Dr. Corey Hebert and Dr. Napoleon Higgins Discuss Transition of ADHD Care From Childhood to Adulthood

QBE.2023-0018

In this podcast, listen as Dr. Corey Hebert and Dr. Napoleon Higgins discuss strategies to optimize care transitions for patients with ADHD from pediatric services (ages 6 to 17 years) to adult services (18 years and older).

Read the full transcript:

Dr. Hebert: Before we begin, I would like to introduce myself. My name is Dr. Corey Hebert, and joining me today is my colleague, Dr. Napoleon Higgins. We are consultants who have been compensated by Supernus Pharmaceuticals. We welcome you to this podcast where we will be discussing the transition from pediatric to adult care for patients with ADHD also known as Attention/Deficit-Hyperactivity Disorder. Thanks for joining me for this conversation, Dr. Higgins.

Dr. Higgins: Thank you so much Dr. Hebert, it’s good to be here.

Dr. Hebert: Well Dr. Higgins, from your clinical experience, what are the most problematic struggles for patients with ADHD when transitioning care from childhood—to adulthood? 

Dr. Higgins: You have raised an excellent question, Dr. Hebert, on a topic often ignored. When ADHD patients move from child services to adult services, it often coincides with other major life events like completing their education, starting a job, or leaving their parents’ home. Thus, patients may be deprived of their familiar support networks while simultaneously facing increasing demands in several domains that may compromise ADHD care. Patients with ADHD can face several issues in which they demonstrate reduced ability to organize and regulate themselves. This may even lead them to discontinue treatment and can cause difficulties with managing their disorder into adulthood. Transitional care for patients with ADHD graduating from child services are, therefore, critical.

Dr. Hebert, as we witness the challenges that ADHD patients can experience during the transition of care, what factors do you think contribute to these issues? What common barriers to a smooth transition of care do you witness in your practice?

Dr. Hebert: It may be challenging to transition patients from pediatric to adult services. And one of the reasons, as you mentioned, for an unsuccessful shift in care is changing relationships, especially the connections made with their healthcare team. Practitioners can be hard to find for patients 18 years and older, and the trust that they had in their previous doctor must be re-established when a new one is found. The way I like to approach this problem is to put them in the hands of a physician, advanced nurse practitioner, or physician assistant through a referral. Once they are with their new provider, I continue the follow-ups every three months for about a year, just to see how everything is going with their new practitioner. Further, it appears that there is a lack of knowledge on the part of patients regarding the long-term effects of ADHD, services for their age group, and transition preparation. All of these barriers to a successful transition of care can substantially impact their ability to manage their ADHD.

To combat these barriers, how do you think parents of ADHD patients can help navigate accessing adult services for their children?

Dr. Higgins: I have found that parents play a pivotal role as advocates in patient education. While parental involvement is assumed in child services, services for patients 18 years and older do not necessarily include parents. If parents are highly involved in supporting their child's access to healthcare, their exclusion from adult mental health services may lead to discontinuation of care.Adolescents need help navigating the transition from being passive recipients of care from their caregivers to becoming self-reliant in their healthcare management. I start the transition process early to ensure that patients understand their ADHD diagnosis and symptoms and take ownership of their treatment. Also, I allow patients to lead their appointment rather than their parent speaking on their behalf. For instance, I asked the mother of one of my patients to let her child be the one on camera to describe their symptoms and issues in school. Adolescence is the bridge between childhood patients and adult patients, so clinicians should maintain a treatment alliance with adolescent patients and their families.

So, Corey, for a minute, if we were to focus on the healthcare team and their involvement in patient care, how do you think clinicians can help patients transition across healthcare settings?

Dr. Hebert: Well Napoleon, one of the barriers to a smooth transition of care falls on the clinicians’ lack of communication, coordination, guidelines, training, and protocols between the pediatric services and adult services. The method for implementing a successful transition process is to support key decision-makers providing services for these two age groups, providing updated guidelines, and training the healthcare team. A cross-functional team of healthcare providers, social workers, nurses, and insurers should coordinate and communicate in their follow-up care to provide the ideal treatment plans for their patients. Additionally, when transferring to adult services, certain patients with chronic conditions who were seeing a pediatric ADHD subspecialist may need an adult ADHD subspecialist. However, in the absence of a particular adult ADHD subspeciality, it may be prudent to transition to an adult primary care clinician until an ADHD subspecialist is available, to avoid any discontinuity in care.

So Napoleon, in your clinical experience, what strategies should be implemented to optimize transition of care on the pediatric services end for patients reaching adulthood?

Dr. Higgins: Corey, I can certainly think of a few things that are particularly beneficial to incorporate. To ensure a successful transition from pediatric services to adult services, treatment strategies for ADHD in adolescent patients should be optimized. Motivational interviewing is a counseling technique that can be incorporated. It helps provide patients with the ability and mindset to take charge of their care as they go through  life challenges. Additionally, cognitive behavioral approaches and mindfulness-based techniques can also be incorporated to improve adolescents’ self-awareness as well as their organizational, problem-solving, and decision-making skills. These techniques can be performed by engaging patients through smartphone apps and games, which have been demonstrated as valuable tools. 

How about you, Corey? In your clinical experience, what strategies should be implemented in adult services to optimize transition of care?

Dr. Hebert: Absolutely, Napoleon. Certain care models of transitional care have been developed. The transition to independence model advocates for a transition worker to support individuals in planning their future care concerning their needs. Certain models stress the need for dedicated specialist services and a multi-disciplinary team. Clinical guidelines state that adults with ADHD should be provided the following services: transitional care, assessment and diagnostic services, drug titration, monitoring and review, and psychoeducation.

So Napoleon, overall, what is your experience prescribing ADHD medications? Have you experienced positive adherence rates as patients have transitioned from pediatric services to adult services?

Dr. Higgins: Adherence is crucial when you are talking about someone with ADHD. The transition to adulthood is challenging, especially at this age when many are leaving for college. It depends on whether the patient will attend school in- or out-of-state. Out-of-state imposes challenges with difficulty of follow-up and the different laws and required licenses to prescribe certain medications across state borders.  A helpful strategy I like to utilize is ensuring patients set up a follow-up appointment in my care. This strategy allows the opportunity to solidify their understanding of their disease and their current treatment and to help with booking follow-up appointments to ease the transition of services. 

What about you, Corey? Have you experienced positive adherence  rates as patients transition from pediatric services to adult services?

Dr. Hebert: Napoleon, I totally agree. This is crucial when you are talking about someone with ADHD. The transition to adulthood is challenging. Many students end up going to college and need medicine because they are still doing their academic work. But a large number do not go to college. And they may believe that they don’t need the medicine since they are not attending school. But what they might not realize is that they could suffer because, while they do not have to pay attention to academic pursuits, their jobs will still require them to be attentive and on task. So it is important that patients continue the medication under the direction of the healthcare provider. I have experienced a very high level of adherence with my patients, because, when you explain things to people in a relevant way that they truly understand, they will adhere. They also trust my judgment because I’ve been taking care for them for so many years, so the goal is to have that support system so that they can be followed up not only by me but with support services.

Well Napoleon, it was great to see you, I want to thank you for this important discussion today. And thank you to those who have listened in to this discussion on transitions of care in ADHD.

Dr. Higgins: Corey, it was great to see you as well, thank you. Thanks to all of the folks in the audience for tuning in, and I hope that the information we have shared regarding the transition of ADHD care from pediatric to adult care for patients with ADHD, is helpful. Thanks again, Corey.

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QBE.2023-0018