Attention Deficit Hyperactivity Disorder

View episode transcript

Featured guests: Kimberley Levitt, MD

Objectives

• Define the diagnostic criteria for attention deficit hyperactivity disorder (ADHD).
• Understand varying presentations of ADHD including hyperfocus and agitation.
• Apply principles of psychopharmacology for the management of ADHD.

Resources

• Stimulant rebound: how common is it and what does it mean? (Journal of Child and Adolescent Psychopharmacology)
• Meta-analysis: Risk of tics associated with psychostimulant use in randomized, placebo-controlled trials. (Journal of the American Academy of Child and Adolescent Psychiatry)
• Hyperfocus: the ADHD phenomenon of hyper fixation. (Attitude)
• ADHD and behavior problems. (Child Mind Institute)
• Attention-Deficit/Hyperactivity Disorder. (American Academy of Pediatrics)
• Neurobiology of attention deficit hyperactivity disorder (ADHD) – a primer. (Pscyh Scene Hub). 
• ADHD Neuroscience 101. (Attitude)

CME

Credits available: 0.5 credit 

To enroll for CME credit, visit our CME course overview page for CME credit, or complete this survey for social work CEUs.

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Transcript

Dr. Christina Cwynar:

Hello, and welcome to our podcast, Breaking Down Mental Health, with myself, Nurse Practitioner Dr. Christina Cwynar, Social Worker Syma Khan, and Child and Adolescent Psychiatrist Dr. Heidi Burns. We are joined today by Dr. Kimberly Levitt to dive into attention-deficit hyperactivity disorder, or ADHD. Dr. Kimberly Levitt is a clinical assistant professor within the Division of Developmental Behavioral Pediatrics at the University of Michigan. Dr. Levitt completed her undergraduate education at Duke University, and medical school at the University of South Florida Morsani College of Medicine. She completed pediatric residency and developmental behavioral pediatric fellowship at the University of Michigan. She is board certified in general pediatrics and developmental behavioral pediatrics. Welcome, and thank you for joining us today.

Dr. Kimberly Levitt:

Thanks so much. I'm so excited to be here.

Dr. Heidi Burns:

All right. Well, let's kick today's discussion off with reviewing the diagnostic criteria for ADHD.

Dr. Kimberly Levitt:

Yeah, absolutely. When we think about diagnostic criteria, it certainly calls to mind the Diagnostic and Statistical Manual Mental Disorders or the DSM-5. Ultimately, when we think about ADHD, it falls within the neurodevelopmental disorders, and what it's really trying to capture is this persistent pattern of either inattentive symptoms or hyperactive impulsive symptoms. And one of the key things is that it really has to be interfering with functioning or development.

And so then, within those two categories of either inattentive type symptoms, of which you have to have six out of nine, or the hyperactive impulsive symptoms, again, having to have six out of nine at least, and also present for at least six months. So this is again, getting back to that persistent pattern and that you're seeing these really notable symptoms in either of these two domains, specifically that you have to have six out of nine of those symptoms.

So just to highlight a few, when we think about the inattentive type symptoms, it's difficulty paying close attention, difficulty with sustained attention, difficulty following through on instructions, difficulty with organization, forgetting things, losing things, et cetera, I think a lot of things that come to mind when people think about inattentive type symptoms. Similarly, when we think about hyperactivity and impulsivity, again, the famous driven by a motor, moving, fidgeting, up out of their seat, but then also the impulsivity symptoms of blurting out answers, intruding or interrupting others, difficulty waiting.

And so really, it's those constellation of symptoms present for at least six months, present too in young children, at least under the age of 12. And that these symptoms are really occurring across settings, that they're not just happening at home, they're not just happening at school. They're occurring in lots of different contexts and that they're interfering with the individual's functioning. And so ultimately, that is a little bit about the diagnostic criteria in a nutshell.

Dr. Christina Cwynar:

Thanks so much for starting us off with that definition of what ADHD is and what we can typically expect or see from youth that we're concerned about having an ADHD diagnosis. But I think as you shared, we can also see that that presentation varies a little bit, and some people assume that a youth doesn't have ADHD because they can sit still or that they are doing well in school. They're not having some of those really classic symptoms. So can you share a little bit more about how the presentation of ADHD can vary and how we may miss it or misdiagnose it?

