physician, who prescribed a nonstimulant. My pressure is on track and I’m doing great with the ADHD nonstimulant now.”

“I mostly felt as though the professionals I saw were short on time and eager to get done talking to me so they could move on to the next patient,” said Susan, who was diagnosed with ADHD on Cerebral and prescribed Adderall XR.

A whopping 97% of the Cerebral users diagnosed with ADHD reported receiving a new prescription, according to the survey. Roughly 59% of those respondents were prescribed Adderall; 34% were prescribed Wellbutrin; and less than 10% were prescribed Vyvanse, Strattera, or Ritalin each.

“It seemed like a pill shop,” wrote one woman diagnosed with ADHD, depression, and anxiety by a Cerebral provider who prescribed her Adderall. “It was very impersonal. I could have come in and said any symptoms and they would have given me drugs.”

The Rise and Fall of Cerebral

Earlier this month, Cerebral came under investigation for possible criminal violations of a federal law that regulates the distribution of controlled substances, including stimulant medications like Adderall. The U.S. Drug Enforcement Administration (DEA) also recently interviewed former Cerebral employees as part of an apparent probe, according to a news report by Insider.

That investigation came just two months after Bloomberg reported that 95 percent of Cerebral patients received a prescription, that care coordinators were assigned as many as 1,000 patients at a time, and that 27 former employees believed Cerebral was prioritizing pills and profits over people. “In its hunt for explosive growth, it has made appointments too short, set follow-up sessions too infrequently, advertised too aggressively, and pushed prescriptions too hard,” Bloomberg reported about Cerebral.

Cerebral’s rise was, indeed, meteoric. Founded in January 2020, the San Francisco startup was quickly touted as a mental health savior for offering virtual diagnosis and prescription services to hundreds of thousands of Americans cut off from in-person doctor visits during a global pandemic and mental health crisis. Within its first year, Cerebral had landed $300 million in funding. Esteemed clinical advisors, and the appointment of Olympic gymnast and ADHD role model Simone Biles as chief impact officer, lent credibility to Cerebral’s subscription service. In March 2020, Cerebral’s virtual prescription services became available as the DEA temporarily lifted consumer protections and allowed “practitioners to prescribe schedule II-V controlled substances to patients for whom they have not conducted an in-person medical evaluation.”

Among the most common controlled substances are the stimulants used to treat ADHD, namely Adderall, Ritalin, Concerta, and their competitors. Suddenly, patients were no longer required to meet in person with prescribers of these drugs — and, just as quickly, Cerebral amassed a user base of 200,000 and a valuation of $4.8 billion.

“The venture capital models that prioritize profits seem to hit challenges in the health care sector, which prioritizes patient safety,” said Margaret Sibley, Ph.D., of Seattle Children’s Hospital in response to news of the Cerebral probe. “The two goals are hard to simultaneously balance, which means that profits are not maximized when one takes the proper steps to stay in compliance.”

Last week, ousted Cerebral co-founder and CEO Kyle Robertson accused the company’s board of directors of pressuring its prescribers to write scripts for Adderall, according to the Wall Street Journal. Former Cerebral Vice President Matthew Truebe has made similar claims. In April, Truebe filed a lawsuit alleging that its chief medical officer, David Mou, M.D., instructed employees to prescribe stimulant medication to all patients with ADHD.

Days after that lawsuit was filed, Walmart pharmacies, TruePill, CVS, and others said they would no longer fill prescriptions for stimulant medications like Adderall prescribed by certain telehealth providers, including Done and Cerebral. Cerebral then announced it would stop writing new prescriptions for controlled substances used to treat ADHD, effective May 9. It also confirmed it would stop prescribing all controlled substances to new patients on May 20 and to existing patients in mid-October. Mou denies any wrongdoing by Cerebral and says this policy change is needed to prepare for the expiration of the temporary DEA suspension of drug rules.

“It is acknowledged that there is an extreme shortage of experienced clinicians who are willing to diagnose and treat ADHD, especially in adults,” said Dodson, one of the first practitioners to specialize in adults with ADHD three decades ago. “Most MDs and nurse practitioners get little, if any training, in ADHD even though 20% of mental health patients have ADHD. Easily accessible and affordable care for ADHD is desperately needed. This poor start [in telehealth] will probably set back much needed change for many years.”

Can Telehealth Be Saved?

Among those Cerebral patients losing prescription services this year are many ADDitude survey respondents who shared their experiences with the startup. Despite recent controversy and criticism for its practices, Cerebral earned generally high satisfaction scores from ADDitude survey respondents, who rated the service 4.07 out of 5 for its evaluation and/or diagnosis services; 4.06 out of 5 for its prescription services; and 3.93 out of 5 for its access to telehealth appointments with a doctor.

“After years of struggling to be seen by mental health experts, I gave up following the traditional route and went looking on my own. I am so glad I did; it’s been life-changing!” wrote one woman in Washington. She was diagnosed by Cerebral with ADHD, anxiety, obsessive compulsive disorder, and sleep disorders, and was prescribed methylphenidate ER.

Some ADDitude survey respondents reported great success using a telehealth service like ADHDOnline to diagnose their symptoms, and then taking that diagnosis to their primary care physician. This solution, they said, was more efficient and cost-effective than waiting months to see a specialist, many of whom are not covered by insurance.

Survey respondents’ primary motivations for using a telehealth service over the last two years were:

• Convenience: 60%
• Ability to receive care without leaving the house: 56%
• Ability to receive and/or renew prescriptions remotely: 39%
• Privacy: 18%
• Cost: 18%
• 24/7 access: 14%

For many of these users, access to telehealth evaluation and prescription services meant the difference between receiving mental health care during the pandemic and being cut off from all support. Most ADDitude survey respondents said they found their chosen telehealth provider through an online search (31%); their health care provider (29%); Facebook (12%); Instagram (8.5%); or a friend (6%).

“The practice of telehealth restored my sanity,” wrote one woman in Maryland who used the service Doxy. “I have struggled for decades with mental illness, especially with undiagnosed ADHD. At 67 years of age, I feel better than I have for many, many years.”

This sentiment was echoed by many survey respondents, especially women, who often battle false ADHD stereotypes and unhealthy societal expectations when seeking an ADHD diagnosis later in life.

“I was able to finally get a diagnosis with less shame and stigma,” said a 44-year-old mother of three in New York who was diagnosed with ADHD using Cerebral. “I find the telehealth interface less uncomfortable and much more streamlined than a traditional provider. The providers are specialists and there was no referral delay. Also, the team assigned to me checks in to see how my experience is going.”

