GUIDELINES, RESOURCES, AND TIPS FOR APSARD MEMBERS
Information re: COVID-19 for clinicians as of 3/24/20, compiled by Ellen Littman, PhD
- The American Psychiatric Association has updated telehealth restrictions in response to COVID-19 https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/blog/apa-resources-on-telepsychiatry-and-covid-19?utm_source=Internal-Link&utm_medium=COVID-HUB&utm_campaign=Covid-19
- While clinicians are normally required to be licensed in the state in which their patient is located at the time of video session, many states are waiving those licensing restrictions, as governors declare states of emergency. A continually updating list of states waiving restrictions is available on the Federation of State Medical Boards website: https://www.fsmb.org/siteassets/advocacy/pdf/state-emergency-declaration-licensure-requirements-covid-19.pdf
- The Office of Civil Rights, responsible for enforcing HIPAA related rules within the US Dept. of Health and Human Services is waiving penalties for the use of videoconferencing software that fails to comply with HIPAA guidelines, such as Skype, FaceTime, and Google Hangouts. Facebook Live, Twitch, and TikTok are not acceptable. Some better encrypted HIPAA compliant platforms are listed at the HHS site, as well as additional information regarding the use of telehealth: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html
- The Drug Enforcement Administration has suspended the Ryan Haight Act, the requirement for an initial, in-person patient examination before a physician can prescribe a controlled substance electronically. Details: https://www.deadiversion.usdoj.gov/coronavirus.html#TELE
- Most but not all insurers will reimburse patients for telehealth services. Patients will need to contact their insurers directly. Medicare has committed to covering these sessions. More details: https://www.medicare.gov/coverage/telehealth
- The above waivers are temporary, although there are currently no set end dates.
- The FDA has authorized the first rapid ‘point-of-care’ test for COVID-19 that can provide results in 45 minutes. They intend to roll-out availability, primarily to hospitals, by March 30th. https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-issues-first-emergency-use-authorization-point-care-diagnostic
- The World Health Organization details the overarching principles for mental health and psychosocial responses to COVID-19 for providers on the WHO website under the subheading MHPSS. https://www.who.int/docs/default-source/coronaviruse/mental-health-considerations.pdf
- The Center for the Study of Traumatic Stress offers guidelines re the psychological effects of quarantine for providers https://www.cstsonline.org/assets/media/documents/CSTS_FS_Psychological_Effects_Quarantine_During_Coronavirus_Outbreak_Providers.pdf
- Anxiety and loneliness are overwhelming many. A resource for patient concerns is the SAMHSA Disaster Distress Helpline. 1-800-985-5990 or text TalkWithUS to 66746. https://www.samhsa.gov/find-help/disaster-distress-helpline
- The National Child Traumatic Stress Network (NCTSN) offers parents guidance for helping families cope with COVID-19. It can be accessed here: https://www.nctsn.org/resources/parent-caregiver-guide-to-helping-families-cope-with-the-coronavirus-disease-2019
APSARD members offer vital connection, support, advice, and structure to our patients as we ride out this time of uncertainty. To experience an exemplar of remote connection: https://slippedisc.com/2020/03/believe-it-orchestra-plays-beethoven-9th-from-their-homes/
While you shelter in place, you can connect with your APSARD colleagues via the message board, which can be reached by logging into the APSARD website.
I hope this is helpful to you—stay safe!
Here is an interview by APSARD board members Sandra Kooij, M.D., Ph.D. and Vatsal Thakkar, M.D. on sleep and health issues related to living with ADHD.
Come and view this poster at the APSARD Annual Meeting this January 12 - 14, 2018 at the Marriott Wardman Park.
Burton, C., Schachar, R., Zarrei, M., Engchuan, W., Merico, D., MacDonald, J., Xiao, B., Paterson, A., Strung, L., Marshall, C., Crosbie, J., Arnold, P., Scherer, S.
