What is Telemental Health?

shh_headshot-smallBy Susan Herman

Telemental health (TMH) is the use of telecommunication technologies to provide behavioral health services such as assessment, education, treatment, counseling and consultation. It refers both to live, real-time interactions as well as data sharing via asynchronous communication.

Over the phone and video teleconferencing systems, clinicians can provide care for most, if not all, the same conditions they treat in the office. Having a distance care option can increase access and decrease costs for consumers. However, telemental health can present certain logistical and safety complications. According to David Luxton, Eve-Lynn Nelson, and Marlene Maheu in their new book A Practitioner’s Guide to Telemental Health, complications can arise in regard to:

  • establishing informed consent
  • adapting intake and assessment protocols for the long-distance environment
  • involving emergency or support services, if necessary, at the client’s location
  • handling emotionally charged conversations when the client can easily power off their device, or when there might be another person in the room out of the clinician’s view

Asynchronous communication in TMH can include messaging technologies such as text or email—say, to ask follow-up questions or to check in on how well a patient is following a prescribed routine.

Software, apps, and peripheral devices for self-care and remote monitoring are also proliferating in the marketplace. These tools are broadly referred to as eHealth, or mHealth when deployed via mobile devices such as cell phones or wearables. They can be useful adjuncts to care, but cannot be used to diagnose mental health problems.

telemental-healthSome eHealth technologies provide alerts to prompt care providers to check in, similar to blood glucose monitoring systems for diabetics. According to the National Institutes of Mental Health (2016), “Such apps might use the device’s built-in sensors to collect information on a user’s typical behavior patterns. If the app detects a change in behavior, it may provide a signal that help is needed before a crisis occurs.”

Apps and wearable devices may include various coaching functions, self-monitoring, journaling, and/or stimuli (music, imagery) for help with:

  • Anxiety and stress management
  • Breathing and heart rate
  • Challenging thoughts
  • Recording moods
  • Activity, sleep, food intake
  • Meditation and mindfulness

Though it can be difficult to keep pace with innovation, providers and consumers alike should evaluate all telemental health tools carefully to make sure their data stays secure, and that actually using the technology doesn’t introduce more complications.

For a complete list of practice and ethical standards and guidelines in telehealth, including information on provider reimbursement for TMH and legal/policy issues, click here.

References

Luxton, D. D., Nelson, E., & Maheu, M. M. (2016). A Practitioner’s Guide to Telemental Health: How to Conduct Legal, Ethical, and Evidence-Based Telepractice. Washington, DC: American Psychological Association.

National Institutes of Mental Health (2016). Technology and the Future of Mental Health Treatment. Retrieved September 30, 2016 from https://www.nimh.nih.gov/health/topics/technology-and-the-future-of-mental-health-treatment/index.shtml

 

A Conversation With Russell A. Barkley, PhD, About Adult ADHD 

 

russell-barkley-photo

Russell A. Barkley, Ph.D., is a Clinical Professor of Psychiatry at the Virginia Treatment Center for Children and Virginia Commonwealth University Medical Center. He holds a Diplomate (board certification) in three specialties: Clinical Psychology, Clinical Child and Adolescent Psychology, and Clinical Neuropsychology.  Dr. Barkley is a clinical scientist, educator, and practitioner whose publications include 22 books, rating scales, and clinical manuals, 7 award-winning DVDs, and more than 260 scientific articles and book chapters related to the nature, assessment, and treatment of ADHD and related disorders.  He is also the founder and Editor of the clinical newsletter, The ADHD Report, now in its 24th year of publication.  Dr. Barkley has presented more than 800 invited addresses internationally and appeared on nationally televised programs such as 60 Minutes, the Today Show, Good Morning America, CBS Sunday Morning, CNN, and many other television and radio programs to disseminate the science about ADHD.  He has received awards from the American Psychological Association, American Academy of Pediatrics, American Board of Professional Psychology, Association for the Advancement of Applied and Preventive Psychology, the Wisconsin Psychological Association, and Children and Adults with ADHD (CHADD) for his career accomplishments, contributions to ADHD research and clinical practice, and for the dissemination of science about ADHD.  His websites are www.russellbarkley.org and ADHDLectures.com. 

shh_headshot-smallBy Susan Herman

Did you know that adults can have ADHD? It’s true—ADHD is not confined to children and teens.