Dr. Kimberly Levitt:

Yeah, it's a really great question. I think that hearkens back into the different presentation types. So you can have predominantly inattentive type presentation, predominantly hyperactive-impulsive type or a really combined. And so inherently, as you mentioned, somebody with an attentive type ADHD might sit very well during class and might even do well academically, but it doesn't mean that they're working doubly hard as the person next to them to pay attention, to maybe filter out that extraneous stimuli in the environment, to not be distracted by it, to really stay on target.

So I think you've really highlighted the saying of you've met one child with ADHD, you've met one child with ADHD. There certainly are these core symptoms that we look at from a diagnostic perspective, but how that manifests in each child can be a little bit different. And so definitely great to have it on your diagnostic list when you're thinking about possibilities, if you're noticing that children are having challenges in these certain domains. But again, as you said, it can be sometimes easily missed or construed as another diagnosis.

I think in my own clinical practice, something I see the most is the impulsivity symptoms being underrecognized or misattributed to other diagnoses. And I think that's something, in particular. It's really important to talk about with families. A lot of that is tied in with safety concerns. So my patients that primarily have impulsive symptoms, those are the ones that I might worry about being unsafe in the neighborhood or darting out into traffic. And those symptoms don't go away just because school's out for the summer. So again, it's really important to have those conversations with families and think broadly when you are thinking about ADHD.

Dr. Heidi Burns:

I think sometimes we can see that kids will go undiagnosed until they reach a certain threshold. Maybe they move into a more academic situation, maybe they move into a more difficult social situation, as they age. Particularly things like going into middle school, where the demands that are put on them are much different maybe than they were able to compensate for when they were younger. And then you see these middle school-aged kids coming in actually and there's concerns for ADHD. All of a sudden they're not doing well. Didn't mean that they didn't have it before, but they were able to find ways to compensate for what they had problems with when they were younger, but can't when the threshold is higher.

Dr. Kimberly Levitt:

Yeah, absolutely. I think that's a great point that the demands increase with time. And so ultimately ADHD, the heart of it is challenges with executive functioning, those higher order processes that contribute to behavior and learning. And so when those demands increase, it might be hard to keep up in areas of organization or socially or these other things. It might start to be more impactful. And that's where, exactly as you're saying, that's what I think families maybe have noticed and would be a good time to bring up to pediatricians or their primary care providers or their sub-specialists, having that conversation about is it becoming functionally impairing now?

Dr. Christina Cwynar:

And I think the other common thing, at least I run across in my practice, is that families maybe misattribute or even pediatricians or other providers, certain behaviors to other things. So a common thing I hear is they're just misbehaving. Well, okay, they couldn't follow the two-step instructions you gave them when you get down to the crux of the issue. Maybe you said, "Go brush your teeth and take a shower." But they got through maybe pulling their toothbrush out, not putting the toothpaste on, them brushing their teeth, rinsing off, putting it away. There's multiple steps in that. So really, that inattention and that following through and the deep diagnostic things going on and the executive functioning involved in all of that.

And then sometimes it equates to them becoming agitated or frustrated, and that's where they present, is with that agitation and that frustration that now has mounted to aggression. I know Dr. Burns and Sima and I often see kids presenting to our emergency room with agitation and aggression, and then when you get down into it, you're like, "Oh, I think there might be some ADHD going on." And families have trouble understanding, like, "Okay, you're telling me my child might have ADHD and we brought them in for aggression." We see that often. So what are some maybe underlying cause of agitation and aggression in the setting of ADHD?

