Revisiting best practices: a reflection on the online evaluation and treatment of ADHD and implications for future practice

We should not overlook the potential for electronic ADHD treatment platforms to improve care and acknowledge several reputable platforms that have emerged during the pandemic. Online services offer the opportunity to provide accessible, high-quality, evidence-based ADHD care for adults and children. At this vital juncture, it is critical to consider best practices for assessing and treating ADHD, whether provided remotely or in person. For diagnosing ADHD [14], fundamental principles include clinical interviews with the patient and obtaining collateral (parents, teachers) about functioning across multiple settings (home, school, work, etc.). Evaluation should involve standardized measures of ADHD severity involving multiple informants rather than strictly subjective reports. Additionally, a thorough review of comorbid or alternate psychiatric disorders and a review of medical, social, and family histories are crucial to clarify ADHD symptoms caused by other etiologies. Treatment should involve psychoeducation; community, workplace, and school resources and accommodations; behavior therapy; and pharmacotherapy. Additionally, there should be frequent reassessment to evaluate for adequate treatment response, side effects of interventions, and whether continued treatment is necessary.

There are numerous advantages to online services. They can improve access to mental health care and make accessing assessment and treatment of psychiatric disorders easier, thereby addressing the nationwide provider shortage. In this way, online services can reduce the time waiting to connect with a provider, distance traveled, and inability to communicate due to conflicting schedules. Additionally, patients with psychiatric disorders may be more likely to seek treatment through an online service due to the stigma of psychiatric disorders. Furthermore, online services can also address financial barriers to accessing mental health care by providing subscription models that are less expensive for patients. Finally, although not implemented widely, online services may allow for more standardized and evidence-based assessment and treatment of patients using measurement-based care. Notably, telehealth and virtual care offer access to mental healthcare services in regions of the country where it may otherwise be difficult to obtain, such as in rural and frontier communities [15]. However, disparities remain in telehealth access in low-income and low-resource communities [16, 17]. The accompanying table outlines the basic tenants of quality evidence-based assessment of ADHD regardless of treatment setting (Table 1)

Table 1 Recommendations for assessment of ADHD

Using online platforms integrated into the electronic medical record offers the opportunity to increase the use of standardized assessment tools and structured clinical interviews that can better recognize other psychiatric contributors to inattention, such as self-report instruments such as the Development and Well-Being Assessment (DAWBA). Additionally, online platforms, such as meHealth (https://www.mehealth.com), can integrate the collection of standardized measure data from other sources, such as parents and teachers, to better understand the presenting symptoms. During treatment, online tools can continue to collect and track data from multiple informants to assess treatment efficacy. Furthermore, online platforms present the opportunity to integrate data about prior medication trials and tracking of prescription monitoring databases to identify possible abuse, diversion, or misuse. Checking prescription monitoring services is especially important as patients may give false information to obtain substances for intended misuse [18]. On the other hand, verifying that the person presenting before a provider is providing accurate identifying information can take time and effort. There are notable reports of online platforms providing treatment to patients under 18 without parental consent due to the limited capacity to verify age and identity [19]. Therefore, it is crucial to incorporate identification-verifying software and services to ensure that the intended patient receives the appropriate treatment. Regardless, the automatization, increased access, and economies of scale offered by online platforms also provide an opportunity to improve ADHD treatment for the better.

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