73. ADHD Clinical Pearls: Measuring what matters with Dr. James Waxmonsky

Three Clinical Pearls for Evaluating and Treating ADHD 

Dr. Elise Fallucco chats with Dr. James Waxmonsky (Chair of Child Psychiatry at Penn State) about practical strategies to evaluate and treat children and teens with ADHD.

 Clinical Pearl #1 - Ask Patients about their biggest Challenge and define their Goals, Set Relevant Finish Lines

• Dr. Waxmonsky emphasizes starting with family- and patient-defined functional goals rather than symptom scores, 
• Keep in Mind: stimulant sensations like alertness or “academic confidence” can fade with physiologic tolerance and may not reflect real-world improvement. 

Clinical Pearl #2 - Ask about the hardest time of the day

• Ask about the family WHEN is the hardest time-of-day and WHAT is the specific problem (e.g., meds may help careless errors and pacing more than organization). 

 Clinical Pearl #3 Ask about Drift Time

• He also recommends measuring “drift time” by asking how many minutes of a class period the student is on task

00:00 73. 3 ADHD Tips with Dr. James Waxmonsky

01:00 TIP #1 - Ask Patients about their biggest Challenge and define their Goals, Set Relevant Finish Lines

03:07 Measuring Evidence of Real Focus and Motivation

06:22 TIP#2 - Ask about the hardest time of the day

08:37 Need Branded Concerta not generic

10:01 TIP#3 Ask about Drift Time

13:48 Recap of Clinical Pearls

About our Guest:  Dr. James Waxmonsky

Professor, Vice Chair for Children's Services and University Chair in Child Psychiatry, Department of Psychiatry and Behavioral Health

Penn State Neuroscience Institute

Check out our website PsychEd4Peds.com for more resources!
Follow us on Instagram @psyched4peds

Transcript

71. 3 ADHD Tips with Dr. James Waxmonsky

Dr. Elise Fallucco 0:21

Hello and welcome back to Child Mental Health for pediatric clinicians helping you, health kids. I'm your host, Dr. Elise Fallucco, child psychiatrist, and mom. In our previous episode, we talked a lot about the science of stimulant tolerance with Dr. James Waxmonsky and if you haven't listened to the previous episode, definitely go back and take a listen. But to recap, Dr. W Monki is Chair of Child Psychiatry at Penn State. And co-PI or head PI for a number of NIMH funded studies regarding treatment of kids with A DHD. but for today's episode, we're gonna have Dr. Wax Monki put back on his clinical hat and share with us. Three clinical pearls and strategies he uses when evaluating children and teens with A DHD., So let's continue our conversation with Dr. James Wax Monki. So first, could you share with us some important things that we should keep in mind when assessing kids for A-D-H-D-I?

Dr. Jim Waxmonsky 1:21

Do your job to figure out if a child has a DHD and then get measures of symptom counts. That's fairly easy. The Vanderbilts are very good at that. But then figure out a goal, uh, why is it that the parents here, what is it that the adolescent or even the adult is here for? And that's gotta be in their own real world language. The goal is not symptom reduction. No one comes to you for a lower Vanderbilt score. And then your job as the clinician is to figure out, can you connect A DHD? And then again, the ability of meds to change A DHD symptoms to that goal and live in a pathway of that goal. Well, if your goal is to go from a, it's usually something like, I'm failing and then I need to pass. And so then the question naturally becomes, why are you failing? And it encourages you to dig through those details. And then you just have to the knowledge pieces to know what the meds have a capacity to do and what they don't have to do. But if you don't start with a goal, we're always chasing symptoms and it looks like everything works.'cause yes, the meds do reduce symptoms, but that's just not the relevant finish line many times.

Dr. Elise Fallucco 2:20

Right. And that it's what's the meaningful outcome for the family and for the patient is not necessarily going from, you know, seven out of eight symptoms to three out of eight symptoms or decreasing the severity of each symptom. If it's not resulting in changes in overall functioning, or whatever they care about.