Copy number variants (CNVs) are potentially pathogenic duplications and deletions in the genome that have been found at increased rate in attention-deficit/hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD) and autism-spectrum disorder (ASD). To further understand the impact of CNVs on ADHD there is a need for studies of the relationship of CNVs and ADHD in the general population rather than exclusively in clinic samples. For the first time, we report the relationship of CNVs to ADHD in a large community-based sample of children and adolescents with psychiatric phenotype and genotype data (> 5,000). We also report the association of CNVs to response inhibition (stop signal reaction time) measured in a simple computerized task (stop-signal task) because it is an established biomarker of ADHD. ADHD traits were associated with increased CNV deletions, particularly those > 500kb (p=0.014) known to affect synaptic transmission and nervous system development while response inhibition was associated with an increased burden of duplications (p=0.004) in genes known to play a role in neuronal projection, axon guidance and neurofunction in mice. These results highlight the relationship between rare variants and psychiatric traits and provide a context for further research into ADHD’s cause and into the utility of microarrays in clinical practice.
J. Russell Ramsay, Ph.D.
Associate Professor of Clinical Psychology
University of Pennsylvania, Perelman School of Medicine
As part of the symposium on non-medical treatments for adult ADHD, I’ll be presenting on CBT for adult ADHD. One of the principles in framing interventions is turning “managing ADHD” into actionable steps the patient can “do” to improve functioning. Similarly, being a practicing clinician specializing in adult ADHD, it has been helpful to see how the cognitive-behavioral therapy (CBT) model has been adapted to meet the needs of these patients and, more specific to the conference session, how this framework can guide all different varieties of therapists in terms of increasing their confidence when working with this clinical population – which by definition is characterized by difficulties organizing behavior over time and following through on the coping strategies necessary to manage ADHD.
The session will highlight different domains of interventions within CBT for adult ADHD and specific examples of each, focused on promoting their actual implementation, using the clinical example of procrastination, a common area of difficulty for ADHD adults.
If you are interested:
Ramsay, J. R. (2016). “Turning intentions into actions:” CBT for adult ADHD focused on implementation. Clinical Case Studies, 15, 179-197. doi: 10.1177/1534650115611483
Ramsay, J. R., & Rostain, A. L. (2016). Adult ADHD as an implementation problem: Clinical significance, underlying mechanisms, and psychosocial treatment. Practice Innovations, 1, 36-52. doi: 10.1037/pri0000016
Dr. Ramsay will be presenting at the 2018 APSARD Annual Meeting on “Outside the Pill Bottle: Assessment and Management of Adult ADHD.”
Kathleen Nadeau, Ph.D.
Chesapeake ADHD Center of Maryland
As a psychologist who has spent the past several decades thinking and writing about ADHD in its various manifestations, I have always tried to focus on segments of the ADHD population that have been under-served – adults when most thought ADHD was a disorder of childhood; girls and women when most thought it was a disorder primarily affecting males. Now, I have turned my attention to a large and growing group that is remarkably underserved - those over age 60 with ADHD– a topic about which there is almost no research. My hope is that by focusing on issues of aging, my preliminary research will spur interest in how best to diagnose and treat people with ADHD in their later years. I hesitate to call them the “retirement years” because many older adults with ADHD are woefully unprepared for retirement due to a lifetime of poor money management and under-employment.
I have launched into a project to individually interview older adults with ADHD and will share with you some of my preliminary findings, having interviewed approximately 50 older adults to-date. The themes they present to me include:
Difficulty finding someone to treat them. Psychiatrists and primary care physicians need to become more aware that ADHD is often a disorder that needs to be treated over a lifetime. Many physicians either “don’t believe” that a 60-something or 70-something could have ADHD or are simply not experienced enough to be comfortable prescribing stimulants to older adults given the likelihood of more complex health concerns. And yet the majority of adults that I have spoken to have reported finally, after much effort, finding a more enlightened physician and benefitting greatly from stimulant medication.
