Brain injury and ADHD share a complex relationship, with research evidence highlighting the disorder among neurobehavioural complications of TBI and amid widespread recognition that more studies are needed to shed light on this complex picture. NR Times reports on a pioneering approach to ADHD which aims to revolutionise management of the condition.
Children with traumatic brain injury have a heightened risk of developing ADHD, and recent research suggests that it may not develop until years later.
A separate study (Gerring et al, 1998) presents ADHD secondary to TBI as occurring in 20 to 50 per cent of individuals post-injury.
Meanwhile, ADHD diagnoses are on the up. In the US, the National Health Interview Survey estimated the prevalence in children aged four to 17 years to be around 10 per cent in 2016, up from six per cent in the 1990s. And this trend seems to have continued, with more recent figures up to 2019 from the Centers for Disease Control and Prevention showing that ADHD has recently been diagnosed in 13 per cent of children aged 12 to 17 years in US.
Against the backdrop of this trend, ADHD Online has emerged as the only organisation in the US to offer ADHD assessment online that is compliant with the Health Insurance Portability and Accountability Act (HIPAA); which protects sensitive patient health information from being disclosed without the patient’s consent or knowledge. The platform provides certified results from licensed psychologists.
NR Times spoke to CEO Zach Booker and senior clinical staff at the company about its novel approach to ADHD and their views on the outlook for ADHD management.
NRT: Tell us about the ADHD Online journey so far and how COVID shaped your development
Zach Booker, CEO of Mentavi Health/ADHD Online: “When it comes to managing treatment for ADHD, many of the options, such as obtaining prescriptions for controlled substances, require a formal diagnosis of ADHD by a licensed psychologist. Patients sometimes wait nine to twelve months and spend US$2,000 or more just to be diagnosed.
“ADHD Online was founded in 2018 with the mission that everyone should have access to an affordable, quality ADHD assessment. Over an 18-month period, we created a solution to help individuals get an ADHD assessment from a Doctorate level, licensed psychologist faster than they could in person.
“Before COVID, we were only providing ADHD assessments. COVID opened the door to new treatment options that allowed us to expand into direct patient care using HIPAA-compliant telehealth visits as our ‘clinic’. Our team is filled with industry experts across the United States who all share the same passion for ADHD and making sure patients have access to critical mental health services.
“Today, we’re leading the way with being a critical voice for those who might be struggling with ADHD. We are the only organisation to offer this level of HIPPA-secured ADHD assessments online with certified results from licensed psychologists. We’re proud to be active in all 50 states.
“And as the DEA waivers expire in May that introduced virtual treatment as an option, we’re the sole telehealth provider of scale that’s actively working towards maintaining our virtual treatment services by tightly integrating with our patients’ existing care team. It’s a win/win for all of us.”
Part of your stated mission is streamlining the process of ADHD diagnosis. Why is this streamlining is needed and what is the alternative without your intervention?
Zach: “The process of ADHD diagnosis has traditionally been lengthy and complex. It involved multiple visits to a healthcare provider, such as a primary care physician or a specialist like a psychiatrist, as well as completing various assessments and questionnaires.
“This can take several weeks or even months once the assessment process begins. That’s frustrating for people seeking answers to very personal challenges. The delay keeps them from treatment, typically compounding whatever they’re going through. It’s time-consuming and may be costly, especially if they don’t have health insurance. There are barriers to accessing healthcare in certain geographies or for individuals with limited mobility or transportation options.
“We streamline this process by providing an online platform that allows individuals to complete a comprehensive assessment for ADHD in the comfort of their own homes. The assessment includes a series of questions and tasks that are designed to evaluate the presence and severity of ADHD symptoms, anxiety, and depression.
“The results of the assessment are then reviewed by a licensed provider who can provide a diagnosis and recommend appropriate treatment options.
“We strive to help more individuals receive the care they need to manage their ADHD symptoms and improve their overall quality of life.
Are there any dangers or downsides to this streaming in pursuit of speedier diagnoses?
Dr. Gayle Jensen-Savoie, clinical division chief of psychology: “No, there’s no downside to a more efficient, not speedy, diagnosis.
“We haven’t removed any elements of the diagnostic process. Actually, due to our dynamic branching and asynchronous interview, we’re able to develop a more complete, thorough, and robust assessment than is typically used at a brick-and-mortar diagnosis facility, where they might feel rushed or time constricted.
“Many of our psychologists say that they learn a lot from how much or little eort patients put into their responses. What time of day do they complete and submit the assessment? How many times did they stop and come back?”
How robust is the online diagnosis process you facilitate and how might it improve over time?
Gayle: “The diagnosis is as reliable as one you get in a brick-and-mortar office.
“First, we use validated tools embedded in our assessment and over 300 questions that utilise branching logic to ensure our psychologists have all the information they need to ensure the DSM V diagnostic criteria are met.
“Our assessment has gotten more robust over time as we have added additional tools and questions. We’ve added diagnostic criteria to diagnose anxiety and depression, as they’re the most co-occurring diagnosis with ADHD.