“Telehealth made taking the first step so much more accessible. I was never diagnosed as a child, and as an adult, I’ve heard so many stories of dismissive doctors, long waiting lists and expensive evaluations. For so long, it was all too overwhelming to even start looking for help,” said a 27-year-old woman in Florida diagnosed using Klarity. “I do see it as a starting point… I would like a more thorough evaluation eventually, partially because I also want to be evaluated for other conditions like sensory processing disorder and dyscalculia that weren’t really addressed in the telehealth session. But the access I have to treatment now means I can afford to take the time to find the right fit while I learn more about what works for me.”

ADDitude survey responses like these suggest that the benefits of continued access to telehealth services outweigh its risks for many patients with ADHD and its comorbidities. It is not yet known when the government will reinstate consumer protections on the prescription of controlled substances and require in-person evaluations once again.

“Both amphetamine and methylphenidate were over-the-counter medications or schedule 4 (the least restrictive category) for 20 years without significant abuse. While there is misuse in college students, true abuse is very uncommon,” Dodson said. “The pandemic was a once-in-a-lifetime opportunity to move the legal restrictions on the stimulants back to something that does not obstruct care. The chance for reform is likely to be much harder due to the sloppiness of the first online clinics.”

Even among users who said they benefit from telehealth prescription services, there was some acknowledgment that government regulation could help the industry grow in a smart, measured way that better balances medication with other ADHD treatment options such as cognitive behavioral therapy.

“The proliferation of apps providing unfettered access to drugs without requiring talk therapy or ADHD coaching is detrimental not only to the people using these apps, but it’s also giving the whole field a black eye,” said one Headspace user diagnosed with ADHD, depression, and anxiety and prescribed Wellbutrin and Adderall. “These conditions are real and can’t be solved with a few pills. You need behavioral follow-through.”

Cerebral & ADHD Telehealth: Next Steps

• Live Webinar on June 22: Virtual Mental Health Providers – How to Get Quality ADHD Care Online
• Find: ADHD Specialists Serving Patients Near You
• Understand: How ADHD Is Properly Diagnosed in Adults

*not her real name

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Managing ADHD well is a challenging process. It becomes more difficult when a co-existing chemical or behavioral addiction is part of the picture. Many adults with ADHD struggle with addictive behaviors, which are often unrecognized and untreated.

There is no direct genetic link between addictive behaviors and ADHD. Addictive disorders are complex and often caused by behavioral, emotional, and life factors. Thrill-seeking behavior, the need for immediate gratification, and a search for novel pleasure-seeking experiences are more common for many people with ADHD. Life stressors, such as job loss and financial difficulties, are more frequent with ADHD, and are also risk factors for substance use and other addictive behaviors.

Initially, addictive behaviors provide a jolt of dopamine that is very satisfying for the brain’s reward circuitry. Over time, the “thrill” wears off, but the addictive behavior continues due to physical or emotional cravings. Some indicators of addiction are:

• Strong and urgent cravings for the substance or behavior. These might include physical cravings (alcohol, cocaine) or emotional cravings (gambling), or both.
• No control over consumption. This is why one drink leads to seven, and 30 minutes of video games turns into five hours (or an entire night).
• Continued use despite negative consequences. Sometimes this involves denial (“I don’t have a drinking problem”), but many individuals are aware of the problems caused by their addictive behaviors and continue them anyway.
• Inability to stop the behaviors despite the desire to do so. When this is the case, it is time to see a counselor who specializes in working with people with addictions.

[“The Story of My Son’s Video-Game Addiction”]

Below are some common chemical, behavioral, and food addictions. These are potential problems for everyone, but their risks are heightened for adults with ADHD.

Addictive Behaviors with Chemicals

The lifetime occurrence of substance use problems among adults in the general population is approximately 25 percent. They may be addicted to alcohol, recreational drugs, or prescription medications. In comparison, 50 percent of adults with ADHD have a history of dealing with substance use at some point in their lives.

Many reasons account for addictions among adults with ADHD, however two general causes come up again and again. First, adults with ADHD are more likely to self-medicate, particularly so when they lack awareness or understanding of their ADHD biology and have not yet learned how to manage it well. Second, many adults with ADHD are drawn to thrill-seeking and novel experiences. One individual said he liked to “play with” his brain.

Stimulants and the ADHD Brain

Many adults with ADHD self-medicate with large amounts of caffeine on a daily basis. Some self-medicate with nicotine via cigarette smoking or vaping. Other stimulants that are abused include cocaine, crystal meth, MDMA (ecstasy), and ephedrine. All of these pose serious health risks (including caffeine in large amounts), and some lead to fatal consequences. The temporary “benefits” of these drugs are limited, and are far outweighed by their serious risks to health and life.

[Download This Comprehensive Chart Comparing Stimulant Medications for ADHD]

Prescribed stimulant medications, when used properly and taken as prescribed, are more effective and safer than the drugs discussed above. If you’re going to medicate yourself, do it right and do it safely. To be used safely, the medications must only be taken orally and in prescribed doses.

Alcohol and the ADHD Brain

When used in moderation, alcohol can enhance life experiences, such as dining and social interactions. When used in excess, it becomes highly addictive. Alcohol addiction is considered to be as severe as heroin addiction. Alcohol is often the self-medicating drug of choice for individuals experiencing symptoms of depression or anxiety.

Marijuana and the ADHD Brain

Marijuana is approaching a level of social acceptance to rival that of alcohol. It is used by many people to promote a sense of calmness and relaxation. There are many different strains of marijuana that produce different effects for different people. Some adults with ADHD who are hyperactive believe that it helps tone down their hyperactivity. Some just enjoy the pleasant “high” that they get from the drug. Marijuana, for many people, falls into the “play with my brain” category.

Adults with ADHD who consider using marijuana should be aware that regular use can have a negative impact on attention, memory functioning, and activation difficulty. In other words, regular marijuana use could potentially exacerbate problems associated with distractibility, forgetfulness, as well as procrastination.

Opiates and the ADHD Brain

Opiate drugs include heroin, morphine, and codeine. In the past several years, the abuse of opioid prescription medications (e.g., Vicodin, OxyContin, Percocet), commonly prescribed as pain relievers, has become a national epidemic, resulting in thousands of deaths. These are highly addictive drugs and deadly when abused. They cause more than twice the number of deaths by overdosing than does heroin.

Sedatives and Tranquilizers

Prescription sedatives and tranquilizers act as central nervous system depressants. Their effect on the brain is basically the opposite of that caused by stimulant medications. They are commonly prescribed for anxiety, tension, and sleep disorders. Some people with ADHD take them to help their problems with falling asleep and staying asleep. When the medications are prescribed as sleep aids, continued long-term use can lead to addiction.