Measuring Evidence of Real Focus and Motivation

Dr. Jim Waxmonsky 2:38

We have to remember, these are stimulant meds. They create a sensation of alertness and particularly amphetamine, they create a sense of what I'll call academic or cognitive confidence. that doesn't really correlate with actual functional improvements. So relying on sensations of feeling, medicated sensations of feeling more alert, we do know there's very quick physiologic tolerance to that. That sensation fades. And if we chase that, that's when we get into weird regimens of three times a day extended release capsules or really high doses, but that doesn't really map on to functional improvement. Um, and so I think is absolutely critical to think about goals, functional, measurable activities that you do either more efficiently, more accurately, or more of across the day instead of a general sense of focus.

Dr. Elise Fallucco 3:28

You bring up a great point here that initially when we start a medication, we expect to see that patients feel subjectively more focused and more alert, and that that can be a clue that this medication is gonna be more helpful. But you remind us that this feeling doesn't necessarily last. And that doesn't mean that the medication is not working so much as our body develops some sort of physiologic tolerance to it. And ultimately, big picture, what we wanna find out about is larger functional outcomes. Whether that is grades or fewer behavior problems in class, or fewer calls home from the teacher or whatever it is. That in parallel to asking the patient what their subjective experience is of being on the medication, we need to also be looking at bigger outcomes and more specifically family determined or family defined goals and outcomes.

Dr. Jim Waxmonsky 4:20

I think the patient experience with this is critical. I think it's just our job not to take the first answer and interpret that as definitive proof of beneficial med effect.

Dr. Elise Fallucco 4:30

So your first big clinical tip in evaluating a kid with A DHD is to get patients to define their goals. And I love how you worded this for them to set relevant finish lines so that we as clinicians can figure out first if meds can help with this. And then if so, which medications can help meet their goal.

Dr. Jim Waxmonsky 4:52

The second we are pretty confident it's A DHD doesn't necessarily mean the meds are particularly effective at it. We know there are things the meds are better at and things they're not so good at, they're not really good at making you more organized. so if your primary academic deficit is you lose track of things. So you don't turn them in. not really gonna be real optimistic about the meds for that. If the main deficit is you rush through work and make careless errors, but you know how to do what you're doing, yeah. The meds are pretty good at letting you pace yourself better.

Dr. Elise Fallucco 5:21

And I think it's easy to lump all of these things that are frustrations either for the patient or for the teachers and the parents, and kind of lump them in one basket as this is A DHD, but I like how you're disentangling like if the main issue is organization and potentially higher level executive functioning skills, like knowing when to do what assignment and how to pace if you have a big science project coming up in a couple of weeks, that a medication is not going to teach you any of that or fix that necessarily.

Dr. Jim Waxmonsky 5:49

I, I'm always very impressed by any co any colleague prescriber in primary care.'cause I know you, the average visit you're gonna get seven, eight, maybe if you're lucky, 15 minutes to test this apart that. I get 30 sometimes 45 minutes to do this, and it's challenging to do it. But, you know, getting parents who come in who have that specific information as to what's behind the challenge, that really does help to focus the meds as much as we can.

TIP#2 - Ask about the hardest time of the day

Dr. Elise Fallucco 6:14

Just tell me more about the biggest challenge is it more in the area of organization, executive functioning, planning and prioritizing? Or is it more in the area of physical motoric hyperactivity rushing through assignments, potentially impulsivity, blurting out answers in class, which the meds would be better at addressing? When you're taking a history from a family about A DHD, are there any specific questions that you like to ask that you found really give you helpful clinical information in a short period of time?

Dr. Jim Waxmonsky 6:44

one of the most useful things I've ever figured out is ask families when their biggest challenge of the day is, all day is an aspirational goal. we can't start with all day. if it's a big struggle in the morning, I don't know about Concerta. If it's a big struggle school day until 6:00 PM then that's a pretty good profile for it. But they're, the drugs do differ when they on an offset and that's one of the most useful things we can do for our families is gimme your couple hour window, which is your priority concern. We'll get to the other parts of the day, but it helps us to pick where we start. Uh, much more than anything else I've ever found useful.

