The Adult ADHD Quality Measures Initiative
Faraone SV, Silverstein MJ, Antshel K, Biederman J, Goodman DW, Mason O, Nierenberg AA, Rostain A, Stein MA, Adler LA. J of Attention Disorder 2018:1-16
attention deficit disorder
The New York Times: Older Adults with ADHD
On September 30, 2015, The New York Times ran an article in the Tuesday Science section on ADHD in older adults. I was interviewed for the article and discussed a former patient age 73 who was first diagnosis with ADHD by me and successfully treated. The article is an introduction into an important clinical area for ADHD heretofore ignored. As we discovered, 60% of children will continue to have ADHD symptoms to an impairing degree into adulthood. The presumption is that ADHD in adults will simply continue throughout one’s life. However, the research is only just accumulating to support this assumption. The largest collection of research in this age group is published by my colleagues in Amsterdam and additional research from other research groups around the world.
Early this year I wrote an article for CHADD’s Attention Magazine on issues related to diagnosis and treatment of ADHD in older adults. The diagnostic issues and treatment considerations in older adults are more complex. In brief, diagnosis needs to consider medical illnesses, medications, history of head trauma, and other medical illness that worsen thinking ability. Treatment consideration are complicated by the presence of medications and medical illnesses that might limit the use of ADHD medications. Older patients and families considering an evaluation for possible ADHD should see a psychiatrist or mental health professional who has expertise and experience treating adults with ADHD.
Remember, while attentional changes occur in those of us over age 50, the cornerstone for the diagnosis of ADHD is the presence of symptoms since childhood that are relatively chronic and unchanged over one’s life and that these symptoms cause impairment in daily functioning. A comprehensive evaluation of all possible psychiatric and medical is critical for the accuracy of the diagnosis.
David W. Goodman, M.D., FAPA
Arbitrary medication denials leads to restriction of optimal treatment
In my periodic entries of insurance companies’ denial of ADHD medication dosing, I offer you this recent example.
A female in her late 20s treated for ADHD with a combination of Adderall XR and Strattera. Strattera adds a benefit for her executive function not optimized with Adderall XR. I carefully dosed the Strattera upward and suggested increase to 120 mg daily.
Well, the folks at BlueCross Northeastern Pennsylvania denied the dose “As per the FDA recommended dosing guidelines for Strattera in adults the maximum dose is 100 mg per day.” Correctly stated per the package insert for Strattera. “There are no data that support increased effectiveness at higher doses. Therefore medical necessity for 120 mg of Strattera per day has not been met.”
This last statement is a misrepresentation of the purpose of a drug package insert. In fact, the adult registration trial for Strattera submitted to the FDA lists the dose that was used as up to 120 mg daily. Registration trials are designed for the purpose of seeking drug approval for a specific disease state. This research DOES NOT answer the question “If the patient is suboptimally treated with x dose, will they improve further with a higher dose?” So the logic of their denial is a misrepresentation of research for the sole purpose of constricting treatment and conserving money, in my opinion.
Yet more damage is done with these letters. People reading these letters may think the doctor is over-dosing them and not considering safety issues. This is simply not true since safety data on medications are routinely undertaken at much higher doses. There was no unusual safety concern with Strattera at 120 mg daily in the adult registration trial.
It is unfortunate that I find myself blogging about the denial of medication authorizations for my patients who clearly need better outcomes from their medications. While these companies have set up appeal processes, this tends to administratively time consuming without any guarantee that the medical necessity and logic of the dose request will be reviewed with the patient’s interest in mind.
So, what can YOU do if this happens to you? Here are the steps:
1. Call the insurance company and respectfully explain why you need your medicine. If the person is unresponsive, ask to speak to supervisor. If you don’t get to speak to someone with authority, ask if the conversation is being recorded and tell them to “tag” the audio file so that the State Insurance Comissioner’s Office with be able to listen to the audio file. Now, write down the date and time.
2. File a complaint with your state insurance commissioner’s office. You can find the contact information online by searching “<your state> insurance commissioner office”. In your complaint, which should only be one page (no reads anymore), state your brief history of medication history and why it is necessary to have the new dosing authorized for coverage. Write that you spoke with the insurance on what date and time.
In my experience, more often than not, you’ll be getting your approval. However, no guarantees. Good luck.
Reliable ADHD information
If you’re reading this blog, you are one of the millions of people who now use the Internet to gain information on medical issues. In a recent survey of consumers, this is where people are looking for medical information.
Most accessed online resources:
53% web M.D.
22% Wikipedia
19% health magazines and websites
16% advocacy group websites
12% YouTube
10% Facebook
10% blocks
9% Pharma company websites
(results from third annual national consumer survey by Makovsky Health and Kelton, 2014)
I would like to take this opportunity to direct your attention to the attitude magazine website that has a large number of webinars from noted academic and professional experts in ADHD. For many with ADHD it’s often easier to watch a video on a specific ADHD topic then to read a book. While many with ADHD can sit and read for extended periods of time, it always struck me as odd that clinicians referred patients to books knowing their ability to sustain attention would be limited, especially in the evening when it medication affect us dwindled.
Explore the webinars on this site as a can be extremely helpful. On this blog site, I will continue to direct my patients in readers to reliable sources of information and clinical insights from my practice not available elsewhere.