The trademarks of Attention Deficit Hyperactivity Disorder (ADHD) are inattention, combined (for some) with hyperactivity and/or impulsive behaviors. According to the National Institutes of Mental Health, some people with ADHD only have problems with one of the behaviors, while others have both inattention and hyperactivity-impulsivity. It is normal to have some inattention, unfocused motor activity and impulsivity, but for people with ADHD, these behaviors are more severe, occur more often, and interfere with or reduce the quality of how they function socially, at school, or in a job…Children and adults with ADHD need guidance and understanding from their parents, families, and teachers to reach their full potential and to succeed.

Professor, researcher, and clinician Russell A. Barkley recently published a self-help book with APA LifeTools for family members of adults with ADHD, titled When an Adult You Love Has ADHD: Professional Advice for Parents, Partners, and Siblings. You can find more information about the book and purchase it here.

I recently interviewed Dr. Barkley about his work with adults who have ADHD, and how loved ones in their inner circle can support them.

How recently was adult ADHD recognized? 

A German-language textbook published in 1775 has a remarkably accurate description of what we now call ADHD in adults. But, aside from very periodic mentions in the literature—as “minimal brain dysfunction” in the 1950s, and as “hyperkinetic reaction” or “hyperkinetic disorder” in the 1960s—neither the public nor the research community much recognized it. It wasn’t until the 1970s that a series of longitudinal studies was conducted to find out whether ADHD continued beyond childhood. Interest in this picked up throughout the 1980s and 1990s as it was found that half to two-thirds of kids who were diagnosed with ADHD continued to have symptoms into their twenties. This was the first real evidence base that began to show us how ADHD, like mental retardation, dyslexia, and autism, can continue into adulthood.

What would you say has been your greatest contribution to the field of adult ADHD?

In 1991 I started an adult ADHD research clinic at University of Massachusetts Medical School, and the same year my psychiatrist colleague Joe Biederman started one at Massachusetts General Hospital in Boston. We were collecting data on a variety of domains of impairment and symptoms on these adults to see if it was equivalent to the childhood form of the disorder – it clearly was.  Later, Alan Zametkin and colleagues at the NIMH did the first PET scan study showing brain related deficits in functioning in adults with ADHD.  Other studies on never-before-diagnosed adults were done to learn whether they responded to the same types of drugs that children were being given for ADHD.  Results showed that they did so.

In 2008 I published a monograph where I compared results of my own 20-year longitudinal studies on children with ADHD followed to an average age of 27.  Drs. Kevin Murphy and Mariellen Fischer and I compared them with adults diagnosed with ADHD alongside data I’d been collecting in the

clinic from adults who were not diagnosed as ADHD. This was the first time anyone had compared the two groups directly (children with ADHD grown up vs. adults diagnosed with ADHD). The monograph was massive, but I chose that format over journals because with journal articles you have page limitations and you have to peel off tiny bits of your research and present it over multiple, disparate articles. Instead I presented it all at once, and this allowed adult ADHD to really hit the research map. Others followed up my work with various methods of neuroimaging to show differences in brain activity for adults with ADHD.

Why did you decide to focus on parents, siblings, and partners of people with ADHD in your latest book?

Ever since I wrote a self-help book for adults who have ADHD, called Taking Charge of Adult ADHD (in 2010), I’d been wanting to write one for the family members who support them. At the time there was no science-based trade book available for loved ones of people with ADHD. Also, ADHD is in my family. I had been trying to help various of my own family members, get them treatment and offer a safety net, so I knew there were others out there also feeling frustrated after picking up and dusting off their loved one again and again.

I was ready to write the book when my twin brother died. He had ADHD, and I know that it indirectly contributed to his death. He was driving 40 miles per hour on a country road in the Adirondacks. He never wore a seatbelt, and he had a habit of going too fast and drinking while driving. He ran off the road and was killed. I put the book aside while I was grieving him. Not long after my sister, who had physical disabilities, also died. And about three years after that, my deceased brother’s son, who also had ADHD, hanged himself.  So I just “couldn’t go there” for a while due to all this grieving.

Finally, in 2015 the time was right. Several books on how ADHD affects marriage had appeared by that time. Writing about how to love someone with ADHD was cathartic for me. I feared that re-living events would make me feel worse, but actually I felt better.

Thank you for sharing that personal story. I’m glad you decided to include some of it in the book, too. 

adult-adhdLet’s back up a bit and talk about how ADHD can affect adults who have it. Also, how many adults have ADHD—how common is it in the population?