Dr. Kimberly Levitt:

Absolutely. I think as really mentioned, it's really important to think about a lot of these things, what you're seeing is behavior, but a behavior is a means of communicating. If you don't have other means of communicating, you're using your body, you're using your actions to communicate what's going on. And thinking diagnostically about an ADHD diagnosis helps us think about how is that child wired? Like you said, what's the crux is what's leading to this behavior or what's making this difficult for this child? And so I think that's a great tactic to take when you are seeing aggression or agitation, of what is stemming from this? And like I mentioned before, especially in the setting of ADHD, I often see this related to impulsivity, that zero to hundred really quickly, the difficulty putting on the brakes of saying, "Hm, is this really the best decision that I can make at this moment?"

That's really hard. And so that ability to modulate our behaviors and self-regulation can be really hard in the setting of ADHD, right? And there's so many factors that could be contributing. Like you said, it could be misunderstanding or not quite paying close enough attention to understand what was asked of them or what the exact situation was. Again, that trigger response of this is how I feel in the moment and it's hard to modulate that. And so I think a lot of that can be misattributed to, again, anger and aggression or viewed as that. But what's really underlying are those ADHD symptoms.

Dr. Heidi Burns:

Another interesting symptom or observation that you might see in kids with ADHD is actually hyper-focus, that it may be something that is missed a lot or that people wouldn't expect necessarily. When they think of ADHD, a lot of times people will think about the inattentive part of that, but actually they can experience hyper-focus. Can you define this concept a little bit or maybe share some examples?

Dr. Kimberly Levitt:

Mm-hmm. And I think when I conceptualize hyper-focus, when we think about ADHD, it's really difficulty modulating focus. It doesn't mean it's a complete lack of focus. It's how do you modulate it? How do you use it appropriately in that context, in that environment? And so we absolutely can see children that have these perseverative interests or particular topics or activities that they really like to engage in. So I do hear that often in clinic, "My child can't possibly have ADHD because they can play with LEGOs for four hours." I think the thing we hear about the most is media. Media use is really sticky. It's really hard for kids to be torn away from it. And especially if you have attentional differences, that can make it even harder.

When we think about it, media is really predictable. If we're playing a certain game, things act the same way. It has these construct that's maybe easier to pay attention to, if paying attention is a little bit harder for you. So it might feel like a more comfortable space, a place you want to go more than the regular world that is unpredictable and has a lot of nuance to it. So we certainly see that around preferred topics, and, like I said, the example of media. So good to not rule out the possibility of an ADHD diagnosis just because we have great skills in certain settings. We want to look at the bigger picture.

Speaker 4:

When I think about ADHD a lot, I do also think about the mental work, and you spoke to that a little bit, that it can sometimes take more effort for these youth. They can do activities, but they may require more time to do them and there's more mental effort. And that can also then impact them emotionally or interpersonally with peers because they're putting in that work behind the scenes, but then also thinking about how demands change over time. And so sometimes with the younger children we tolerate more.

There is almost this ability to say, oh yeah, they're going to want to play. Of course they're going to want to play. They don't understand that they've got to maybe take care of X, Y, Z before they can play because they're five or six. But when they're 12 or 13, the expectations change and we expect that higher level thinking. But I think youth with ADHD are struggling more there because they still want to do that positive reinforcement, the thing that feels good first because that's just the way their brain is wired. In a way, that's the reinforcement that they get because of that executive functioning. Just any reflections on that?

Dr. Kimberly Levitt:

Yeah, I think it's really excellent points, and I think thinking about how is the individual child really experiencing this? Again, like you said, what is the wiring, what's the default wiring? And all of us would rather engage in a preferred task. But like you said, we expect more with maturation, when there's more, again, organizational tasks you'll have to do, more other tasks. And again, that's because typically the typical progression that you have advancing executive functioning skills.

Even children with ADHD, their executive functioning skills are going to be improving with time. But again, you might start seeing those gaps or differences. And so I think it is really important to think about the cognitive load. I had a mentor that used to talk about that ADHD in and of itself is not inherently "bad." It can be thought of as a superpower. And he used to give the example of when we lived in hunter-gatherer societies, the person that noticed the blade of grass move lived. It was really adaptive. But now when you have to sit in class and look straight ahead for eight hours a day and not notice the blade of grass move outside the window, the environment has changed, the expectations have changed.

