Place of Telemedicine in ADHD

Theresa R. Cerulli, MD: Why don’t we move to segment 2? Disease management and factors guiding treatment selection in ADHD [attention-deficit/hyperactivity disorder]. Birgit, you alluded to some thoughts with regard to treatments as we’re discussing the general clinical burden of ADHD. How are you and most clinicians using telemedicine to manage ADHD in your practice? Are there any differences in private practice vs academic hospital settings? What do you think?

Birgit H. Amann, MD: At my office, we’re still doing a lot of telehealth. We’re still 80% telehealth. We’ve learned how to be very efficient with it and better at it. There are definitely challenges. One is getting people to come back to the office. We all have days that we’re in the office to see patients. At home, there are a lot of distractions and things that limit their full attention. They might have better attention if they were sitting in front of you at the office. The other thing I found that has been a big challenge with telehealth is making sure I’m getting proper vital signs. I want to make sure I have up to date height, weight, blood pressure and pulse that the blood pressure and pulse needs to be done. I tell them I need them within a week of your appointment. I’ve been having them use their own blood pressure cuff or go to the pharmacy and use theirs for free. That has been a challenge. But it’s important for the medications that we’re writing because we can impact that. We’ll see what happens moving forward. I anticipate that moving forward, we’ll continue using both telehealth and in-person treatment.

Theresa R. Cerulli, MD: The challenge with getting vital signs in telemedicine has also been enormous in my practice. Alice, at Baylor College of Medicine, do you have any thoughts in how telemedicine is being used differently in an academic setting?

Alice Mao, MD: We like to see them in person for the first visit because when we’re evaluating patients by telemedicine, especially children, they don’t like to stay on screen for a long time. If they move off-screen, we don’t get to see the interaction between their families or how much they’re fidgeting when they’re sitting in a chair and moving around. We usually do the first evaluation in person. In our academic setting, we have patients who drive to 2 to 3 hours to come in for appointments. We may allow them to be seen on every other appointment by telemedicine to make it more convenient for the families. But we require that the child is dressed and able to sit in front of the screen. The family has to make sure the child is awake. We’ve had some interesting events where we’re talking to them and we find out the child is sleeping. Needless to say, they’re not very cooperative when they’re woken up.

If it’s an adult, we still do the normal mental status exam. We ask them to start from 100 and subtract 7 and continue to subtract 7 down to 51. We also ask, “How is ADHD affecting your life? Have there been improvements in your life since starting treatment?” They’ll often give us examples of things they’re forgetful about, like picking up their kids from school or meeting deadlines. If there’s a particular problem that they’ve mentioned, we try to follow up at the next visit to ask them if that area has improved. They get very bored doing the serial sevens, but it’s amazing how much they can improve after they’ve started treatment. Also, they can let us know how much happier they are in terms of being able to get their projects completed more successfully. It’s nice to get affirmation when college students make good grades and meet all their deadlines. It’s a very rewarding field to be in when treating adults.

It has been nice to do telemedicine during COVID-19 because many patients would not have been able to come in for their appointments. Seeing children in person is very important because we see so much information, such as their body language, how much they’re fidgeting, whether they’re able to sit still. With adults, since the hyperactivity seems to diminish in adulthood, they’re able to stay in front of the screen, so we’re able to assess them. But we still prefer the live appointments because we get much more information and you’re not dealing with technical problems in the transmission of information. Also, they get to see our body language and feel more comfortable in appointments when they’re there. With kids, we learn a lot about them when they’re doing telemedicine because we get to see their homes, we get to see how their rooms are organized, and sometimes we get a sense that parents may also have a little ADHD in terms of how they set up the virtual appointments and the details surrounding that, like having the child dressed or awake. Sometimes we come on screen when evaluating the younger kids and the parents forgot that the child needed to be present at the appointment. They thought it was OK to show up by themselves. They tell us their kid is at school, and we tell them we need to reschedule the appointment because we have to evaluate the child.

There are other issues, such as vital signs, that are important when treating with certain medications. It’s very important to get the blood pressure and pulse measurements. If our adult patients are going to be doing a virtual appointment, we have to train them how to take a pulse or get a pulse oximeter so we can get their pulse. Also, [they have] to get blood pressure readings. Weight is important to check in children and adolescents because they’re growing. With the adults in a telemedicine appointment, we can ask them to weigh themselves and hope they’re honest about reporting their weights. It’s an advantage to have both modalities of treatment to improve compliance. But live appointments are always better.

Theresa R. Cerulli, MD: What do others think? Mike?

Michael Feld, MD: I’m mixed about virtual, even though I’m getting a lot of it. I like the initial diagnosis to be in my office. I’m trying to shift more to that.

Andrew Cutler, MD: Yes.

Michael Feld, MD: I often have separate meetings depending on the age. I have more than 1 meeting if it’s an adult. In the office, there’s much better connection. You know if you’re a good fit. But you also get a better feel for their ability to connect and how inattentive, how restless they are. Some kids at home, sitting at their computer, look pretty together. But then the second they’re in my office, I see things flying off my desk.… There’s a better feel for it. I’ll do it if I have to. For patients I know well, medication follow-ups virtually are great.

Andrew Cutler, MD: Yes.

Michael Feld, MD: Not only that, but those of us who are specialists know that over 80% of the kids in this country are being treated with ADHD meds by non-pediatric psychiatrists and non-pediatric neurologists. We’ve got people willing to drive 1½ hours to our office. Some make a 3½-hour trip for a med follow-up. I’m more than willing to take the burden away for that. I find it useful for that. It’s much less disruptive to people’s schedules, especially when I want to see them during school hours. I don’t have all evening hours, so there’s a good compromise for that. I’m trying to find the value. I’m asking a lot of my patients not to drive or to pull over while we’re doing virtual stuff.

Theresa R. Cerulli, MD: Telemedicine has certainly had its advantages and disadvantages. There are some real positives. We’re able to reach people who we might not otherwise have been able to. There’s a shortage of folks who are specialized in ADHD for kids, adolescents, and adult patients. Otherwise, they may not have access to care. But there’s a difference between doing telemedicine with somebody who’s specialized, trained, well-educated and who has a lot of experience vs the “pop up online, get your diagnosis and medication in 45 minutes” visits. It’s not just the tool. The user of the tool might make a big difference in terms of safety and outcomes. Whether you’re seeing patients in person or online, we need to look at the person doing the evaluation, right?

Michael Feld, MD: Yes. I’ve maintained a better connection with my college kids. I used to wait for them to come back into town.Now I’m much more open to help change meds early in the school year and do some more intensive follow-up than I even thought about a few years ago.

Theresa R. Cerulli, MD: Yes, that’s a really great point. Birgit, did you want to say something?

Birgit H. Amann, MD, PLLC: In reflecting on this conversation, I’m probably enabling some ADHD patients because I have a certain number of minutes whereby if they’re not connected with me on my telehealth visit, I can ping them through the chart. After a certain another number of minutes, I’ll call and say, “I’m trying to salvage your appointment for you.” I’m like their ADHD coach.

Theresa R. Cerulli, MD: Yes.

Birgit H. Amann, MD, PLLC: As I reflect on this, I’m thinking, “I probably need to stop doing that.” Because they need to learn to remember when their appointment is.

Theresa R. Cerulli, MD: A little therapy, a little coaching, and a little psychopharmacology.

Transcript edited for clarity