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“ADHD Telehealth Trades Convenience for Accuracy and Nuance”

“Subtle non-verbal communication reveals how each parent feels about their child’s diagnosis or treatment much more than what they say.”

By Walt Karniski, M.D. Updated on July 16, 2024
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The following is a personal essay reflecting the opinions of the author.

A few years ago, Michael, a nine-year-old boy, was brought to my office by his parents. Mom and Dad seemed comfortable when I greeted them in the waiting room, and they easily conversed as they followed me back to my office. They joked with Michael, and he appeared at ease.

After talking for a few minutes, I asked them, “So, why did you bring Michael to see me?

“The teachers say that he has a lot of trouble staying focused in the classroom,” his mom responded. “They say that he is very bright but doesn’t do well on tests because he rushes, doesn’t check his answers, and seems to stare off. Often, he only completes half of his tests. While he answers questions correctly, he fails the test because he does not complete it.”

At this point, Dad spoke up. “Wait a minute, Gayle. You know my mother told you I had the same trouble in school, but I turned out fine.”

I would have missed it had I not been sitting directly across from her, but it was at this moment that Michael’s mom rolled her eyes.

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After some testing and discussions with the teacher, Michael was diagnosed with ADHD. However, over the next five years, his father resisted the idea of treating Michael with ADHD medication, even though he responded extremely well to it, with minimal, non-serious side effects.

Dad also frequently “forgot” to give Michael his ADHD medication. If I had missed this earlier warning, I am sure I would have eventually picked up on Dad’s resistance. But the point of this story is not that Michael’s medical care would have been compromised had I missed the eye-rolling. It is that every person emits hundreds of these small, non-verbal communications every hour. And all of us, including physicians, unconsciously interpret these communications, usually accurately. Telehealth interferes with those subtle cues, which may result in a patient’s misdiagnosis or inappropriate treatment decisions.

Pros & Cons of Telehealth Evaluations for ADHD

There are certainly advantages to telehealth medical evaluations for ADHD. For one, they are relatively easy to set up. They eliminate the need to travel from home to a clinic or office, which can be problematic for some. For patients who do not have a steady income source, these evaluations also may be less expensive than in-person evaluations.

Regardless, there are serious concerns about the accuracy of telehealth evaluations. Since there are no blood tests, specific laboratory findings, X-ray findings, or diagnostic findings on a patient’s physical or neurological evaluations, the diagnosis of ADHD usually depends on a patient’s (or their parent’s) self-reporting.

[Free Directory: ADHD Specialists Serving Patients Near You]

This has proven problematic — and, in some cases, fraudulent. In June, the Justice Department charged two executives at the telehealth company Done Global with allegedly distributing Adderall and other stimulants for ADHD to patients without a proper diagnosis. Done reportedly made ADHD diagnoses based on a patient’s minute-long self-assessment and a 30-minute or less virtual evaluation with a provider.

A Better Way to Evaluate ADHD

Most pediatricians will evaluate their young patients with one parent in the room. I strongly encourage both parents to come to the initial evaluations and follow-up visits.

During the 40 years that I have evaluated patients for ADHD, I have noticed that subtle non-verbal facial expressions and messages reveal much more about how each parent feels about their child’s diagnosis or treatment than what they say. These cues could be easily missed during a telehealth evaluation.

For example, I met Danny several years ago. His mother sat in front of my desk, with Danny to her right. He appeared uninterested in our conversation but was in a good mood and smiled occasionally. While his mother spoke, Danny fidgeted, looked out the window, moved around in his seat, and interrupted occasionally.

When I asked Danny’s mom what her biggest concern was, she said, “Well, he is highly intelligent, but he has a tough time staying focused and quiet in school. As a result, he has a difficult time learning. He is very scattered.”

So, I asked my usual questions: When did this start? How was he doing in school? How were his grades? How did he get along with other kids?

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She tried to answer each question but became visibly frustrated. Her voice quivered, and she seemed on the brink of crying. Then, she stopped talking and reached into her bag. She pulled out a brightly colored, ragged spiral notebook and handed it to me.

“Danny’s teacher uses this calendar notebook to communicate with her students’ parents,” she explained. “The teacher will write a short note about how Danny did that day. I can write a response or ask a question. The notebook goes from home to school and back again daily.”

Later that day, I started reading the notebook. But by the time I got to the third page, I felt tears in my eyes.

I didn’t need to continue reading to know what was in the rest of the notebook. I was so used to treating children with behavior and learning problems like a detective, objectively analyzing the facts, that I had forgotten what it felt like to a child and their parents. Suddenly, reading this notebook, I could tell exactly how Danny and his mother felt.

If I had used telehealth, I might have received the notebook eventually, but I would have missed how Danny’s behavior affected their lives. I might also have seen Danny’s mother’s tears on the computer monitor. However, my bigger concern was what I may have missed and how that could have affected Danny’s diagnosis and treatment.

Telehealth ADHD Evaluations: Next Steps

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