“In addition, after a psychologist completes the asynchronous assessment and the patient enters our medical treatment service, they’re reassessed at every visit, synchronously. This way, the providers can measure if the patient is improving over time.”
How might treatment options for ADHD develop in coming years?
Raafia Muhammad, MD, MPH, clinical division chief & interim chief medical officer: “Telemedicine and teletherapy will continue to evolve and provide a more inclusive treatment option for patients that, due to geography, time, and transportation, would not otherwise be able to receive care.
“As long as patients are taking medications that require monitoring, we expect and will help push to integrate remote monitoring and regular vitals reporting.
“We’ll ensure patient data is available to and current for our patients’ care team. New advances in patient feedback and monitoring with machine learning and AI will help with diagnostic and therapy options in the future as well.”
Are attitudes towards ADHD, both among healthcare professionals and in wider society, evolving, whether positively or negatively?
Zach: “There’s been a significant shift in attitudes toward ADHD in recent years. In the past, ADHD was often seen as a behavioural problem that could be managed through discipline and punishment. Over time, research has shown that ADHD is a neurodevelopmental disorder that requires specialised treatment and support.
“As a result, attitudes toward ADHD have become more positive in recent years. Healthcare professionals and clinicians are now more likely to recognise the symptoms of ADHD and provide appropriate treatment, such as medication and therapy. Society has also become more accepting of ADHD and less stigmatising towards individuals with the condition.
“I’m aware of the comments we see through our social media channels every day that suggest there’s still a long way to go to help everyone understand the difference between monitored clinical treatment and the abuse and addiction to street drugs. This is true especially among those who may not have direct experience with the condition. It’s important to continue to educate and advocate for individuals with ADHD to ensure that they receive the support they need to thrive.
Playing devil’s advocate, you are obviously a business that benefits from the rising interest in diagnosis and treatment of ADHD. But what are your views on the argument that many adults too readily seek a diagnosis, possibly as a result of social media influence (as reported here for example)?
Gayle: “Social media has had an influence on the rise of ADHD diagnosis as the fast-paced world of social media fits well with someone who has ADHD (impulsive, distractible, etc). There is also an encouragement to be transparent and open about symptoms that really require a clinical evaluation, not your social media audience.
“However, overall the pandemic has allowed people to obtain an assessment via telehealth that otherwise would not be possible too. For example, this article which states that, in 2021, over 5.4 million people took a mental health screen, representing a nearly 500 per cent increase over the number of people who completed a screening in 2019 and a 103 per cent increase over 2020.
“It’s so exciting that a huge part of our population is now able to receive treatment for their mental health and physical health.
“For those seeking a diagnosis alone, our assessment is very good at sniffing out ‘prescription-seeking’ behaviours and responses. We expect that we’ll only get better at this the more we learn the patterns.”
Are there any risk factors of modern living that are also increasing the levels of ADHD diagnosis?
Raafia: “There’s some research that shows people with long-term Covid are exhibiting severe inattention.
“There is other research that is showing ongoing ‘brain fog’ for all ages suffering from Long-COVID.
“There is also some new research that just came out this week related to looking at the crossover between the microbiome of a child and their risk of ADHD.”
Evidence suggests that brain injury is a risk factor for ADHD. Anecdotally, do you see ADHD diagnoses intertwined with other conditions, neurologically or otherwise?
Raafia: “ADHD can be intertwined with other physical and psychological conditions. However, we really want to assess each client as an individual to provide the most valid diagnosis and treatment.
“We do ask about the history of any traumatic brain injuries (TBI) in the assessment as part of past medical history.”
Are there any messages about ADHD you’d like to share with the neuro-rehab community?
Raafia: “ADHD related to TBI can be seen as secondary ADHD, and this is a multidimensional approach and should be treated and managed relatively the same with medications and therapy.
“People who are diagnosed with ADHD as adults may have been misdiagnosed with anxiety, depression or overlooked completely because they didn’t fit the ‘hyperactive boy’ stereotype so many of us grew up with.
“It’s also the case that we do an assessment for some patients who previously have been told they have ADHD and been treated for it, that once they complete our thorough assessment, our psychologists exclude them from having ADHD and diagnose them with something like anxiety or depression.
“We can see indications of PTSD and other conditions as well but not diagnose them today. And for some patients, their current diagnosis and treatment of more complex mental conditions means telehealth isn’t for everyone.”
Do the treatment options for people with ADHD + another conditions such as brain injury differ from those solely with ADHD?
Raafia: “Yes and no, the treatment options for ADHD involve medication and therapy, which would still be the chosen course of treatment even if the patient had another condition. The treatment would be integrated with the treatment for the patient’s other condition (eg brain injury).
Would you say America is ahead of the curve on awareness and management of ADHD and are you aware of countries where living with ADHD is particularly challenging?
Raafia: “In the countries that do not allow psychostimulants, specifically Adderall (Japan, Thailand, the UAE and Saudi Arabia), it can be challenging for those with neurodiverse conditions to live or travel there.
“I don’t believe America is ahead of the curve, but here at ADHD Online, we hope to help push America in that direction!”