Hallucinogens

The hallucinogens include LSD, mescaline, psilocybin (“magic mushrooms”), PCP, and DMT. These are powerful, mind-altering drugs that can produce hallucinations, severe mood alterations, and changes in reality perception.

[“Opening Up About ADHD and Alcoholism”]

Behavioral Addictions and ADHD

Behavioral addictions get less attention than chemical addictions. However, like all addictions, they can cause severe problems in people’s lives. They should be taken seriously, and, when necessary, treated professionally.

Internet Addictions

The Internet is designed to be distracting and addictive. It gives immediate gratification. There is an endless variety of entertainment, information, and social connections. “Hello, there,” says the ADHD brain, “where have you been all my life?”

Internet addictions include excessive use of online media, including social media, message boards, and innumerable websites. But most people will say, you just described modern life! Actually, no. What makes an addiction is excessive use. If time spent on the Internet makes you fail to get work done, or ignore or hurt the people you love, then it must be acknowledged that you have a problem with the Internet.

Gambling Addictions

Gambling addictions are among the most powerful and destructive behaviors. Whether this involves sports gambling, casino gambling, or other forms of gambling, they cause disruptions in people’s lives. Financial and relationship problems follow in their wake.

Shopping Addictions

For many people, with or without ADHD, shopping provides instant gratification and a temporary mood boost. People with ADHD are at high risk for overspending and for shopping addictions for two major reasons: People who are naturally impulsive are impulsive shoppers. And not keeping track of finances makes it easy to lose track of how much money a person is spending.

Sexual Addictions

By definition, a sexual addiction involves a loss of control over one’s sexual behavior. For some people this involves having “serial affairs,” whether or not the person is engaged in a committed relationship. For some it involves soliciting sexual partners online, or making use of prostitutes. The most common form of sexual addiction is porn addiction.

Addictive Behaviors with Food

Food addictions are considered to be both physical and behavioral addictions. They are so common that many people regard them as regular eating habits. Unfortunately, the foods that are most addictive are the foods that are the most unhealthy. A steady diet of them not only increases risk for obesity and physical illnesses, such as diabetes, but also wreaks havoc with mood regulation and cognitive functioning as blood sugar levels take a roller-coaster ride.

Highly processed foods, such as cookies and cakes, are addictive for the same reason that addictive drugs are addictive: They deliver a high dose (in this case, of sugar) and have a rapid rate of absorption. That “sugar high” you feel after a bowl of ice cream is an actual high. That “carbohydrate craving” you feel for a bag of chips is a real craving for carbs. Strong cravings are a symptom of addiction.

When does eating become a food addiction? Important factors to consider are:

• When having a cup of ice cream leads to eating the whole pint, there may be a problem. As there might be with eating half of a large pizza, the entire bag of chips, and so on.
• When a person is significantly overweight (a BMI over 30 is considered obese), or having health problems, such as hypertension or diabetes, but cannot stop eating, there is a problem.
• Making an effort to change unhealthy behavior, and being unable to do it by yourself, is a primary defining characteristic of addictive behavior.

Addictive Behaviors and ADHD: Next Steps

• Learn: The Truth About ADHD and Addiction
• Understand: Is ADHD Medication Safe If You Have a History of Substance Abuse?
• Read: Book Review: When Too Much Isn’t Enough

From the book, Life with ADHD (#CommissionsEarned), by Peter Jaksa, Ph.D. A clinical psychologist in Chicago, Illinois, Peter has worked extensively with adults and children diagnosed with ADHD for the past 35 years. He serves on ADDitude’s Scientific Advisory Board.

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Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

#CommissionsEarned
As an Amazon Associate, ADDitude earns a commission from qualifying purchases made by ADDitude readers on the affiliate links we share. However, all products linked in the ADDitude Store have been independently selected by our editors and/or recommended by our readers. Prices are accurate and items in stock as of time of publication.

Winter is coming.

Game of Thrones fans know this as a grim warning and a call for vigilance. It also feels like an apropos motto for this moment in time — nine months into a global pandemic, the second wave of which is crashing down predictably upon many nations as the days grow shorter, the air colder, and the political landscape no less acrimonious.

Grim. Frustrating. Suffocating. This is how 2,589 ADDitude readers described their world in our eleventh pandemic survey, fielded from October 19 to November 1, 2020. The emotions reported were as follows:

• Overwhelm or exhaustion: 74% of respondents
• Worry or anxiety: 70%
• Sadness or depression: 54%
• Loneliness: 45%
• Grief: 36%
• Anger: 33%

Notably, 41% of ADDitude readers said they are more concerned about the coronavirus now than they were one month ago; only 14% said they were less concerned. The reasons cited were numerous, and sometimes heart-breaking, as dozens of the 230,000 Americans lost to COVID belong to ADDitude readers’ families and circles of friends:

• “Outbreaks are increasing, hot spots are growing larger, the general public is tired of taking simple precautions and letting their guard down way too much. It’s getting colder, gatherings are moving indoors. This is only going to get worse,” said one woman with ADHD and anxiety in New York.
• “I work in health care. We got hit with a COVID outbreak and lost around 30 patients in 2 months. The lack of concern for others is baffling,” said one woman in Tennessee.
• “With the holidays coming up, I am nervous about college students returning home and infecting their families throughout the country,” said one reader in Virginia
• “More and more people I know are experiencing serious long-term health consequences and/or death as a result of complications after COVID,” said the parent of two children with ADHD in Missouri.
• “I’ve never been terrified about an election like this before. I’m afraid and not sleeping well ,” said one reader with ADHD and comorbid conditions in California.
• “I am currently operating at 20% of my normal workload — just enough to keep the bills paid with the newly created Unemployment Insurance assistance,” said one woman with ADHD in Washington.
• “The number of anti-mask conspiracies and people just outright refusing to accept that the virus is real seems to be growing daily. It’s beginning to make me think that this will never end as people will just keep spreading the virus out of ignorance,” said one man with ADHD.

[Read the First 10 Pandemic Survey Results]

The Impact on ADHD Treatment Plans

Indeed, despite mounting scientific evidence that wearing a mask does help to reduce the spread of COVID-19, and calls from the Centers for Disease Control and Prevention (CDC) to wear face coverings in public, others’ refusal to comply with medical guidance is a persistent worry for ADDitude readers. Among the 1,649 survey respondents who said their own treatment plan has been impacted by the pandemic, many said that concerns about visiting their doctor’s office and/or pharmacist kept them from accessing their ADHD medication.

“I wasn’t comfortable going to my doctor during quarantine, so I had to go without my Adderall for several months,” said one reader with ADHD, anxiety, and depression. “I’m only recently back on it.”

Overall, 85% of adults said their treatment plan has changed since March. Many cited a disruption in medication, but even more said the quarantine — plus new WFH and learn-from-home realities — threw off their previous exercise, nutrition, and therapy routines.