Four to five percent of adults in the USA have ADHD. The percentage is closer to 3-4% worldwide. It’s higher in Western countries because of longer life expectancy and better access to care. In children the ratio of boys to girls with ADHD is three to one; for adults there’s less of a split; it’s closer to 1.4 to 1 male to female. It’s been great seeing more women come out of the woodwork to talk about ADHD. I recently consulted on articles in Elle, Glamour, and Cosmopolitan magazines about adult ADHD.

ADHD is genetic in about two thirds of all cases; in about one third it is acquired either prenatally or after birth because of head trauma or environmental conditions that affect the brain’s frontal lobe development.

Adults who have ADHD typically achieve a lower level of education than they are capable of, and they have problems in the workplace with boring tasks that require sustained attention. Adults with ADHD tend to do well in non-traditional careers, often those that involve performing, music, athletics, police work, and the military. There are people with ADHD in law and medicine, but fewer than you’ll find in the more physically active careers.

Money management is a challenge for many people who have ADHD, as is driving. Adults with ADHD are 2-3 times more likely to be dead by age 46 from accidental injuries, many of which involve driving. About one third of adults with ADHD exhibit antisocial behavior and may even get involved with crime.

New research areas in adult ADHD include risky sexual behavior, along with marriage and parenting problems. ADHD is really one of the most impairing outpatient disorders there is—I would venture to say it’s even more impairing than depression—because it affects so many diverse areas of life. Clinical care and family counseling for adult ADHD exists and is increasingly available but is far from where it needs to be. As of ten years ago, only about one in ten adults with ADHD was diagnosed. The percentage is better now but there is still much progress to be made.

What do family members and partners need to understand about ADHD to best support their loved one who has it?

It’s important to adopt a biologically-based view of ADHD. ADHD is a neuro-genetic disorder. You can’t attribute your loved one’s behaviors to personality quirks, defective morality, laziness, or poor lifestyle choices or say they deserve whatever they get. You can’t be a good support person if you keep thinking, “My loved one could change if they wanted to, but they don’t want to.” People in the inner circle are their loved one’s best safety net and closest influence, but they can’t step up as stakeholders if they don’t adopt a more compassionate outlook about ADHD.

What kinds of support can family members provide to an adult who has ADHD? 

In my clinical work I walk through six steps with adults who have ADHD and their families. Step One is to get a thorough mental health evaluation to document not only ADHD, but any other disorders that the person might also have. Eighty percent of adults with ADHD have an additional disorder, and about half have two additional disorders. These might be anxiety, depression, a learning disability, bipolar, or something else. Detecting secondary disorders affects the course of ADHD treatment. Psychologists, psychiatrists, and behavioral neurologists can diagnose ADHD.

So the support person might offer to set up various appointments for their loved one and help them follow through getting to the specialist’s office.

Yes.

Step Two is to help the patient “own” their ADHD as a part of their identity. It’s easier to accept a diagnosis intellectually than it is to incorporate it as a part of your own view of yourself. Treatment will be superficial if the person doesn’t accept ADHD as a part of their self-view. When the patient starts to grieve their old self-image, that’s when we know we are getting through. Accepting the new you is also a positive thing because it means you’re giving up the old view of yourself as stupid, lazy, or immoral.

Step Three is to read widely and educate yourself about ADHD. I like to say that “truth is an assembled thing.” You can’t just depend on one source for all your information. Jeff Copper’s podcast, Attention Talk Radio, is a great resource, and I offer many more in the book. Think about it: if you’re diabetic, you have to understand how diet plays into your condition, and hygiene [for blood tests and insulin monitoring], and a host of other things. Because ADHD is a chronic disease I sometimes refer to it as the diabetes of psychiatric conditions.

Step Four is to get on medication. Medication is the best treatment for ADHD. And I’m saying this as a psychologist—there is no longer any “us versus them” going on between psychologists [who typically do not prescribe medication] and psychiatrists when it comes to ADHD treatment. Medication is two to three times more effective than behavioral methods alone for treating ADHD. Most adults with ADHD, 80-90%, need medication as part of the treatment package. Family members can help their loved one remember to take their ADHD medication regularly.

Step Five is behavior modification. Cognitive behavioral therapy (CBT) boosts the benefits of ADHD medication for self-control and executive functioning. Outside of formal therapy, there’s a lot family members can do to encourage their loved one to adopt exercise routines and other healthy habits. Often times people with ADHD need to get additional treatment to cut back or eliminate their use of alcohol, tobacco, and marijuana.

Step Six is accommodation. This means altering the environment so the person with ADHD is more likely to succeed. It might mean dedicating one computer for work only and another one for games and social networking. Family members can help their loved one find and download software that blocks distracting content. At home and on the job, adults with ADHD can advocate for themselves by finding support people to keep them accountable for changes they want to make and goals they want to accomplish.