And I think that's a really good point that, like you even mentioned earlier, in the example of someone might be looking like they're sitting there, paying attention, doing really well, but you don't know in their mind if they're like, pay attention, pay attention, I got to pay attention. Oh, what did the teacher just say? So I think having those conversations, especially as get kids get older about their experience of how much mental somersaults are they doing to maybe keep up with their peers. And I think that can provide some insight into the lived experience with ADHD. And those are areas that we hopefully work together as a medical team and with the family to make easier because we want children to engage in school, to enjoy school, for it to not affect their confidence. There's so many parts about childhood beyond just school that ADHD can really affect if we don't put good supports in place.

Speaker 4:

And I think that pivots really well into our next question around the management of ADHD and when do we consider medication and what are some of the medication options that providers and parents may want to be aware of?

Dr. Kimberly Levitt:

So when we think about ADHD management, really a lot of it is focused a little bit on age ranges. So if we think about younger children, children less than school age, less than six years of age, it's primarily behavioral intervention. So specifically, parent training and behavior management, things of that nature. So really behavior-focused. For older children, by which I mean school age and older, so six and up, first line really is medication management. That primarily consists of psychostimulants, so the methylphenidate class, the amphetamine salt class. Those really are first line. And the most recent guidelines from the AAP came out in 2019 and really support in that school age range using any FDA approved medication.

So I think a lot of choice comes down to duration of action, side effect profiles, things of that nature. When we look at younger populations, there are some guidelines inherent in that AAP 2019 report that says if behavioral interventions aren't feasible for younger children or you're not seeing improvement with behavioral interventions, recommending thinking about methylphenidate specifically over other options. But again, in six and up, really either class, it's reasonable to consider either. I often get asked questions about pharmacogenetic testing, which really isn't the standard of care and even the American Academy of Child and Adolescent Psychiatry recommends avoiding its use.

So it really is talking about families that we're going to start low, we're going to go slow, we're really going to tailor it personally into your child's response. We're going to look for side effects, we're going to look for duration of action, we're going to look for benefits and making it really personalized to the patient. But I think at the onset, really talking about that there are lots of options out there, that's one of the really nice things. And that is primarily how I start things when I'm thinking about medication use. There are second-line agents, which are primarily the non-stimulants, so those fall into the alpha agonist class, so guanfacine and clonidine, and then the others being SNRIs. So things like atomoxetine. There certainly are second-line agents. There's certainly a role for them, but usually for school-aged children, thinking more about the stimulants.

Dr. Christina Cwynar:

You alluded a little bit to this, but what are some of the things that you look for as a provider to recommend starting medications? It sounds like failure of maybe behavioral interventions for those younger kids. Or maybe not failure, it's not enough. Are there other flags that you look for to help parents navigate that discussion and that decision?

Dr. Kimberly Levitt:

Again, trying to really think about the child holistically. Is it affecting their home life? Again, if parents are saying, "I love my kid, but it takes them 17 reminders to put their shoes on every morning, and it's really affecting our dynamic and our dyadic as a relationship. It's affecting peers because they're calling my kid's name on the soccer field 17 times and he's missing it." So I think the common things that teachers know to look for, and parents are often looking for academic performance, but that's just one metric. And as we alluded to, you can already be doing well in school and still be working doubly hard or having it affect your confidence or these other things.

So I really hearkened onto the question of is it functionally impairing? Is it affecting their quality of life? Is it affecting their social relationships, their interests, their activities, their home life? And if so, can we put the appropriate supports in place? Can we build skills? And that's the aim of making a diagnosis so we can really support and understand our youth.

Dr. Heidi Burns:

So let's say we've gotten to that point with a child where they do need to start a stimulant medication and they go ahead and start that medication. What are some of the important factors to consider when you are starting a stimulant?

Dr. Kimberly Levitt:

So some of the primary things that I really think about is making sure that the family is really well-versed and know what to monitor from a side effect profile standpoint, the most common being changes in appetite, changes in sleep, you certainly can have physiologic headaches, stomach ache, things of that nature, irritability, especially when the medication is wearing off. So I think making sure that families know what to look out for, what the risk factors are.