“The uncertainty and disruptions to routine have completely undermined my abilities to manage my ADD,” said one man in Kansas. “It has been an exceedingly difficult time.”

“As a part-time worker with no insurance, I’ve been unable to afford to seek therapy during the pandemic to treat my anxiety and ADHD,” said one woman who is an essential worker.

[ADHD in a Pandemic: A Survival Guide]

Caregivers reported fewer treatment disruptions for their children. Of the 676 caregivers who responded to this question, the majority reported no medication changes. That said, many have also resumed, added, or increased the frequency of therapy sessions — both individual and family sessions — with teletherapy now the norm.

Quite a few adults with and without children said the time at home allowed them to fully recognize and confront their own symptoms for the first time, prompting them to seek a diagnosis and treatment.

“Lockdown gave my significant other the opportunity to see my symptoms and bring his concerns to my attention,” said one middle-age woman in Michigan. “I was subsequently diagnosed with ADHD.”

The Impact on Productivity and Motivation

Disruptions to productivity and motivation were even more common among adults with ADHD. More than 95% of the survey respondents reported some lost productivity or motivation due to the pandemic.

“I started the COVID-19 lockdown period with an odd but refreshing sense of motivation that stemmed from the reduced social pressure to always be doing something. This allowed me to do things around the house I’ve been wanting to do for ages,” said one parent who is working from home. “As time went on, this motivation faded and I’ve begun feeling incredibly listless, with nothing to plan and no apparent end in sight.”

“I have exactly zero motivation to do anything, and any productivity I manage is focused on non-urgent tasks,” said one woman in Texas.

Among caregivers, waning motivation may be the most common and persistent problem associated with the pandemic. Survey respondents reported plummeting grade-point averages, school avoidance and refusal, a need for constant supervision while learning from home, and more family fights. Others say that, without sports teams to motivate them to maintain their grades, some student athletes are struggling both physically and academically.

“He is so sick of online school,” said one mother of an 8th grader in California. “The Zooms are exhausting and there is no motivation to work on projects. The absence of the fun things of school has made him hate school, which has never happened before.”

The Impact on Health

The pandemic’s impact on physical and mental health is significant as well — nearly 93% and 95% of adult respondents, respectively, reported a change in these areas. Most of the change was not good. A quarter of respondents reported suffering from new or resurgent feelings of depression and anxiety; only 3% said they feel mentally better now.

“My mental health is almost completely gone,” wrote one mother of a 1st grade student with ADHD. “I feel like most days I don’t even know who I am anymore.”

Among children, the mental toll is similar. More than 11% of caregivers reported increased depression, and another 11% reported increased anxiety in their children. Sadness and loneliness were other commonly cited emotions.

“My child has much more anxiety toward other students (and adults) who refuse to follow COVID safety precautions or admit that there even is a pandemic,” wrote one mother of a 7th grade student in Texas. “She has difficulty understanding the selfishness and lack of compassion and empathy in others.”

Roughly 15% of adult survey respondents mentioned gaining weight this year, and about 5% reported feeling fatigue or exhaustion. Others have reported that the time at home has allowed them to focus more on diet and exercise than they did before the pandemic, leading to healthy habits and some weight loss. Still others have ridden a roller coaster of highs and lows.

“When COVID started, I began Weight watchers and lost 25 pounds,” said one mother in Illinois. “Being home helped me to stay on track. Now, as always, I’ve lost interest and find myself eating to cope with stress and overwhelming emotions.”

Children with ADHD benefit hugely from physical exercise, so the cancelation of organized sports and even normal P.E. and recess time at school has had a large negative impact. Many survey respondents reported a stark decline in physical activity over the last seven months. For almost everyone, too much screen time is a concern.

“It is a struggle to get kids outside when they want to connect with friends through gaming,” said one mother of an 8th grade student with autism in Missouri.

School Uncertainty Taking a Toll

About 45% of survey respondents said their children are learning remotely now. In addition, 31% of students have experienced a major change of some kind — schools moving from remote to in-person instruction, and vice versa — just since this school year began. The A/B schedules of those students doing hybrid learning is also causing disruption and confusion, especially among kids with ADHD who thrive on reliable routine.

“Our school started all online, but then we were forced to choose between all in person or all online, so a lot of things changed between the first and second quarter,” wrote one parent of a 5th grade student with ADHD. “It’s a little stressful because now she has a new teacher and has to stay motivated all the time. Not ideal.”

Whereas the primary challenge last Spring was orienting students to virtual learning, the biggest hurdle now is navigating unpredictability and inconsistency, two features that do not play well with the ADHD mind.

“Monday through Thursday, my kids are in school and Fridays are remote learning. BUT, if there is a confirmed COVID-19 case, the school shuts down to disinfect,” said one parent of an 11th grade student in Alaska. “We’ve had four different confirmed cases this year so far, and every time we remote learn, it is a different process. There is absolutely no consistency.”

Even those families with relative consistency at school have faced changes with services and accommodations that have proven disruptive.

“We chose remote learning, but the plan was not very well-developed,” said one parent of an 8th grade student with ADHD in Michigan. “It has been difficult to get IEP services in place since the teacher for this year has never met my son in person or worked with him 1:1. And resource room services are not very helpful in a remote environment.”

In a year marked by massive change, it seems the only constant is anxiety — if not sparked by the pandemic itself, then elevated certainly by the upending of routines, the uncertainty about the future, and a culture of divisive political rhetoric. It bears pointing out that one of those factors is entirely within our collective power to change — today.

More Coronavirus Updates from ADDitude

• Read: How to Reduce Stress In Your ADHD Household
• Read: How Could This Pandemic Change Me for Good?
• Download: Distance Learning Strategies for Children with ADHD

THIS ARTICLE IS PART OF ADDITUDE’S FREE PANDEMIC COVERAGE
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Telehealth advantages may be even stronger for mental health treatment, perhaps due to better continuity and the comfort and convenience of being seen at home. According to Stephanie Sarkis, Ph.D., a clinical specialist in child and adolescent counseling, teletherapy benefits her patients. “There is evidence that cognitive-behavioral (CBT) teletherapy is just as effective as in-person therapy. For the treatment of depression, studies showed that CBT teletherapy was more effective than in-person therapy.”

In any situation, a patient should have the opportunity to communicate with a provider who listens well and asks appropriate follow-up questions. In the fields of child development and psychology, clinical care depends largely on observation and discussion, not physical examination. Effective supports rely not on a single office visit but on trusting your provider and feeling he or she understands your daily life.