A new type of accommodation that’s becoming more popular is called ADHD coaching. An ADHD coach makes daily contact via text or other channels to help the person stay organized, cope with frustration, and/or work through social problems. The field of ADHD coaching is still developing and is beginning to police itself. Some people are coming to ADHD coaching from financial planning or life coaching and are not currently held to a specific standard of knowledge or experience within psychology or behavior modification. I expect within five years certification requirements and accreditation for ADHD coaching will be in place.

 

Note: The opinions expressed in this interview are those of the author and should not be taken to represent the official views or policies of the American Psychological Association.

 

Roberta Golinkoff and Kathy Hirsh-Pasek: On Becoming Brilliant

This is the latest in a series of interviews with APA Books authors and editors. For this interview, Susan Herman, Development Editor Consultant for APA Books, talked with Roberta Golinkoff of University of Delaware and Kathy Hirsh-Pasek of Temple University and the Brookings Institution.

Note: The opinions expressed in this interview are those of the authors and should not be taken to represent the official views or policies of the American Psychological Association.

golinkoffRoberta Michnick Golinkoff, PhD, obtained her bachelor’s degree at Brooklyn College, her PhD at Cornell University, and was awarded a postdoctoral fellowship at the Learning Research and Development Center of the University of Pittsburgh. She is the Unidel H. Rodney Sharp Professor of Education and professor of psychology and of linguistics and cognitive science at the University of Delaware.

hirsch-pasekKathryn Hirsh-Pasek, PhD, is the Stanley and Debra Lefkowitz Distinguished Faculty Fellow in the Department of Psychology at Temple University and a senior fellow at the Brookings Institution. Her research examines the development of early language and literacy, as well as the role of play in learning. With her long-term collaborator, Roberta Michnick Golinkoff, she is the author of 12 books and hundreds of publications.

“I enjoyed working with this dynamic author team on their APA LifeTools book, Becoming Brilliant: What Science Tells Us About Raising Successful Children.  (The book has been widely discussed in academic circles and national media, and is already an Amazon bestseller.)  One of the reasons I enjoyed it so much is that I felt like the book was actually for me: a mom to two school-age kids! Also, I loved getting emails like this: “We’ll get back to you soon about the edits. We’re away at a conference now and Kathy is filming her flash mob this afternoon.” –Susan Herman

How long have the two of you been collaborating?

KHP: Roberta and I have been working together 37 years. We have lasted longer than most marriages. We would have each been good as solo scientists, but when you have a wonderful working relationship it actually feeds creativity. And I think it also feeds the product.

How did you come from developmental science, primarily working with young children, into looking at school-age children and what’s happening in K-12 education?

KHP: The book isn’t only about K-12. It really is about 0-99. If we want to prepare an educated citizenry of the future, we need to think not only about what’s going on in the schools but also what’s going on outside the schools, in the communities in which children live. If we think of education as only taking place inside the school walls, then we’re missing literally 80 percent of the waking time of children.

This book is really more about redefining education for the 21st century. It poses this central question: what counts as success? When our children grow up, what do we want of them as a society?

What I believe the 21st century answer ought to be is: we want happy, healthy, social, caring, and thinking children today, who are going to grow up to be compassionate, collaborative, critically thinking, creatively innovative, and responsible citizens of tomorrow.

What skills do you need to achieve that? You have to work backwards, reverse engineer it. The business community has been screaming for this for the better part of a decade. We want to reduce inequities and we want [education] to dovetail with the skills you need in the workplace.

Do we want to let [standardized] tests tell society what we can and cannot value? Or do we want to figure out what we value and find ways to see how children learn?

 

I saw an ad for an online learning company that says, “Each child is uniquely brilliant.” Is brilliant a buzzword now? What does it mean to be brilliant?

RG: We’re not about making people exceptional. We want to call attention to the fact that children have a vast range of capabilities, and while we’re mostly teaching content in the schools—and content is great, it’s got to be there—we must broaden what we do.

Because in this new world, it isn’t enough to be brilliant in the classic sense of getting straight A’s. Those people don’t necessarily get the jobs now. What matters for kids is to develop all the skills that will help them be better people.

For me, that’s number one—I want to create menschen. I want to create citizens who are members of their community and who play well together, who will function at a high level in their society. We want to help children get the jobs of the future.