WYPR interview on ADHD with Dr. David W. Goodman
My discussion with Dale Archer, M.D. (psychiatrist, best-selling author) on WYPR September 27, 2014 about ADHD, over- diagnosis, and over-prescribed medications was lively. While Dr. Archer advocates “medication as a last resort” and “the goal of treatment is to get off medication” after learning new skills, I offered the research on medication benefit and a quality of life measure to evaluate medication utility. Certainly, treatment of ADHD at all ages incorporates behavioral therapy, organization skills, couple/family/individual therapies, and academic/occupational accommodations, in addition to medication, when indicated.
For those of you interested, the radio broadcast is available and runs 35 minutes. I invite you to listen and decide for yourself the merits of each position. Ultimately, this information best serves those who have ADHD and their families.
Dr. Goodman interview on Dan Rodricks show on WYPR Jan 27 at 1pm
I have been invited as an expert on ADHD to participate in an interview on the Mid-day with Dan Rodricks show on WYPR on January 27 1-2pm. This is a live panel discussion that will include Dale Archer M.D., a psychiatrist and writer, to discuss the use of medication and treatment options for ADHD. The discussion is moderated by Dan Rodricks who is a distinguished journalist in Baltimore with a regular feature in the Baltimore Sun newspaper.
Dr. Archer wrote an article online for Forbes on January 6, 2014 on his perspective of ADHD and the overuse of medication and the over-marketing of ADHD. His article highlights and echoes the sentiments of Alan Schwatz in his New York Times article “The Selling of Attention Deficit Disorder” published December 15, 2013.
This one-hour program will give me the opportunity to highlight the national and international scientific literature and research on ADHD. I hope to highlight the well documented negative consequences over the course of one’s life with untreated ADHD as reflected in several international prospective studies following ADHD children into young adulthood.
This program promises to be a lively discussion and offers listeners the opportunity to call in with questions. I encourage you to mark your calendar. I believe the program can be accessed online. If you listen, please leave me your comments for feedback.
Faculty speaker, annual American Professional Society for ADHD and Related Disorders conference
American Professional Society for ADHD and Related Disorders (APSARD) is an organization founded by a national and international group of experts in ADHD treatment and research. The annual meeting, “ADHD Advances: Challenges and Opportunities” being held September 27 – 28, 2013 at the Hyatt Regency Washington on Capitol Hill in Washington, DC brings together these experts and other professionals interested in learning and advancing their skills. The presentations are the cutting edge research, treatment options, and technology developments to further our understanding of ADHD and the co-existing psychiatric and medical disorders. Information and discussions extend beyond U.S. research to include Canadian, European and Middle East research and treatments.
I am honored to be invited to present a 60 minute workshop on the “Choice and Optimal Dosing of Medications for Adults with ADHD” with my co-presenter Dr. Janet Standard, a psychiatric Advanced Practice Nurse at the NYU Health Services.
The conference is open to professionals in the health care field and registration is available now. . this link, you can browse the conference agenda, location, and hotel accommodations. This is a top-level, relatively small conference that allows all participants to engage and exchange thoughts and ideas. If you are in the field of ADHD, this is a conference not to miss. See you there.
David W. Goodman, M.D.
Nondrug ADHD treatments not very effective
I was recently invited to write an editorial for an international medical journal on a study by Sonuga-Barke and colleagues. This published study was an extensive review and analysis of published research looking at several different nondrug treatments for ADHD. My editorial will be published by the British Medical Journal in Evidence-based Mental Health June 2013. Dr. Sonuga-Barke’s analysis looked at 2904 studies of which 59 were selected because they satisfied high-quality data. I’m unable to provide my editorial text as the manuscript is embargoed until publication.
Dr. Peter Yellowless briefly reviews the study conclusion in a Medscape video.
The study divided treatments into several categories: restrictive elimination diet, artificial food color exclusion, free fatty acid supplementation, cognitive training, neurofeedback and behavior interventions. Only artificial food color exclusion and free fatty acid supplementation were statistically significantly effective, although the effect was relatively small.
Single clinical trials are often published showing some positive benefit. These studies then receive media coverage, especially if published in high impact journals. However, publication bias exists because negative studies often don’t get published, leaving readers with a false sense of benefit.
Publications like Dr. Sonuga-Barke’s help doctors and patients review multiple studies to see if replication of positive findings occurs. Evidence-based medicine in not based on single study reports but on the accumulation of studies over time.
As I like to say “On the highway of opinions, let science be the designated driver.” David W. Goodman, M.D.
Women and ADHD at HealthWomen.org
Although the gender distribution of ADHD in children is 3 boys to 1 girl, in adults the distribution is 1 woman to 1 man. Women are being diagnosed more often in adulthood because they usually don’t have the disruptive behavior in childhood like the boys. Women and men get diagnosed because the persistent inattention, distractiblity and disorganization impairing their ability to complete tasks in a timely fashion.
HealthWomen.org invited me to be the medical editor on their article on this subject so as to insure the accuracy of the information. I was pleased to review, edit and update the information for their readers.
I invite you to take a look. This is a long and comprehensive review with up-to-date information to help women, men and their family with ADHD.
ADHD Stimulant Shortage Video Maryland Public Television Jan 30, 2012
Watch my interview from Maryland Public Television live 15 minute interview by Jeff Salkin on Direct Connection with Jeff Salkin on January 30, 2012 Monday at 7:30 pm discussing the recent problematic shortage of ADHD stimulant medications. I offered explanations for the shortages and “work arounds” for patients. Let me know what you think.
David W. Goodman, M.D.