There is a potential risk in the setting of structural cardiac abnormalities or arrhythmias, though more recent studies have really suggested that there is no statistically significant association between ADHD, medication use and cardiovascular disease. But again, it is still something to very much be thinking about a cardiovascular standpoint when you're starting a new medication, especially a stimulant. And then of course there is the US box warning, so talking about the potential for use or abuse or addiction, especially in older teenage range, I think that becomes a more poignant conversation, but I think those are some of the things we certainly don't want to miss. In our care, we monitor vital signs, we're keeping an eye on blood pressure, we're making sure that weight is continuing to track appropriately. Same with linear growth, so making sure that we have good monitoring of those effects as well are the primary things I really counsel families on.

Syma Khan:

Thanks for that summary, Dr. Levitt. And you touched a little bit about some of the side effects that our patients may experience or things that families may observe, but could you share some recommendations around managing those side effects such as appetite suppression, medication rebound and growth concerns, so that I think our audience just knows a little bit of what to expect and can then support these families, knowing that oftentimes this care is being delivered in pediatrician's offices and there may be challenges accessing a psychiatrist.

Dr. Kimberly Levitt:

As you mentioned. I think appetite suppression is one of the most commonly encountered, and also one that certainly families have concerns about. The things that we do proactively a lot of times is talking about incorporating a big breakfast before you give them medication. I talk a lot about snack opportunities, and so maybe lunch is not going to be a full meal, but could we offer some preferred foods at lunchtime? Can we offer a snack when we come home in the evenings. Even having a larger evening snack before bed, if really we're on a long acting medication where most of the day we don't have the most appetite, but it really picks up in the evening. Sometimes I'll encourage offering half a turkey sandwich and a cup of milk or something even after dinner, making sure they're meeting those needs other ways. There is the potential for decreased linear growth velocity, but again, that's something we really monitor for and make sure that children are tracking. And over time, that is something that we're monitoring for, but kids generally tend to do very well in that regard.

When I think about irritability specifically, I do think I most commonly hear about it when the medication is wearing off. And so that might be a reason to think about a longer acting formulation. If you're doing short-acting twice a day, you're going to have that on-off effect. So you might see more irritability there versus the long-acting one, we might be able to have a gentler on-and-off effect. So that might be some thoughts to discuss with the family. So again, I think it has to be very personalized to the patient's experience, and that is the good and the bad. It is a little bit of trial and error. Some kids, one of the things to monitor for is increased motor ticks. I've had certain patients that had tons more on one and none on the other. So again, it's very personalized, but there are certainly some tenants to think about and ways to support families to hopefully mitigate those side effects.

Dr. Christina Cwynar:

Thank you for walking us through the most common side effects where parents have concerns and maybe how we monitor, but also how we can support a kid to be successful on a medication, because they are very helpful in supporting kids experiencing these symptoms and still remain on their medication, but overcome these side effects. Now switching gears a little bit, we often diagnose ADHD young, elementary school, sometimes a little bit older. How do you go about explaining an ADHD diagnosis to a child? They may have a lot of questions.

Dr. Kimberly Levitt:

Yeah. It's something like I alluded to earlier about saying that it really can be a superpower, and I really approach it as this is a little bit about how your brain is wired. And if that helps other people and your teacher and your mom and dad and even you understand a little bit how your brain is wired and how you interact with the world, then that's why this is a hopefully helpful diagnosis. It's about understanding yourself, again, understanding how you engage the world and with that comes strengths and challenges, as does everybody.

Everyone has things for them that are hard at school or easier at school or harder at home and easier at home. And so really normalizing that experience, that this is nothing wrong or bad, it just helps us understand you and helps us to support you. And it probably contributes to what makes you great in lots of areas. Again, it can certainly contribute to a wealth of great skills as well. And so I think that's a conversation that I try to really impart to the patient themselves and the family. There are some lovely books out there too, Smart But Scattered and things like that that, again, I think just really highlight that. That this is just a means to have a common vernacular to understand how somebody is wired.

