It Takes a Village (and a Plan) to Stay the ADHD Treatment Course
A follow-up appointment with your doctor — especially one that facilitates coordination with a coach, psychologist, or other care provider — is the key to effectively managing ADHD medication. While appointments can be expensive and time-consuming, they are the best insurance that your investment in getting a diagnosis and effective treatment will pay off.
Medications for ADHD are among the safest and most effective treatments in medicine. So why do so many people stop taking them, and what can be done to prevent this? Little research has been done on why people do not stick with ADHD treatments. The research we do have, however, is consistent: The most effective thing we can do is check in with clinicians more often — in person or via a telemedicine appointment. Though expensive and time-consuming, this solution is the best insurance that your investment in getting a diagnosis and effective treatment will pay off.
Forty years ago, ADHD was defined as “an inability to sustain progress toward a goal.” People with an ADHD nervous system finally get started after a lot of procrastination, then are distracted from what they are doing by the next thing that crosses their minds. They can’t get anything done because they jump from one distraction to the next. This inability to stay engaged that defines ADHD also prevents its treatment.
ADHD Prescription Procrastination
Half of people across all age groups who start an ADHD medication never fill the third prescription. Nine months into treatment, only 13 percent of medication responders are filling their prescriptions or doing any non-medication treatments. This is the worst rate of treatment retention in medicine. For most, it isn’t a conscious decision to stop. People just “wander off,” don’t fill the next prescription, and don’t book the next appointment with their doctor.
Medication is the only treatment that many people try (or it is all that they are offered). Most people hope that the medications are going to fix everything immediately. When the medications fail to work magic, patients conclude, “I tried medications, and they don’t work for me.”
Savvy clinicians try to nip medication dropouts in the bud. They repeat over and over that the medications, as good as they are, will be only the first step of many in mastering ADHD. The prescription is not the end of the process; it is the beginning of it. Medication gets you in the game, on a level playing field, but you still have to learn the rules. Every standard of care is clear about this: Medications are not enough by themselves.
Stimulant medications are great at one thing: They keep you focused when you are engaged with a task. In order for stimulant medications to be fully effective, the individual with ADHD must still learn how to get engaged on demand. Learning this skill often requires help from a coach, counselor, or therapist — other members of the treatment team.
Teaming Up to Treat Symptoms
Most medication adjustments (and initial education) can be managed by an experienced clinician in the first three to five appointments. When the medication is stabilized and a comprehensive treatment plan developed, your pediatrician or family practitioner becomes the coordinator of a multidisciplinary treatment team. This coordination of professionals takes a lot of time, which is usually not reimbursed on its own by insurance companies. Consequently, most clinicians must do case coordination as part of follow-up appointments, which may be reimbursed by insurance.
Does Your Doctor Measure Up?
This type of planning and monitoring is a tall order for any clinician. They need help from coaches and counselors with specialized experience in ADHD to offer the range of services that most families need. The practitioner must develop a plan and continually monitor it to be sure that it is being implemented and that it is effective enough to justify the money and effort invested.
Finding such an experienced primary clinician is hard to do. The 2019 guidelines from the American Academy of Pediatrics (AAP) cite the lack of training for pediatricians as the biggest systemic barrier to adequate ADHD treatment.
More than half of pediatricians report that they do not think that they were adequately prepared by their specialty training to diagnose and treat ADHD. Most specialists in ADHD live in larger cities, leaving rural communities with few local resources. This adds to the burden of seeing your clinician frequently or finding coaches to help with therapies and psychoeducation.
Nonetheless, the effort and expense are worth it. Research and experience demonstrate that intensive, frequent follow-ups with your doctor are necessary in the vast majority of cases. Without them, people with ADHD “fall through the cracks” and abandon treatment altogether. Worst of all, it sabotages the future and potential of the patient who would have done well had he stuck with treatment.
William W. Dodson, M.D., LF-APA, is currently a speaker, consultant, and writer in adult ADHD medicine living in Denver, Colorado.
Mastering Your ADHD Nervous System
No medical standard says that anyone has to try medications for either herself or her child. Standards are insistent, however, about the importance of “psychoeducation” as the core component of the mastery of one’s ADHD nervous system. Psychoeducation consists of several things:
- Learning about the cognitive style of ADHD, in which the importance of the task does not compel getting engaged or not being distracted from the task. Other motivators — such as interest, challenge, novelty, and urgency — have to be harnessed to work at a task.
- Learning social skills and how to make and keep friends.
- Learning how to manage strong, sudden shifts of mood.
- Learning about the unique needs of children with ADHD and the special skills their parents need (taught in behavioral parent training/behavior management programs) in order to parent effectively.
- Learning about the school system and how to be an effective advocate for a child with ADHD.
- Learning about the effects of ADHD on intimate relationships.