Teletherapy for ADHD Evaluation

For the treatment and evaluation of ADHD, telemedicine can simplify the process through the follow-up stage. For both adult and childhood ADHD, your intention should be to share openly with someone who takes time to understand. When preparing for an ADHD evaluation, make notes about your concerns and collect information from teachers or therapists who might have something useful to add.

There is still no single test for ADHD, and symptoms are not always observed during an office visit. Diagnosis relies on clinical observation, discussion, and outside materials — like report cards and educational testing, and rating scales. Most patients do not require a full medical or neuropsychological evaluation. Evidence-based diagnosis comes from multiple reporters confirming symptoms, which is manageable online in most situations.

Of course, not everything that can be observed in person is observable online, and an initial evaluation should rule out medical conditions that mimic ADHD. Once again, however, that evaluation is largely based on medical history. Monitoring ADHD medication is also recommended, yet medical risk to ADHD patients is low. Periodic in-person sessions are ideal, but they can be temporarily deferred in most situations. Well care with your general physician is likely adequate, but you should discuss with your provider what’s most appropriate for you or your family.

[Download This ADHD Medication Tracking Log]

Teletherapy for ADHD: Pediatric Sessions

Parents may have concerns that their children will not engage fully online, or that a provider will miss details over the Internet. But as Ari Tuckman, Psy.D., MBA, an ADHD specialist and author of More Attention, Less Deficit (#CommissionsEarned), says, “It’s been helpful to see some kids at home — they are more themselves than when in some new guy’s office. It gives me a more accurate sense of who they really are.” A child’s behavior may be much worse or much better than usual during an office visit, and while some children have a hard time connecting online, many find it easier.

Diagnostic observations must always be put into the context of real life at home, school, and elsewhere. In-person sessions allow for direct interactions, but online sessions allow a child to engage in their own environment. Each has advantages. Children tend not to see their own ADHD in full, so ADHD diagnosis does not rely on a child giving her own history. A clinician seeks a full understanding of a child’s developmental history and life at home, at school, and with peers largely through parents, teachers, and therapists.

Teletherapy for Monitoring ADHD

Sorting out how ADHD affects life requires conversation and questioning. Monitoring medication requires descriptive feedback, too. Because comprehensive care relies on this kind consistency and talk, follow-up visits are typically effective and easier through telemedicine.

[ADHD in a Pandemic: ADDitude Surveys Its Readers About WFH, Distance Learning, Stress & More]

It can be difficult to get to appointments on time; when someone has ADHD, that logistic gets even harder. As Tuckman adds, with telemedicine “fewer clients are late or miss appointments. There has been more flexibility about scheduling, which has been helpful.” Many parents report that not having to get to the office greatly reduces their stress, too.

When possible, removing tech barriers also facilitates communication. Place lighting behind the computer, not your head. Set the camera at eye level. Use an Internet landline if possible, or stay close to your WiFi source. Shut down any extra programs on your device during the visit.

ADHD care relies on communication and trust. Continuity of care, emotional connection, and sharing details of your life may be simpler through telehealth. Amid our ongoing crisis, health care visits from home may be one small change that makes life easier.

Teletherapy: ADHD Medication Tips

Social distancing has meant cancelled appointments and delays in new diagnoses. At the beginning of the pandemic, those just beginning to explore the diagnosis of ADHD were in a precarious situation. Why? The Haight Act of 2008 restricts the prescription of controlled substances on the Internet if someone hasn’t been previously seen in person by the prescriber.

Studies have found that the diagnosis and treatment of ADHD through telemedicine is as effective as in-person services. Telemedicine is especially helpful for rural and disadvantaged patients. Even before the pandemic, telemedicine had been the fastest-growing means of health-care delivery for mental health patients. Outcomes and patient satisfaction ratings of telemedicine were the same as for in-person care.

When COVID became a national emergency in March 2020, the federal government made changes to telemedicine restrictions and services. It eased the restrictions of needing an initial in-person appointment. It has allowed people to get the support and services they need without an office visit.

What This Means for Prescribing ADHD Medication

Physicians can now prescribe controlled substances, like stimulant medication, without an in-person medical evaluation first. However, medical practitioners must adhere to the standards of the professional guidelines in the state in which they practice.

The Health Insurance Portability and Accountability Act (HIPAA) has been waived. This change allows the use of any video-conferencing modality, including audio only, if that is all that is available, to deliver services.

Some states now require reimbursement for all telemedicine services from in-network physicians at the same rates as for in-person visits. This includes waiving co-pays, deductibles, and co-insurance for medically necessary treatment delivered through telemedicine. To find out if your state has made this change, check with your state’s board of medicine.

Who knows how long all these changes will stay in place. Physicians and patients should stay up-to-date.

—Laurie Dupar, PMHNP, RN, PCC

Teletherapy for Teens with ADHD

Telehealth is surprisingly effective for teens. Thanks to texting, gaming, and social media, digital communication feels like a natural way for adolescents to connect with friends and family. This ease with media extends to teletherapy.

There are several benefits of online sessions for teens with ADHD. Electronic appointment reminders cue them to show up on time. They can see you in the comfort of their home. With no pressure to make direct eye contact or to show emotions in an office setting, many kids can be more willing to explore deeper issues.

Online therapy helps them with executive functioning skills and self-esteem issues in real time. There’s a unique digital window into their daily lives that I don’t see in my office. I helped a 13-year-old girl organize her closet as we discussed the best way for her to keep things orderly. I assisted a 16-year-old boy with making a schedule for school via screen-sharing. In addition, we explored options to reduce his anxiety in real time.

Of course, there are also limitations. It’s hard to comfort someone who is crying or is agitated through a screen. Sometimes I have to ask for eye contact, or remind a teen not to multi-task or leave the room to get food.

Online therapy relies on verbal skills: It’s tougher to connect with kids who aren’t talkers. This takes more creativity and planning for the therapist. Sensitivities to sounds and distractions are more pronounced. One tween yelled repeatedly downstairs to her older siblings to be quiet when I couldn’t hear anything. While these interruptions were jarring, we looked at the underlying issues of helplessness and rejection she often feels in her family.

Teletherapy with adolescents offers a unique opportunity to work through behavioral patterns, address emotional issues, and find potent interventions. When you recognize the challenges of being online, and work through them, the end results are usually productive.

—Sharon Saline, Psy.D.

Teletherapy for ADHD: Next Steps

• Read: How Online Therapy Helps Soothe the ADHD Mind and Soul During This Pandemic
• Download: Everything You Need To Know About CBT for ADHD
• Learn: Telemedicine May Benefit Patients with ADHD

Mark Bertin, M.D., is a developmental pediatrician based in Pleasantville, New York. He is the author of How Children Thrive (#CommissionsEarned) and Mindful Parenting for ADHD (#CommissionsEarned) and an assistant professor at New York Medical College.