Dr. Heidi Burns:

Thank you for that. We jumped right into talking a lot about the medication interventions in ADHD. As you spoke before about there is a certain age range where actually, unlike a lot of other areas in psychiatry, we would actually start with medications a lot more with kids with ADHD rather than going for a therapy intervention. But in those younger kids, we still do lean into a therapeutic approach as well. And I think it'd be really interesting if you could talk us through a little bit more about some of the recommendations about non-pharmacological interventions and something that might surprise parents, is that their involvement in that type of therapy and how much more involved they are.

Dr. Kimberly Levitt:

Yeah, absolutely. And I think it's a really great point you mentioned. That in some, I think there's a lot of adage of like, oh, well, you always have to start behavioral interventions first. And as you mentioned, sometimes that's not the case. But certainly in younger children trying to incorporate behavioral interventions, if feasible. What that really looks like is broadly defined as parent training and behavior management. That might look like parent management training or specifically parent-child interaction therapy, which is an evidence-based intervention for younger children with ADHD symptoms.

Really, again, thinking about what's problematic both at home, at school, and how do you address those tenants and, like you said, really reliant on parental involvement and their dyadic relationship and things of that nature. And so I certainly always think that that's a really great option. If you read the 2019 guidelines, essentially if it is ADHD, if it could be ADHD, even if it's not ADHD, parent and child interaction supports and behavioral interventions are never a bad idea. So I really do think that's important, empowering parents that they can play an important role in this.

As children get older, certainly seeking out school-based supports are so important, whether that's through an IEP or a 504 plan, I think that's a really important role too. So making sure that they're well-supported at home and in the school setting. There is good evidence for other behavioral supports in the school system, like daily behavioral report cards, organizational skills supports, things of that nature. So there definitely are other important things to provide a strong foundation, even if medication management is first line in school-age children, there are these other things that are really complementary and help round out the picture and are skill building in that regards too.

I think the other really important thing is just making sure physiologic needs are met, because most importantly sleep. If we have poor sleep quality that contributes to challenges academically, with mood, with behavior. I mean really poor, disordered sleep can look like ADHD. So making sure our kids' needs are met. And from a diet, sleep, physical activity needs are also so important just to make sure that our kids are well-rounded and happy and can do those higher order things like learning and self-regulating.

Syma Khan:

I think it's important to reflect on those behavioral interventions, the parent-child aspect of things. And during our earlier episodes, we talked about the importance of modifying, sometimes, the environment for our youth that are neurodiverse. And so I think that those behavioral interventions are not only things that the youth and family may be participating in, but we want to adapt the school environment or we want to adjust the certain expectations that we have. So it's not all just on the youth with the diagnosis, that they have to learn everything, they have to do everything, but we also want to try and adjust the environment. One other thing that I think within ADHD management we see a lot is if there are disparities, and there's disparities related to race, gender, sometimes histories of trauma, ACEs, those types of things. So I don't know if Dr. Levitt, you could share a little bit about that.

Dr. Kimberly Levitt:

A child isn't raised in isolation. They're so much of the product of the system and the environment as well. And so I think to be thinking broadly about all the factors that contribute to who this child is and their opportunities and if there are certain barriers to care and access to supports as well too. And so I think that's something providers can really do with partnering with a family about what are their specific goals, what is feasible for them. If they're not feasible, being thoughtful about how could we attain supports. So again, if private outpatient therapies or something like that might be hard or there's barriers to care about checking in for med visits and things like that, these are things that we really should be cognizant about. And so there are certain things like making sure there's virtual visits available and access to care is broader I think is really important.

So I think there's the lower level things that we can do to make sure that there's good access. I think, then again, thinking more broadly about the role of adverse childhood experiences and that a child isn't also being mislabeled with ADHD. You can have adverse childhood experiences and ADHD or trauma can look a lot like ADHD. And so I think, again, that's where that diagnostic clarity is really important because it helps us understand how a child's brain might be wired so we can provide the right support. If you don't ask, you won't know. And so really asking parents and children about their lived experiences. Have you experiences racism, inequality, difficulties with accessing care. And so again, I think an important part is just starting that conversation to learn more about their lived experience so that we could really help them and come up with as personalized a care plan as possible.

