The Realities of Clinical Primary Care Management for Children With ADHD

Dawn Garcon Maaks, PhD, CPNP-PC, PMHS, FAANP, FAAN, the Immediate Past President of NAPNAP and the Associate Professor at the University of Portland in the School of Nursing, discusses the realities of clinical primary care management for children with ADHD symptoms.

Alana Hippensteele: Hi, I'm Alana Hippensteele from Pharmacy Times. Before we get started, one of our top articles today discusses how a recent study that is the first of its kind demonstrated that there has been a decline in cancer-related deaths following the adoption of the Affordable Care Act in states that adopted it. There’s more of that on PharmacyTimes.com.

Today, I’m speaking with Dr. Dawn Garcon Maaks, the Immediate Past President of NAPNAP and the Associate Professor at the University of Portland in the School of Nursing, on caring for children with ADHD in advance of her presentation on the subject at the 2020 Virtual Conference on Pediatric Health Care.

So, what are some of the realities of clinical primary care management for children with ADHD symptoms?

Dawn Garcon Maaks: So, I think, you know, first, I have a one-word answer to that: It's reimbursement. If you talk to those of us who work in this space, it's like, you know, our system is set up right now to be a volume-based system. I don't think any of us that work in the clinical arena feel that that's the best thing, but it's the reality of it. In pediatrics, our margins are particularly poor compared to other subspecialties, and so, you know, if I'm a primary care provider, I'm hoping to do this assessment of this kid, if I'm lucky, in a 30-minute visit, but I might be trying to do it in a 15 to 20 minute visit. If you see me in behavioral health, my intakes are an hour and a half. I get to go back to this kids’ development, I get to really assess, you know, symptoms that are suggestive of maybe an autism spectrum disorder, where maybe they're just regulating because they're overwhelmed because of sensory input, and not necessarily that they're impulsive or inattentive in the traditional sense.

So, I think some of it is just the timing of it. I think the other thing that is really hard for people in primary care, like I said, is I know within my FQHC, I had two pediatricians that will not diagnose or manage these kids. They don't feel like they had the training that they needed for it, they don't feel like they have the time for it, and so, you know, I think those of us who work in pediatric primary care, whether it's as family practitioners or as pediatric specialists, that we really understand the gift and the responsibility of taking care of children with developing brains. And so if we don't feel that we don’t have sufficient education to be comfortable with it, if we don't have systems that are in place to allow us the time once we do have the education and know the right way of doing it, then I think that's what leads to people saying, Yeah, no. If you fail the first line, you need to go out and get in the 6 to 12-month line. And that's why I feel like these conversations like the one we're having at our virtual conference are so important because these are direct conversations for people in primary care about increasing their competence and their confidence in this space. So maybe when they fail that first line, they're willing to look at a second line and try that before they send them out, or if there's something more serious that's happening, they recognize that, Hold on, I probably shouldn't monkey with this for two or three other drugs, this is a kid that might have something more severe I need to get him out and get him the care that they deserve.

Alana Hippensteele: Right, right. So, you were talking about how the mild to moderate symptoms may not require medication. In terms of moderate to severe, what are some potential symptoms, except I don't want to be too broad with it, but what are some potential symptoms where it becomes very obvious that medication is the only route?

Dawn Garcon Maaks: I personally never feel like medication is the only route for ADHD, and I'm pretty clear with my families about that because I feel like, in public disclosure, I live with someone who openly admits he has ADHD, and he's a 50-something year-old man who struggled with this for years, and I've watched him develop really good coping skills that use the theory of behavioral economics. And basically what that says is: You and I probably didn't spend a lot of time thinking about what we were going to put on today, like I knew I was doing this interview, and so I needed to look professional, and so I knew a t-shirt probably wasn't appropriate, but beyond that I don't know that I said to him that, Oh today's Green Day, or let's really like, I was standing in my closet and I went, Okay this is the professional section of my clothing. I'm gonna grab something, put it on, does it feel good? I'm wearing this today. It wasn't like some great thought out thing. I got up this morning, I had breakfast, I made my egg whites like I always do, I made my coffee the way I always do. Did I really stand there and think about how much cream I was putting in my coffee? No, I automated it.