Dr. Elise Fallucco 7:18

Oh, fantastic clinical pearls that I wanna emphasize and repeat that you just said. the first one is this question, A clinical question to ask when you're thinking about treating A DHD is ask the family, what time of day do they have the biggest challenge and mm-hmm. You know, getting ready early in the morning.. Great. We could get a short-acting methylphenidate or, you know, potentially short-acting amphetamine salt product that'll get in their system fairly quickly to help in the mornings or potentially do Jornay the night before. whereas if the main issues are after a day of school, my child is bouncing around the halls, it's hard to do homework, it's hard to focus we're all over the place. Then a longer acting medication that where you see a stronger effect later in the day, like Concerta, methylphenidate OROS would be a better option.

Dr. Jim Waxmonsky 8:08

yes, and I, I think just this sense of medicating the whole day is the ideal. I think that ignores tolerability, the medicate when the meds are clearly proven to be helpful. And because medicating the entire day is a hard to do and does increase the challenge with side effects and maybe long term, tolerance. So, simply because I med is helpful at one time a day. I don't think it's proof that it's helpful at another time of day and it's really up to us as the prescribers to figure that out.

Need Branded Concerta not generic

Dr. Elise Fallucco 8:34

I think it's always important clinically to not take for granted that parents may not, and families may not intuitively know that you're taking a medication and that it's not going to dramatically change you overnight and you're not gonna, it's not gonna take away a DHD symptoms consistently over the next 24 hours and four eternity that they are, you know. That it's more complicated than that.

Dr. Jim Waxmonsky 8:54

Yeah, I mean, particularly with the stimulant, because they all have very defined timeframes. Uh, and then my last little tangent on this, and you'll have to rail me in is I'm a big fan of generic meds, but a lot of these meds are release mechanisms and unless the generics account for the release mechanisms, they're appreciably different meds.'cause they're all just methylphenidate generic. Concerta really shouldn't, you shouldn't use that word. It's generic er methylate that exist in the same doses that concert does. That mechanism is very specific. To the Concerta brand and the patent. and it's not recreated in any other generic that has 18 27, 36, 54. Some of the generics are designed to look like it is, but it isn't the same mechanism. So it's the one A DHD drug where we really don't consider the brand product to be equivalent to the generic. So if you want the length, the generic methylates are kind of pot luck.

TIP#3 Ask about Drift Time

Dr. Elise Fallucco 9:48

So we wanna be careful about prescribing generic Concerta and to make sure to prescribe brand if we really want and need true long-acting delayed release. Dr. Waxmonsky, you've already shared two helpful clinical questions to guide us in developing a treatment plan for kids with A DHD. The first is asking the family to define their goals for the issues that they want to improve. And then second, finding out which time of day is most problematic. Do you have any other clinical pearls to share with us that can help all of us assess the level of severity of A DHD and monitor response to treatment? And this is a little bit of a leading question, but I wanted you to tell us about how you think about drift time. I.

Dr. Jim Waxmonsky 10:29

We know, for example, when we do these classroom studies that the average middle school student who doesn't have a DHD, can be on task. Yeah. Can look on task. I'll say that for 37 out of 45 minutes of a class. So we, we kind of know what the average drift time is. So what we try to do instead of do you have you felt more focused is all right. You know, when you're in math, how many of those 45 minutes are you actually on and productive? And, you know, often you'll get answers like, well, five, all right, so that's not good. But when they come in at saying 20 and now they can say, well, you know what, it's really much closer to 35 to 40 minutes or almost 90% of the class. That at least gives me a little bit more sense of precision and confidence that the med is doing something than if I just simply stopped at, do you feel focused? And it's, it's far from foolproof, but it adds a little bit of precision.

Dr. Elise Fallucco 11:19

Do you get a good response from kids when you're asking specifically about minutes, like, you know, out of 45 minutes or in a 50 minute class, how many minutes do you think you're on task? Are they able to say that pretty well?