Speaker 3:

I think those are great points. I think it really has been highlighted in literature as well. There's very famous research studies in the mental health world in psychiatry about the fact that school-aged children who were monitored were said to have a higher level of aggression in ADHD. In you black children, there's research studies that still show that they're being diagnosed at higher rates. Or kids who live in poverty, kids who live under the federal poverty level will oftentimes have a higher diagnosis of ADHD. And just like you suggested, the research really supports the idea that adverse childhood events can really play on some of those symptoms that look like ADHD. And so not maybe jumping to conclusions, but trying to really get those full, descriptive evaluations where we understand what's going on in a kid's life and why they may be acting that way, with those antecedents to behavior. Why are they doing what they're doing and what need is it meeting for them to do that thing might be really illuminating.

Dr. Kimberly Levitt:

Absolutely. I think it always hearkens back to the ABCs, right? What's the antecedent, what's the behavior, what's the consequence? But like you said, there's so many lenses which, and acknowledging what someone's lens might be or what their background might be or how they're viewing this or how a school might be viewing this or things like that. I think it's coming to the table with diagnostic humility and saying, "I might know a whole lot about ADHD, but you're going to teach me about your child and you're going to teach me about your lived experience and we're going to partner together." I think that's just a really important approach in a topic as complex as mental health.

Dr. Christina Cwynar:

Well said. I do have another question for you, and this is way off the topic we were just talking about, but we are, what now? Four-ish years outside the pandemic and we are still seeing shortages for many stimulants and medications to manage ADHD. How are you helping other providers that you're coaching or families navigate this dilemma?

Dr. Kimberly Levitt:

Yes. I wish I had a magic wand. It is really hard. I mean, it's one of those things that I feel like it's like Pokemon Go or something. You hear that like, oh, Meyer might have this or this pharmacy might have that. And it feels like this wild goose chase, at time, for families. I think, again, what I've tried to do is really reiterate that there are so many medication choices, that they have very similar side effect profiles, oftentimes very similar mechanisms of action, duration of action, things like that. And so for families not to get particularly worried if we can't find one, that we'll work together, that we'll find a good option.

This is something we brought about even in our division discussions are like, do people have other ideas? I think I've learned that the big box stores of Costco, Sam Club, you don't have to have a membership to look at their pharmacy and things like that. So trying to come up with what resources we can in the community, but again, also really reassuring parents that if this is not feasible, we can work together. We can find, hopefully, other options that are just a good fit for your child.

Syma Khan:

And I think that just speaks to the importance of being thoughtful about the diagnosis, knowing that these medications may be shortages. And so we want to be thoughtful about when we're prescribing them, how we're prescribing them and really ensuring that they're meeting the need for that youth and their family.

Dr. Kimberly Levitt:

And I think one of the things, as I've practiced longer, I've thought more about the importance of anticipatory guidance. So telling families that, especially with stimulants, children are safe to stop it at any time. So if there are questions or concerns or there are a shortage, your child isn't going to be hurt from a medical standpoint about significant rebound effects or things like that. So I think that's an important thing to not mention the moment they're out and they can't find it anywhere in the state, to say that this is something.

Or some of the medications, like the second line agents like the alpha agonist, that is a medication you have to take every day, and so talking about it. So I'm from Florida originally, so I always say, "If you go to Disney World, you have to take your alpha agonist. If you go to Disney World and you forget a stimulant, you're going to be okay. It might be a different Disney experience, but you're going to be okay." And so again, telling to families of what they need to know or not be worried about, but what we can be flexible on, how we can work together and if you come across those barriers, we're going to address them together.

Dr. Christina Cwynar:

Okay. Well, thank you for joining us today. We truly appreciate your time and your expertise. Thank you to everybody that tuned in this week. Nurses, social workers, and physicians can claim CMEs and CEs at uofmhealth.org/breakingdownmentalhealth. You're able to do this anytime within the three years of the initial air date. We hope that you'll join us next time.