Treatment Goals and Treatment Selection in ADHD

Theresa R. Cerulli, MD: Bringing the conversation back to our patients, Birgit, how do patient and caregiver treatment goals impact treatment selection? What if the patient and caregiver roles aren’t the same?

Birgit Amann, MD, PLLC: When I see a new patient at the end of that first session, I always ask for anybody in the room to give me the top 2 or 3 goals that they have. The child may have 1, but the mom or dad may have 10. I have them give me the top 2 or 3 because we use those to move forward in treatment or move along in treatment. We’re always going back and reflecting on “What have we improved on within those? What haven’t we?” Then, revise accordingly. That helps me.

The other thing that helps me is in that first session, when I get a sense of what their goals are, I can determine if this goal is something that a medication is going to help. This goal is about organization. It’s so critical, as we all know, to recognize that meds can’t do it all. I’m constantly saying that. Meds can’t do it all. Maybe a goal is to be better organized. That tells me that I need to make sure I have an ADHD coach on board. Maybe I need to have some parental guidance, with a therapist, to help the parent help the child. But maybe some goals are more medicinal, and I need to look at a proper medication to cover as much as possible. One of the goals was to improve homework time. That question pertains to my practice all day, every day, with all my new patients.

Theresa Cerulli, MD: I love hearing that each of you has said, at some point during our conversation, how important it is to look at the nonpharmacologic approaches to treatment as much as we look at the pharmacologic. That’s an open-ended question, and you went right to explaining how important that was, Birgit. I had just asked about treatment goals, and it was so nice to hear that included both pharmacologic and nonpharmacologic treatment goals.

Andrew Cutler, MD: Could I add 1 quick thing to Birgit’s excellent answer? We tend to focus on symptoms, as we have to. We need to have a certain number of symptoms to establish the diagnosis. Many of our rating scales are symptom based. But as Birgit said, the goal may not be symptom driven. It may be something to do with quality of life or function. It’s important to ask folks, “What things bother you the most? What are the things you’d like to see go better?” It may be quality of life and function in addition to the symptoms that we’re so focused on.

Theresa Cerulli, MD: Anything you want to add or share on this topic, Dr Feld?

Michael Feld, MD: I always have things to add, but…for me, I’m like, “Why now? What are your largest concerns?”

Andrew Cutler, MD: Yes, exactly.

Michael Feld, MD: Then, realistically, I set out an algorithm because that’s the magic of all these new medication products and formulations. We have such an ability to help kids and adolescents and adults respond to meds that they might not have 10 or 20 years ago because of these newer meds. People gain hope when you let them know there’s an algorithm. But you also have to get the wheels on the train track before you can push the train forward.

Andrew Cutler, MD: That’s good.

Michael Feld, MD: What if I’m interested, and everyone wants the kid to exercise more? Everyone knows nutrition has to be an issue. Everyone knows sleep has to be an issue. Maybe pick up a sport or an interest or an activity. We all know that, but what if that’s not going to happen until there are certain symptoms, like the wheels on the train track? Lay out a plan. Tell the patient, “No, I’m not going to expect you run a mile tomorrow before we start you on meds.”

Andrew Cutler, MD: Right.

Michael Feld, MD: But this is the goal. This is what we’re working toward pharmacologically and non-pharmacologically. I like the metaphor of just getting the train rolling a little.

Theresa Cerulli, MD: Am I allowed to borrow that from you, Dr Feld? I’ll give you credit. That’s beautiful.

Andrew Cutler, MD: Yes.

Michael Feld, MD: There’s no way I didn’t get that from a supervisor.

Andrew Cutler, MD: I’m stealing from all you guys. But I always cite my sources, so don’t worry.

Transcript edited for clarity