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One of the most difficult challenges of ADHD is managing the intense emotions and moods that can hijack everyday life for children and adults alike. Emotional dysregulation — or the inability to properly modulate and regulate feelings — is a formidable problem for many people with ADHD. Yet standard treatments for ADHD, designed to optimize attention, only partially address emotional regulation. Because emotional control is not a struggle unique to people diagnosed with ADHD, we can benefit from what is known about managing tantrums and anger when they occur in association with other conditions. Listen and learn from Joel Nigg, Ph.D., about:

• The causes of emotional dysregulation and why it is an integral part of ADHD
• The most effective psychosocial treatments for children and adults with ADHD
• The interplay of ADHD medication and emotional dysregulation
• Lifestyle changes and habits to manage concerns about anger and emotionality
• Other conditions that should be considered if tantrums or anger are the main challenges

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Read More on Emotional Dysregulation from Dr. Nigg:

• The ADHD-Anger Connection: New Insights into Emotional Dysregulation and Treatment Considerations
• How ADHD Amplifies Emotions

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Meet the Expert Speaker

Joel Nigg, Ph.D., is a clinical psychologist and a professor in the departments of psychiatry and behavioral sciences at Oregon Health & Science University. He directs the OHSU ADHD Research program and is also director of the division of psychology. Dr. Nigg is the author of Getting Ahead of ADHD. | See expert’s full bio »

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The march toward independence is exciting for teens and young adults – and is often overwhelming, even terrifying, for the adults in their lives. If your teen has attention deficit hyperactivity disorder (ADHD), added responsibility over their life and health comes with extra considerations.

Responsible use of prescription stimulant medication is an important aspect of managing ADHD symptoms, but many teens with ADHD may not be accustomed to managing their medication regimens — including when to take their medications, where to store them, and how to dispose of them — without the help of parents and caregivers.¹ Working together to build safety-focused habits is important especially as your teen starts meeting new people and having more experiences outside of the home. You don’t have to do this alone; there are resources to help you build your knowledge and start conversations.

Free Video Series for Teens with ADHD on Medication Responsibility

For teens and young adults with ADHD who have already been prescribed stimulant medications by a healthcare professional, the Prescription Drug Safety Network (“the Network”), in partnership with Adlon Therapeutics, has developed a free, interactive video series and digital course focused on safe and responsible medication use. The resources were created using information compiled from government and peer-reviewed sources written by medical professionals.

For parents and caregivers, four modules within the digital course – intended to take about five minutes each – cover responsible use of prescribed medications from your point of view, including how to talk with your teen about their medications, how to read prescription bottle labels and medication guides, and how to recognize signs of prescription stimulant misuse. The information can help you lay the foundation to engage and support your teen. The course also includes a set of resources designed to get teens thinking about prescription considerations, using their medication responsibly, and making smart choices.

Practice Responding to Tricky Scenarios – Before They Happen

The new resources include a series of videos that allow teens to virtually explore various situations they might encounter at home, in school, or in a workplace. As your teen watches the videos and selects the fictionalized characters’ actions and reactions, they see the results and consequences of different choices related to safe medication storage, proper disposal, and potential risks. These aren’t always easy topics to discuss, but the videos offer an interactive way to think ahead and work to build responsible habits, refusal skills, and diversion techniques.

Following is a preview of what you’ll find in the videos – and some insights from experts on the responsible use of prescription stimulant medications. Have you and/or your teen thought about what they might do in the following situations?

Video Scenario 1: Someone asks your teen to share their prescription stimulant.

Unfortunately, people who take prescription stimulant medications may face this type of pressure in different environments, as Kyle’s story demonstrates. Here are the facts, straight from the experts:

• Prescription stimulant medications won’t help someone academically who doesn’t have ADHD and can cause health problems.²
• Prescription stimulants are Schedule II controlled substances, and it’s illegal to give a Schedule II substance to anyone other than the person for whom it was specifically prescribed.³

Takeaway: The only right answer to a question about sharing is “no,” but since peer pressure can be a strong force, this video offers refusal skills that can help individuals think through what they might do in similar situations.

Watch Video 1 now →

Video Scenario 2: Your teen stops taking their stimulant medication as prescribed.

Ben’s story follows a college freshman adjusting to life on campus and his new ADHD prescription. He struggles with whether his prescription is strong enough and if he needs to take more medication or talk with his doctor. This situation illustrates how teens and young adults with ADHD might get off track, even when they have the best of intentions.

Takeaway: Using a prescription stimulant medication in any way that is not as prescribed by a healthcare professional is misuse.[4] Experts recommend that both you and your teen gain a full understanding of how their prescription stimulant should be taken so that you can offer support if they ask questions about their medication – and encourage them to contact their healthcare professional if they have questions.⁵

Watch Video 2 now →

Video Scenario 3: Someone takes your teen’s prescription stimulant because it wasn’t stored or disposed of properly.

In Morgan’s story, you see several different ways someone could acquire prescription medications that don’t belong to them. The U.S. government has specific guidance to help limit this risk.

Takeaway: The U.S. Centers for Disease Control and Prevention (CDC) and other experts recommend ensuring the medication bottle’s safety cap is locked and storing it in a lock box or other secure storage device after every use.⁶ For proper disposal, the U.S. Food and Drug Administration calls for dropping off unwanted prescription stimulants medications at an authorized take-back site – but as an alternate, remove prescription stimulants from their original container and mix with an undesirable substance such as kitty litter or used coffee grounds. Place the mixture in a container, can, sealed plastic bag or another container that will prevent the prescription stimulants from leaking or breaking out of the garbage bag. To protect your identity, remove or scratch out all personal information on prescription stimulant label.⁷

Watch Video 3 now →

Opening Doors for the Future

Growing up is an exciting and difficult process – and learning how to make responsible choices is an integral part of the experience. Starting conversations and sharing information with your teen or young adult family member now is one way to help equip them for what’s ahead and create an open door to be a source of support.

This post is sponsored by and was developed in partnership with Adlon Therapeutics L.P., a subsidiary of Purdue Pharma L.P.

The Prescription Drug Safety Network is a nationwide coalition of public and private-sector organizations convened by EVERFI, a national leader in prevention education, to help address prescription drug misuse among teens and young adults, with a focus on at-risk communities. The Prescription Drug Safety Network partnered with Adlon to develop the resources featured within this article.

¹ U.S. Centers for Disease Control and Prevention. Attention-Deficit / Hyperactivity Disorder (ADHD): Treatment. https://www.cdc.gov/ncbddd/adhd/treatment.html. October 8, 2019. Accessed July 16, 2020

² Lakhan SE, Kirchgessner A. Prescription stimulants in individuals with and without attention deficit hyperactivity disorder: misuse, cognitive impact, and adverse effects. Brian and Behavior. 2012; 2(5): 661–677. July 2012. Accessed July 16, 2020.

