Dr. Jack Krasuski:  Welcome.  It’s Dr. Jack Krasuski here with Dr. Jefferson Prince.  Jeff, thank you so much for joining us.  You are here to talk to us about ADHD.  I know that you’ve researched it and you definitely see a lot of patients with ADHD.  I think that one thing that you can really help us understand is when you have people coming to you, I’m sure a lot of patients are not coming to you de novo where they haven’t been treated before, and they have been receiving often times years of treatment.  What kind of shortcomings maybe do you see or maybe gaps in treatment that seem to crop up?  Something that you can highlight for us so that we’re less likely to miss an important component of assessment or treatment?

Dr. Jeff Prince:  Oh, sure.  Jack, it’s great to be here with you.

Dr. Jack Krasuski:  Thank you.

Dr. Jeff Prince:  I really enjoy this.

Dr. Jack Krasuski:  It’s a great place here, isn’t it?

Dr. Jeff Prince:  It’s a terrific place, and the staff and the faculty are great.  You’re great.  Michael’s great.

One: Lack of Treatment Adherence

Dr. Jeff Prince:  The things I can kind of see the most frequently that cause difficulty are really adherence with treatment, and we see this coming through, the lack of adherence, either with medications and/or with behavioral treatments.  In order to improve adherence to a treatment plan and we really are very familiar with the foundations of success or treatment for ADHD across the lifespan, although it does remain not well enough studied in terms of long-term trajectories, but we need to understand psychoeducation.  We often see that people don’t understand actually what they’re targeting.  I think really be very personalized about what are the symptoms that are causing difficulty and getting a lot of clarity around symptom targeting and prioritizing which symptoms are causing the most difficulties, that is one element.

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Two: Customizing Treatment

A second element is really optimization of both behavioral treatments and pharmacologic treatments.  We’re fortunate that we have more and more choices, which is helpful because we can really tailor our treatments and we have different innovative ways of delivering the medicines, primarily methylphenidate amphetamine and then the nonstimulants, but we have a lot of choices now.  I think that it will be important for clinicians to really keep up to date about what the new formulations and new innovations and the way to deliver medicines have become.  We don’t have anything that’s fundamentally different, but we have ways to deliver the medicine and hopefully reduce the number of doses people have to take and really tailoring their pharmacologic treatment.

Three: School Transition Years

The [third] part is if we don’t have anything that works when it stays is the bottle. So we have to have people [actually] take their ADHD medicine in order for it to be helpful.  Often that really involves, especially in these transitional-age youths, people get through high school and either go off into the workforce or go to college and we really need to support their taking their medicine and participating, really using what they’ve learned over time.  I see so many people get to the end of high school, and they’re like, yep, thanks a lot, and I’m done, and they go out into the world and have a lot of difficulty and then often come back.  Really, we’re recreating what they already know is effective, but that’s the process that I see often and over and over again.  Or, in that same transition from an elementary school student who’s treated and has a nice support system in their school and at home, and as they’re growing up they’ve become more independent and aren’t as adherent with the ADHD treatments that we offer.

Dr. Jack Krasuski:  You’ve made three excellent points.  You talked about adherence and then you talked about really customizing the treatment, pharmacologic together with psychosocial treatment, and then also taking the developmental point of view that a person with ADHD changes as they go from elementary school, middle school, high school, and then go off to college and then maybe the work world.  Of course, those three points are very closely related.  If you customize the treatment so it works better and is easier to adhere to, where it’s not an overly complex medication schedule or regimen, and that also that you make adjustments over time, then it’s more likely to be effective treatment and there is less chance of downsides being prominent, thus raising the adherence.  Those are three important interrelated topics.

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As you were talking about the adherence, it struck me that in CBT, and DBT, all the outshoots of CBT, it’s a formal component of the therapy that you do psychoeducation, that you teach people about the nature of their psychopathology and the nature of the treatment, how the two work together.  I think when we administer medications, we often seem to kind of assume that it should be clear.  Oh, this is going to help you.  How could you not see when you take a stimulant that it doesn’t help?  I think your point is well taken that we need to take that additional time to really educate the patient, the whole family, on why this is going to be helpful and really incorporate them into the treatment.  What are you seeing?  What are you seeing?  What are the upsides?  What are the downsides?  So it is a continual conversation.

Comorbid Conditions with ADHD

Dr. Jeff Prince:  As psychiatrists I think we can learn from our psychological colleagues who have done a much better job I think in terms of psychoeducation.  Also targeting treatments, or like with CBT, you pick what you are going to go after.  I think in medicine we can learn a lot from that, and that’s particularly true in another part that gets in their way of adherence is comorbid conditions.  We know over the lifespan that comorbidity and ADHD is the rule, rather than the exception.  Comorbidity is another, if you will, obstacle to adherence.  We need to try and identify comorbidities and then differentiate between comorbid conditions and ADHD and structure the treatment.

Dr. Jack Krasuski:  Thank you.  I find that your point of stressing the target symptom to be very valuable because if we can identify it, not only can we better track response to that target symptom, but we’re actually more responsive to the patient because really it’s their target symptom.  If we’re saying we’re helping exactly what is most bothersome or what is most holding you back, then they’re more likely to be motivated to continue it.

Jeff, this has been a wonderful few minutes.  I can’t wait to hear your talk because it’s already been so informative just in five minutes.

Dr. Jeff Prince:  Jack, you make it easy for me.

Dr. Jack Krasuski:  Alright.  Thank you.

Dr. Jeff Prince:  Thank you.