What we know is that human only have so much processing bandwidth in their brain. And so, for people with ADHD, the worst thing you can do is take them to a Chinese restaurant with a 10-page menu because there's so many choices there they just get completely overwhelmed. And so like, a great coping mechanism is, if you go to a restaurant and there's like 5 pages of things, knowing that food style, what's something that you like that's pretty sure to be on the menu, and then you don't have to get overwhelmed by the menu. Like, you know, I'm a General Tsao's chicken person. I openly admit that that's my jam, and so, if I have ADHD and I'm sitting there getting overwhelmed by 5 different styles of egg foo yung, my brain just goes, Alright, I'm going to make this decision, because it needs that bandwidth for the fact that, if I have ADHD, while you and I are having this conversation, the back of my brain is having a whole separate conversation, and I'm thinking about something that has nothing to do with what we're talking about right now. You don't ask kids with ADHD to make repeated kind of boring everyday decisions, you simplify things for them. The child has a uniform, okay in the winter, you need to wear long pants, and a long shirt, you need socks on your feet, you need a closed-toe shoe. In the summer, you need a short sleeve shirt, you're gonna wear, you know, this color shorts, and pretty much when you go out and you buy stuff for your child, you put it all in the same color range so that everything is kind of mix-and-match. Almost, if you think of like your garanimals, if you remember your garanimals, they were kids clothing where like the lion tag always went with the lion pants, and the tiger shirts always want with the tiger pants.

We know that we as humans don't always think about the things that we do repetitively. We've all been in our car going home or walking home after commute, and we're like, how did I get this far? Like I don't remember crossing here? Because we were thinking about something else. Well, that's their life all day, every day. So if we know that's what it's like for these kids, then teaching them behaviors and skills that they can put into place to make them be successful, teaching them organizational skills, teaching them documenting skills of where they can save things that they can retrieve at a later date, so something like the Evernote app is an amazing thing for somebody with ADHD because I can create subfolders where I keep important things that I need to remember. So, somebody says to me, Where did you live in 1974? I have a piece of paper that I can pull up on the computer that I can immediately go to that and not have to trust that my brain that has 5 different things going to have the bandwidth to process that additional thing. Teaching parents that sleep matters, if your child has bad sleep habits, and if they're not sleeping well, their behavior is going to be more disregulated. Teaching them that physical activity, running around, getting hot, stinky, and sweaty makes the difference. Michael Phelps became a swimmer because he had god-awful ADHD, and his mom needed to be able to burn some of that energy off. Sticking them in the backyard or going out on a bike ride with them or letting him run around a park and burn that energy off, those are as effective in some cases as medication.

So, if I have a parent who comes in with a kid whose grades are really good, it bothers them cause, frankly, if it doesn't bother the kid it doesn't bother me. I don't treat parents’ concerns with medication, I treat if it disturbs the child. So if I have a kid who comes in and they're kind of worried about it, but they're not sure if they want to take medicine, I'm always like, Great, let's go connect you with one of our therapists, let's work on some behavioral strategies, some behavioral modification, let's see how that works. And then the other conversation when it comes to medication is: These are medications that I'm going to be able to tell you if they're going to help you in 3 days because of their short half-lives. You're going to go home, you're going to take this medication, you're going to notice a difference within a week, and you know what, if you have bad side effects, if you say yeah I can't sleep, stop it, the next night you're going to be able to sleep because it will have worked out of your system. This isn't like, you know, SSRIs and other drugs that have a long ramp up until we see treatment response, and then a long time to get them out of their systems. And so what I think is important is that pharmacists and nurse practitioners and physicians and PAs and nurses and anybody who are mental health people that are working in this space have these conversations with parents about what their concerns are and helping them understand that the very pharmacokinetics of these agents means that we can stop and pivot relatively quickly, at least when it comes to the stimulus. You know, the alpha-adrenergics, not the same thing the, you know, atomoxetine is not the same thing, but at least kind of the first line drug. We've got some wiggle room to deal with the issues that come up and be able to do some education around that, and then pivot and respond if issues develop.

Alana Hippensteele: Yeah, absolutely. Alright well, thank you, Dr. Maaks, so much for taking the time out to speak with me today now let's hear from some of our other MJH Life Sciences brands on their latest headlines.