Appreciation that someone is paying attention to older adults I have found people to interview largely through advertising in Additude Magazine – a small classified ad announcing that I am studying older adults with ADHD and am looking for people to interview. The response from my interviewees has been one of excitement and appreciation. While I offer each interviewee complete confidentiality, most that I interview are excited to be part of this exploration of uncharted territory and tell me they are eager to share their experiences with others.
Stories of brave re-invention One of the unexpected patterns I’ve come across are repeated stories of huge risk-taking and determination to remake their lives. As some older adults have come to understand and accept their ADHD they begin to reject the circumstances in which they had lived due to low self-esteem and lack of confidence. For example:
A man, long-married to a dominant and critical wife upon whom he depended to manage all aspects of his small, struggling business. He told me of being diagnosed with ADHD, taking stimulant medication, having bariatric surgery to combat his chronic obesity, and starting a business that is enormously successful. His new business grew out of one of those quirky “ah-hah moments” that so often occur to people with ADHD; his wife no longer dominates him nor manages his business and he has a new lease on life.
A wife, psychologically trammeled by a very dominant husband who had been repeatedly unfaithful to her. She was diagnosed with ADHD, received medication and support. Because her children were older, she was able to return to school to complete the college education she had abandoned when she entered her early marriage. She left her marriage and struck out on her own in her late 40’s. Years later, she has a satisfying career and enjoys her life as a single woman.
In both of these cases, the diagnosis and treatment of ADHD was the trigger for a cascade of changes that led to self re-invention in mid-life.
Stories of regret and loss In contrast to these stories of re-invention, I have come across stories of loss and regret – stories of people whose lives have gone downhill as their job demands or supervisors changed in ways incompatible with their ADHD. Stories of jobs that were ADD-friendly until technological changes or changes in management led their job to become untenable; stories of people forcibly “retired” as a result of these changes who were living in very financially challenging circumstances as a result.
Does ADHD get better or worse? Not surprisingly, the answer depends upon the individual and his or her circumstances. Some people have told me that they have never been happier since retirement. They no longer have the daily pressure of their job and are enjoying a life in which they are well integrated into their community through volunteer work and creative outlets. In sharp contrast, others tell me of multiple health concerns, social isolation and struggles to simply keep up with the demands of their daily life. Not surprisingly, those that seemed to feel and function better had structure and social interaction in their daily lives.
Little support or information about ADHD available to older adults Almost universally, people I’ve interviewed have told me that they have found little support or information for older adults with ADHD. Support groups are largely focused on helping parents of children with ADHD. Almost nothing has been written for older adults with ADHD to help them understand and cope with the challenges that come with later life.
Next steps for the professional community We need to make a focused effort to educate physicians about the viability and effectiveness of treating older adults with psychostimulant medication. We need to educate coaches and psychotherapists about the particular challenges facing older adults with ADHD and how to address those challenges. In the US alone, over 10,000 baby-boomers fall off the workplace assembly line into the land of Medicare each day. If we conservatively estimate that 3 percent of them have ADHD (I believe it’s higher), then over 100,000 Americans enter the world of older adults with ADHD each year, with no services, support groups or information to guide their way. Perhaps APSARD can play a pivotal role in increasing awareness of the needs of this rapidly growing population.
Dr. Nadeau will be presenting at the 2018 APSARD Annual Meeting on “Outside the Pill Bottle: Assessment and Management of Adult ADHD.”
J. Russell Ramsay, Ph.D.
Associate Professor of Clinical Psychology
University of Pennsylvania, Perelman School of Medicine
Before you know it, we will be in Washington, D.C. at the 2018 APSARD conference. In anticipation of this event, I’d like to remind everyone of an under-utilized benefit of your membership: the members’ forum on the website.
This feature allows for discussions of a range of topics relevant to our shared interests in various aspects of ADHD. With regard to the upcoming conference, the forum is a venue to discussing upcoming presentations and sessions as well as ideas or topics that may be inspired by these sessions. Attendees may also use the forum to suggest ideas for future education programs by APSARD or to seek referrals for assessment or treatment professionals.
I encourage members to visit the website and consider adding something to the forum or suggesting other topic areas we can include to make it more useful to you.