³ United States Drug Enforcement Administration. Drug Scheduling. Accessed June 2020. Retrieved from https://www.dea.gov/drug-scheduling.

⁴ NIDA. 2020, June 25. Glossary. Accessed August 18, 2020. https://www.drugabuse.gov/publications/media-guide/glossary

⁵ Office of Disease Prevention and Health Promotion. Use Medicines Safely. https://health.gov/myhealthfinder/topics/everyday-healthy-living/safety/use-medicines-safely. July 16, 2020.

⁶ U.S. Centers for Disease Control and Prevention. Patient Safety: Put Your Medicines Up and Away and Out of Sight. https://www.cdc.gov/features/medicationstorage/index.html. June 10, 2020. Accessed July 16, 2020

⁷ U.S. Food and Drug Administration. Drug Disposal: Dispose “Non-Flush List” Medicine in Trash https://www.fda.gov/drugs/disposal-unused-medicines-what-you-should-know/drug-disposal-dispose-non-flush-list-medicine-trash. Accessed July 30, 2020.

ADHD Treatment in a Pandemic: Finding a New Balance

Fully 73% of us are feeling anxious and worried right now. In fact, two-thirds of ADDitude readers have been formally diagnosed with an anxiety disorder — the most prevalent ADHD comorbidity, followed by depression, which impacts 56% of you. Then there is the PTSD (4%), the learning disabilities (9%), OCD (6%), bipolar disorder (5%), sensory processing disorder (5%), and autism spectrum disorder (almost 4%).

The above findings from ADDitude’s recent survey of 1,252 readers — the ninth in a series of pandemic check-ins — confirm a long-standing but often discounted truth: ADHD is not a singular condition. It is, for the vast majority of people, a boiling, bubbling morass of symptoms that span multiple diagnoses. These comorbid conditions do not exist in isolation; they feed off of and blend into one another. And that complex, messy relationship makes treatment feel a bit like a living embodiment of the Cat in the Hat balancing on a beach ball while juggling a fish atop an umbrella, a birthday cake on his hat, a full jug of milk on a tray, and some books. While also on fire.

When coronavirus shut down workplaces and schools in March, it punctured a hole in that beach ball under our feet. Our already precarious foundations became unsteady and unpredictable, throwing off the delicate treatment balance for many. Meanwhile, the weight of the anxiety and depression we were holding was doubled by the pandemic, straining even the strongest backs. We came tumbling down — slowly.

A Changed Reality Requires a Changed Treatment Plan

“I am growing more and more incapacitated with depression and a sense that this world will never again be a place I can successfully navigate because it requires extremely high executive functioning,” wrote one mother with ADHD and depression who lives in Maryland with two teenagers who also have ADHD. “There is no use in changing anything. The future is an unending road of the impossible.”

This view, it turns out, is an extreme one. In fact, 44% of the adults who answered our survey during the first two weeks of August said they have made changes to their treatment plan since the pandemic began. Of those who have made changes during this time…

• 36% have increased at least one medication dosage
• 32% have added natural/non-medication treatments
• 19% have started medication for the first time
• 11% have switched medications
• 15% have stopped taking medication or reduced dosage
• 20% made other changes such as exercising more frequently or eating ADHD-friendly foods

[Read: ADHD Medication Reviews by Other ADDitude Readers]

You’ll notice that the above adds up to far more than 100%. This is because, just as ADHD does not exist in isolation, neither does ADHD treatment. As pandemic worry spiked, many readers added a new or increased the dosage of an existing anxiety medication. Many also began taking melatonin or a stronger sleeping medication due persistent and stress-related sleep problems.

“My doctor recommended increasing my antidepressant due to ongoing struggles with concentration and focus,” wrote one woman in Seattle who also takes an ADHD medication and lost her job due to the pandemic. “She said the continuous low-grade anxiety from life just being different now can effect focus and concentration. Increasing the antidepressant is supposed to help with that.”

For many, increasing the dosage of an antidepressant or anxiety medication meant adjusting the dosage of an ADHD medication as well. Some reduced their dosages to off-set new side effects or because healthier exercise routines diminished their medication needs. Others increased their dosages to meet life’s new demands — like working from home, overseeing distance learning, or doing both while balancing on a deflating ball.

[Symptom Test: Generalized Anxiety Disorder in Adults]

“I was so depressed and not knowing how to handle not working,” wrote one mother of two in Colorado with ADHD, anxiety, and depression who lost her job. “I was lying around all day, sad, and even crying. I started drinking more than usual and knew I had to make the change back to full strength on all of my medications.”

“Lack of structure had me depressed and floundering for months,” wrote another woman in California with ADHD, anxiety, and depression. “After I switched meds, I was able to get ideas on creating a weekly schedule and sticker charts for myself. Having structure is like night and day and I’m doing better and feeling empowered being able to provide that for myself.”

ADHD Treatment with Natural Therapies on the Rise

Decades of research shows that exercise is the most effective natural treatment for symptoms of ADHD — in children and in adults. “With regular physical activity, we can raise the baseline levels of dopamine and norepinephrine by spurring the growth of new receptors in certain brain areas,” says Dr. John Ratey, author of SPARK: The Revolutionary New Science of Exercise and the Brain (#CommissionsEarned). The end result? Better focus, emotional regulation, and impulse control.

The benefits of exercise are not lost on ADDitude readers, especially during this strange and isolating time. According to the survey results, only about 57% of you are using ADHD medication but nearly as many are using exercise to manage symptoms.

• 53% exercise regularly to control ADHD symptoms
• 53% use vitamins and supplements like fish oil
• 50% practice mindful meditation
• 29% engage in cognitive behavioral therapy (CBT)
• 17% use coaching, talk therapy, or another natural treatment

“I’ve been exercising a lot more during the lockdown and I find that I don’t need the full dosage anymore,” wrote one woman who decreased her ADHD medication dosage. “I’ve also started experimenting (with the support of my doctor) with lowering/increasing my dosage based on my menstrual cycle because I find that that affects my focus levels.”

“I had no choice but to start practicing mindfulness; it was the only way to survive the overwhelming stress from working from home alongside my son, who also has ADHD,” wrote the single mother of a 7th grader in California. “We also started exercise and gratitude journaling to help us function and get through this thing.”