Dr. Jim Waxmonsky 11:30

if they're here because they want something to be better. And it relates to academics, then yes. Now, obviously I'm not asking a third grader, but when you have, you know, insightful middle school and up

Dr. Elise Fallucco 11:42

mm-hmm.

Dr. Jim Waxmonsky 11:42

Yes.

Dr. Elise Fallucco 11:44

That's interesting. so we're adding to our list of clinical pearls and questions. This question about, in a given class, let's say it's an hour, you know, or 50 minutes. How many of those minutes are you paying attention? these are great tools and great questions to just throw into an A DHD, either eval or follow up visit, to help anchor things and to provide more specific data.

Dr. Jim Waxmonsky 12:04

Over the years I've found that helpful. And the other thing, particularly for middle school and high school students is when you're given a chance to do work on your own How many minutes is assigned? What is your goal going in?'cause if your goal is simply to socialize,'cause you want a break, I am not going to expect a stimulant to change that goal. But if your goal is to actually walk out of there and get work done so you don't have homework, all right, well, how many of those 45 minutes did you actually do work? And most teens I think, know that, you know, whether they did five minutes, 20 minutes, or 40 minutes. And if that's their goal, then let's see if the med gets you closer to your goal. And if it doesn't, it doesn't really matter how focused you are, you're not getting closer to your goal. So why keep the med?

Dr. Elise Fallucco 12:42

Right? Ooh, I like that. I like also getting the patient to define, here's what I care about or here's what I want to do. And also acknowledge that, there are gonna be some classes or or some time of day where. Their goal is not gonna be to pay attention. Mm-hmm. Their goal is gonna be to reconnect with their friends.

Dr. Jim Waxmonsky 12:59

Yeah. Meds don't change your goals. Maybe parents can slightly change your goals. People change their own goals, but meds are facilitators to get more out of your effort to get closer to your goals.

Dr. Elise Fallucco 13:09

And it side note, it reminds me of why I think our field is so hard and in some ways why it's hard to manage and, and sometimes treat mental health conditions. If we have an infection and you can give somebody an injection of antibiotics or like IM Rocephin. Or I don't know, something like that. Mm-hmm. It doesn't matter if the patient really desires for the infection to go away or not, the med's gonna work regardless.

Dr. Jim Waxmonsky 13:33

Yeah.

Dr. Elise Fallucco 13:33

Where,

Recap of Clinical Pearls

Dr. Jim Waxmonsky 13:33

I mean, yeah, I, I agree. And, and it's just, I always feel a little bit lazy when I say. You know, to the parent, it's just not something your adolescent's interested in. I can't medicate them. Now we can talk about how you might, you know, quote unquote kinda leverage them into more health promoting behaviors or better grades or what, all that. But without that, we're gonna get nowhere. Let's try to do stuff to kind of help synchronize goals and come back and see me in a month trying to push a med now, because they're just not gonna take it. Even if they tell you they're gonna take it and it's not gonna do anything because they have no desire for it to do what you want it to do. Right.'cause that's just not their goal.

Dr. Elise Fallucco 14:09

Oh, I love this discussion. And I wanna summarize for our listeners the three clinical pearls that you gave us for assessing and evaluating kids With a DHD. First one is to ask families what is the biggest challenge of the day for them? And to tease apart whether is it more executive functioning, attention hyperactivity, and impulsivity? And on a related note, to then get them to define functional goals or meaningful finish lines for what they would like to see improved or different. The second is to ask about the hardest time of day. And the third is to ask specific questions about drift time. Meaning in a 45 or 50 minute class, how many of those minutes are you actually paying attention? Compared with how many is your attention drifting away or thinking about something else? And if you enjoyed this episode, please click like or subscribe or follow so that you continue to be notified about any future episodes. And if you wanna join our newsletter or mailing list, just check us out on the web at site, the number four peds, and drop your email in so you can join our group of friends and colleagues on child mental health for pediatric clinicians. And if you're driving and didn't write down that website, it's in all of our show notes for every episode. So just click there, share your info, and you can become part of our team. Thanks for listening. See you next time.