In this video, Ann Childress, MD, shares strategies and tips for treating children and adolescents with attention-deficit/hyperactivity disorder (ADHD) during the COVID-19 pandemic.
Dr. Childress is a child and adolescent psychiatrist in private practice in Las Vegas, Nevada. She has authored numerous publications on ADHD and been a co-principal investigator on more than 160 clinical trials. Her research has focused on treatment of youth and adults with mood disorders, anxiety disorders, autism, schizophrenia, and ADHD.
Read the transcript:
Hi. I'm Dr. Ann Childress. I'm a child and adolescent psychiatrist in Las Vegas, Nevada. I spend about 80% of my time doing clinical research trials with ADHD medications, and the other 20% I follow up patients with completed studies.
I'm also adjunct faculty at the University of Nevada, Las Vegas School of Medicine, and also Touro University, Nevada, College of Osteopathic Medicine.
Today I'd like to talk to you coping with COVID‑19, and optimizing medication treatments for ADHD in children and adolescents during this crisis. How do we do that?
Since schools have switched to an online curriculum, many caregivers are wondering, is this a good time to make any medication changes? Should I even continue on medication at all for my child?
Since the crisis has been going on for a couple of months, I can tell you that folks who have thought, well, maybe since my child is actually not in brick and mortar school, we're just at home doing stuff on the computer, maybe we can do without our medication.
Folks that have done that, have tried that for a few weeks, have actually called me back and said, "No. We really need our medication, now really more than ever," because there are a lot of issues that come up with doing school online.
Children have to be really more responsible for themselves. It may not be as interesting doing a Zoom classroom as it is sitting across from your friends in the classroom. It's maybe harder to pay attention, because there can be little fidgets or toys that kids can be playing with to get distracted while the teacher is talking.
And it's not really a lot of fun to just interact with the computer and do your math lesson or read your English or your history. So it really is a pretty good time to take medication, and it's a good time to make changes, because our patients are at home.
If patients can get into the clinic, that's always the best thing for healthcare providers. You can see your patients. You can weigh them, you can get their height, take their vital signs, and sit and talk about medications with the parents. You can observe them in real time.
But as psychiatrists, pediatricians, other healthcare providers, ADHD really gives us a good opportunity to do some of those things via telemedicine. We can still see the kids bouncing in and out of the pictures, or if they're bouncing up and down in the chairs, or if they're calling out and interrupting their parents as they're trying to talk with us on the computer.
Even though we can't get vital signs in real time in our clinic, most families have scales where they can weigh the kids. They may even have blood pressure cuffs, although I don't trust the home blood pressure monitors as much.
And since this hopefully won't go on forever, we can catch up on those sorts of things, getting those vital signs when the kids are actually able to come back into the clinic.
What about medications, if somebody wants to make a change? Well, as I said, it's not a bad time to make a change. If somebody wants to start a stimulant or switch to another stimulant, it's best to follow the package insert. Usually medications will talk about starting at a low dose, but you can ramp up things pretty quickly.
That's one of the nice things, again, about being at home and having the parents so that they can see if you started a child on a low dose of medication, they can see within a few days, really, whether that's going to be a good dose, or whether we're going to need to go up on it.
And you can increase stimulant medications. Most stimulant medications you can increase weekly. That's what we do in our clinical trials.
To get to an optimal dose, when we're looking at open label optimization in our clinical trials, we look at usually a 30% improvement in the ADHD rating scale. You can have the parents download, say, the Vanderbilt online, and they can fill that out in between visits, and go over that with you. You can ask some of those questions.
In the studies, what we do as investigators, we go through the ADHD rating scale, and get the parent's answers at every visit. We look at that, look at the decrease, whether people are having side effects, and then we decide whether we're going to stay at that dose of medications or whether we're going to go up.
30% is the number that we use in a lot of the clinical trials. However, if your child, or your patient, has a score that's 54, well, that's 30% improvement, still having some pretty significant impairment. They're still going to have at least moderate impairment.
So, one of the things you might think about when you get there, are they having appetite problems? Are they having sleep problems? Are there other things that are causing tolerability issues? If they're not, then you can go ahead and go up on medication.
One of the things that you can do as a healthcare provider is have the parents observe the kids when they're playing games, when they're interacting with siblings, when they're interacting with you. Are they interrupting? Are they talking too much? Are they having trouble waiting their turn?
Those will give some really good indications about how well the medication is working.
If you decide to switch them from a stimulant to a nonstimulant, or if they're naive and you want to start on a nonstimulant, it's just important to remember it's going to take a little bit more time, probably, to get to an optimal dose.
Often, when I'm talking with parents about switching to nonstimulants, I say, "Let's wait and until the end of the school year, so that we don't lose any ground."
However, the school year is almost over right now, and again with the kids at home, you're going to have a good opportunity to get good information from the parents about how they're doing.
So, in summary, it's not a bad time at all to look at optimizing medications for your patients with ADHD. As a matter of fact, it's a really good time. And you can use the opportunity to get patients right where they need to be, so that they're set up for success when brick and mortar school starts again, hopefully this fall.