For example, if we’re talking about how manufacturing plants are shutting down and the jobs are moving overseas, we’re not getting it—the nature of the workforce needs to change! The jobs that are going overseas are factory jobs. The jobs that are taking over in America are the high-level jobs.

We need to help our children find the jobs of the future, many of which haven’t been invented yet. We need to educate for the higher-level jobs that we are presently importing people to do because we don’t have enough people who can do them.

In your book, you conceptualize learning as consisting of six skills, the “Six C’s”: Collaboration, Communication, Content, Critical Thinking, Creative Innovation, and Confidence. How do you measure the Six Cs?

KHP: Roberta and I suggest that we can give you a profile of skills, using our Six C Grid [shown below]. What’s cool about the grid is that every one of us can look at ourselves and create a profile for ourselves on the six skills.

 

6 Cs6 Cs

Collaboration is how we learn to communicate. Content builds on communication, our ability to listen, to talk, to have a vocabulary. You’re never going to be a great reader if you don’t have good language skills. And yet we’re starting our tests with reading, not with language. You can do letter-sound correspondence until you’re blue in the face but if you can’t translate sounds into a word that you know, then all of it is moot.

We have too much information—everybody’s talking about big data. But if you can’t sift your way through, then you’re not going to be able to use the content effectively.

Creative innovation teaches you how to use that content that you just critically thought about. So you can use that information to change tomorrow.

Kids need confidence to give it a whirl. We have beaten children into just giving us right answers. The creators of the world—the Edisons, the Steve Jobs—they failed many times before they succeeded.

None of these exists in a vacuum. They build on one another to create a profile of learning.

RG: We’re not arguing that we need a new curriculum for the Six Cs. We’re taking the position that, once you’re aware of these skill sets, you can think about how the assignments you’re creating for your class are building collaboration, confidence, creativity.

Let’s talk about Confidence. One recurring conversation I have with friends who are parents starts with, “Do you let your kid…?” Ride his bike to the park alone? Set up her own YouTube account? That kind of thing. How can parents leverage risk to help their kids build confidence?

RG: The New Albany, Ohio chief of police is now advising parents not to let kids go outside on their own until they’re 16. This is crazy, but not uncommon. This sort of thing happens nowadays for two reasons. One, no one goes on the news and says, “Sally had a good day today. She walked to the library by herself!” The media focuses on the bad stuff and this is the kind of stuff that goes around [on social media].

Two, parents are more fearful. Economic shifts have been profound in recent years and have made people worry that their children will have lesser lifestyles than they did. And this makes them focus more on stuffing that content in the kid, over developing the other skills that kids need.

The way it should work is that little by little, children are given more responsibility for taking care of themselves. Doing errands is the first kind of responsibility, and your kid will want to do it because it’s a way of showing that they’re growing up. Of course, you first have to have a conversation with your kids about how to not go with strangers, and about how to use other adults to help you if someone’s bugging you.

KHP: What do you do when your kid comes home [from the errand]? He has an essay for homework. Do you allow your child to have his own voice, as long as he backs it up? Or does he stick pretty close to the book review he’s supposed to do, “This is what A says, this is what B says…” Push him a little further and say, “what’s your take?”

You encourage him to try that experiment. As long as it’s safe. I remember something my kids wanted to do—they wanted to put water in the sink and add electricity to make a lightning bolt! Other than that one, I was OK with [their experiments].

When your child comes home from soccer and says, I don’t want to do that anymore, are you the kind of person who says, “OK well we’re not going back there anymore!” The lesson, when you stay with it, is confidence.

Everything’s a risk-benefit. Some things you may not want them to take apart, like the television. But you can say “We have this old blender—why not take apart that and see how that works?” Or you can say, “there’s this guy who’s been repairing watches forever. Why not go see what he does?”

How can parents advocate for their schools to teach the Six Cs?

KHP: You can evaluate your child’s classroom based on the Six C grid. The grid becomes almost like a map for us to ask, how are we doing as parents? What do we want from our children? How are we providing opportunities to allow them to get to that goal?

RG: Each chapter in the book has a section called Taking Action where we talk about how to create environments that foster each skill, and we give very concrete suggestions. [We want] to awaken parents’ consciousness to what they need to do to help their children be good, productive people.

And we don’t need to keep it a secret from our kids. We often don’t even talk to our kids about the kinds of things we hope they will get out of school. We can tell them why we want them to do x, y, z. We need to let the kids in on it, have this pervade the culture. It would be so much better than just emphasizing the content, which is giving kids stomachaches when they take these high stakes tests. It’s a culture shift that we’re going for.