Treatment Goals for a Strange Fall with ADHD

More frequent exercise is the most common goal among ADDitude readers struggling to manage their symptoms as the pandemic surges through its sixth month in the United States. About one-third of adults with ADHD say they will continue to make treatment changes, including:

• 23% plan to increase medication dosage
• 21% plan to start a new medication
• 14% plan to switch to a new medication
• 3% plan to decrease a dosage
• 2% plan to stop taking a medication

“I’m still tweaking medications and dosages to find a combination that satisfies my insurance, shrink, pharmacy, and budget that is also an effective treatment for, you know, ME,” wrote one reader with ADHD, anxiety, depression, and sensory processing disorder.

ADHD Treatment with Therapy

Nearly half of ADDitude readers have attended at least one telehealth appointment — via a video or regular phone call — since March. For many, telehealth has meant virtual therapy. And among adults with ADHD and its comorbidities, the reviews are positive.

“I love my virtual therapy!” wrote the mother of two small children with autism spectrum disorder. “I actually kind of prefer it because it doesn’t involve executing a trip out of the house at a specific time, which is often difficult and stressful for me to coordinate.”

“It has been helpful and encouraging to me,” wrote an older reader. “It’s helped me to adjust my perspective and expectations for myself during this challenging time.”

Some adults have found virtual therapy difficult to execute with so many people home all of the time.

“As a parent working from home with two teenagers also at home, it is very difficult to schedule and/or find time to have privacy and meaningful discussion online with healthcare providers of any sort, and especially mental health practitioners,” wrote one parent with ADHD, anxiety, and depression. “So it’s like maybe 60% as effective as it was in person.”

For children with ADHD, 52% of whom have now used telehealth, the reviews are markedly worse. Only 18% of caregivers gave an ‘Excellent’ rating to the telehealth experience, which largely comprised therapy sessions. Half called it good or very good. And 9% said the experience was poor. The most common complaint: kids with ADHD are overdosing on screens right now, and one more ‘boring’ Zoom meeting is just more than their attention and focus can endure.

“When visiting in person, our child would talk to the psychiatrist while playing,” wrote the mother of a First grade student in Texas. “In our telehealth appointment, she was bouncing off the walls, hiding under the computer desk, putting her face in the webcam, etc. At one point, we actually had to remove her from the room because we thought she was going to knock the computer off the desk.”

For others, telehealth has helped to demolish barriers to treatment that previously stood in the way of positive momentum and symptom control.

“It used to be a struggle to physically get my son into see his behavioral therapist,” wrote the mother of a Ninth grader with ADHD in Chicago. “Since telehealth started at the end of March, he has talked to the behavioral therapist weekly — not monthly. He looks forward to it actually and is just more comfortable talking to her. Telehealth has been a blessing for us.”

Treatment Changes for Children with ADHD

Adding telehealth is just one of many treatment changes made during this pandemic by caregivers eager to balance symptom management with overall health — mental, physical, and psychological. Half of the caregivers who responded to ADDitude’s latest survey said they have made treatment changes in the last five months. Of those,

• 33% said their child stopped taking medication
• 24% said their child began taking natural treatments
• 19% increased their dosage of ADHD medication
• 17% decreased their dosage of ADHD medication
• 17% switched ADHD medications
• 15% started taking an ADHD medication for the first time

Among the families that reported ceasing ADHD medication, one primary reason rose to the top: With lighter academic demands and a more flexible learning environment at home, many caregivers felt their children no longer needed medication to help them sustain focus and attention during the day. By taking a medication vacation, they said they hoped to address a common side effect: diminished appetite and weight loss.

“When our son stopped going to public school in March, a lot of the behavior related to his ADHD went away or I was able help him focus by finding the best times to get his work done,” wrote one mother who plans to home school for the first time this Fall. “The anxiety, anger, and frustration caused by his lack of social skills and feeling ‘not as smart’ went away.”

“He needs to be more focused during school, so a higher dose is necessary to help with that,” wrote one Florida mother who decreased her child’s ADHD medication dosage. “At home, it is one-on-one and I can redirect and repeat repeat, which cannot be done at school.”

Other caregivers reported that new spikes in anxiety caused by the coronavirus prompted them to make several medication adjustments.

“We increased my daughter’s anxiety meds because she was experiencing major disappointments and upsets re: missing her senior year, but we decreased her ADHD meds because her school day was shorter,” wrote one parent of a teen with ADHD.

Among those who increased their child’s ADHD medication dosage or introduced meds for the first time, at-home behavior — namely emotional dysregulation, anger, and outbursts — was commonly cited as a motivating factor.

“Behaviors always prompt us to change their treatments, especially as it pertains to meds,” wrote the parent of First and Third grade students with ADHD. “We saw an increase in quick emotional tantrums, the ones that made us seek medication as a portion of their treatment plans.”

More Changes for Back-to-School Season

As of early August, the treatment landscape for children of ADDitude readers looked like this:

• 65% of children were taking medication
• 49% were managing symptoms with exercise
• 47% were engaging in behavioral therapy
• 41% were taking vitamins and/or supplements
• 19% were engaging in regular mindful meditation

In the coming weeks, that mix will change, as 43% of survey respondents said they plan to make further adjustments to their child’s treatment plan before school starts — in person or otherwise. Of those making treatment changes, two-thirds will be boosting meds — 38% said their child will begin taking medication and 28% said they will increase their child’s medication dosage. Another 13% said their child will be changing medications, but less than 1% said their child would be ceasing ADHD medication anytime soon.

“The med helps him focus — period — so he is better able to comprehend work, complete it, and not become overwhelmed,” wrote one mother of a high school student in Kentucky. “He will also be exercising and/or meditating every day, as that helps his mood, cooperation, and energy level, too.”

“Without medication, my child won’t be able to control his impulses to follow the strict social distancing rules at school,” wrote the parent of a Second grade student with ADHD.

Many other parents said they will delay any decisions until they can observe their child learning at home or in a hybrid model for a few weeks. Treatment is just one of many moving parts for families this academic year.

“I’m hoping to not need to restart meds, but unfortunately I do not feel my son will be able to learn half in school and half online without meds, based on his behaviors,” wrote the parent of a high school student with ADHD in New York. “I will certainly try first before restarting meds.”

“Once school resumes (distance learning for now) and we have a few weeks under our belt, I hope to reach out to my daughter’s psychiatrist to see what may need to be done,” wrote the parent of a Fifth grade student with ADHD in California. “My daughter has had a growth spurt and her meds may need to be adjusted. I also need to work with her school to put her 504 Plan officially into place, with accounting for distance learning concerns, if any. We still don’t know what the expectations are and how the schedule will look.”

As with all things these days, flexibility is both essential and exhausting.

ADHD Telehealth and Medication Changes: Next Steps

• Read: Can You Stock Up on ADHD Medication During a Crisis?
• Read: How Online Therapy Helps Soothe the ADHD Mind and Soul During This Pandemic
• Download: Distance Learning Strategies for Children with ADHD

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