Advances in the Management of Complex ADHD in Pediatric Patients - Episode 10
Theresa Cerulli, MD: I want to circle back to our discussion on drug holidays and the fact that a lot of parents are seeing the COVID-19 [coronavirus disease 2019] era as potentially a reason to take a drug holiday because their kids are home more or have been home. Frank, is there less need for medication coverage because of COVID-19? What are you seeing?
Frank Lopez, MD: You know, this has become very near and dear to my heart. Actually, there are 3 sides to a coin. There’s heads, there’s tails, and then there’s the edge. The truth usually lies around the edge. It’s not on 1 side or the other. Why I say that is because I’ve had the opportunity to do telehealth in the era of COVID-19. I get a sense of a microcosm of what’s going on at home as I spend time with the patients in the office. But to be able to visit them and see them in the throes of their everyday life through telehealth has really opened my eyes further than they were before and allowed me to see some of the challenges that they’re facing. Along the lines of the drug holiday, we’ve had parents—I can count them—who say they can manage this. The 1 who went the longest so far went 8 days, and on the ninth day they restarted the medication.
What leads to this? There are so many different challenges. I actually wrote a list of what I’ve seen in the last 100-something days—195 days, but who’s counting?
Theresa Cerulli, MD: Reflections of Dr Lopez in the COVID-19 era.
Frank Lopez, MD: Oh, I’m telling you. Reflections of my mind, so to speak. I’m a musician first, many years ago, so I’ll make references to music very often. But what I’m getting is the lack of structure. That’s No. 1. Parents don’t realize how much structure face-to-face education provides. The teachers are there to present material, but they’re also extensions of ourselves as parents for our children. That’s No. 1. They have to be able to provide the structure. That is not happening. We see a lot of parents who let the children sleep in. Instead of getting them up at the typical time that they would be going to school and getting them ready, the distance learning has allowed for a lot of flexibility in timing. That in itself adds to the lack of structure that the parent can bring. If the distance learning is set—it’s going to start at 8 a.m., it’s going to run until 12 p.m.—you’ll have to be available during those times. That forces that child, forces that parent, to be supportive and available. We have that to contend with there.
The organization of the presented material is a big complaint from a lot of the parents. What my child is being presented on through distance learning is not what they were doing 3 weeks ago, before the school closures began. Even throughout the spring and to the early part of the summer, that kept coming up. It’s not the same material that they were getting presented. Then we have the fact that a lot of parents are not trained or don’t have the personal attributes to be able to support their child and teach them.
Theresa Cerulli, MD: We already mentioned, with the genetics being so strong, that a lot of the parents are struggling with ADHD [attention deficit/hyperactivity disorder]. Structure may be hard enough for them to organize for themselves, and now you’ve got the added layer of trying to do so for their child at the same time.
Frank Lopez, MD: Along those lines, because of that, parents that have ADHD symptoms as well, there’s lack of patience, lack of supervision or supervisory ability on their part, obviously the lack of a structure, and routines are altered. That routine, we’re circling back to the beginning. Distance learning didn’t provide that routine, didn’t help to provide that structure. The other part is, a lot of these kids are bothered by background noise. So 1 of the things I ask of each of the children—not the parent but the child: Are you using a headset? If you are, is it blocking out the background?
Theresa Cerulli, MD: Right, the distractibility, the core symptom.
Frank Lopez, MD: Yes. That is a big deal, and not everybody can afford to have a noise-canceling headset. Again, headset vs. no headset vs. is there a specific room—a specific area where the child can sit and not be bothered, and you can supervise and do your own thing. That’s a piece.
Now, the medication compliance. Oh, my. So do we need medication during this? Yes, we do. Do these parents need to understand that the medication compliance and consistency are important? Yes, they must. Many times, even for younger kids—despite the fact that we teach them not to have the child medicate themselves—many parents, because they need to leave the house earlier, will leave a pillbox, and the child is supposed to take it on their own. Really? An ADHD kid remembering to take their medication? Oh, my. So that is a setup for disaster.
Theresa Cerulli, MD: Right, there’s a whole other level of safety concerns when you’re talking about an unsupervised child with ADHD homeschooling with a parent who can’t really participate in that process because of their own work situation.
Frank Lopez, MD: No question. And for a lot of parents now, 1 of the things that has happened is the loss of their jobs and insurance coverage. Now they can’t afford to have a visit or they can’t afford—if I pay for the medication—for the food. Unfortunately, the cost of medication is high, especially if you don’t have any insurance coverage.
Theresa Cerulli, MD: For me, I don’t know about you, but when I think about the safety issues I mentioned in clinical practice, I normally would be checking blood pressure, heart rate, height, weight. Now with telemedicine, which has been a blessing in some ways. My clients seem to be a little more compliant than when they have to organize to get themselves to my office, so that’s the good news. But the bad news is I’m not able to check some of those really important parameters and measures that I normally would take for safety, particularly with regard to use of the stimulants.
Frank Lopez, MD: I’ll tell you what I’ve done. A good portion of our parents have—I hate to use a brand name—a smart watch. Many of these smart watches—some are like $50 or less—actually give not only your pulse but also your blood pressure. In instances where the child is a little bigger, not a 4- to-5-year-old, I will have the parent put the watch on the child, and I’ll be watching. I have them hold it up to the camera, and I can actually get a pulse and in some cases even get a blood pressure or an approximate. It is not accurate as if I were doing it, but it’s at least some data.
Theresa Cerulli, MD: I have to share a quick story, Frank.
Frank Lopez, MD: Go for it.
Theresa Cerulli, MD: Because this just happened yesterday. Similarly, I’m trying to get whatever data I can and enlisting the parents’ help in doing so. One of the parents diligently went out and bought the blood pressure cuff that I had recommended, because they have a number of kids and adults in the household with ADHD who need their blood pressure monitored. Yesterday, they were holding up the blood pressure monitor to my computer screen to try and show me the reading, and I said, “I’m sorry, I can’t actually see the digital readout. It looks black.” She looked at me and laughed and said it’s because it is black, because after buying the monitor and attempting to read the instructions—remember, I have ADHD myself—I couldn’t figure out how to use the darn thing. Now have the blood pressure cuff, but it might be a few weeks before I can get around to figuring out how to use it.
Frank Lopez, MD: It’s sad but true.
Theresa Cerulli, MD: We have challenges.
Frank Lopez, MD: Ironically, I hate to think of our level of severity that the parent may have themselves when they have something like that. It’s absolutely remarkable.
Transcript Edited for Clarity