Activity Transcript

Andrew J. Cutler, MD: Hello. I'm Dr Andrew Cutler, clinical professor of psychiatry at SUNY Upstate Medical University in Bradenton, Florida. Welcome to this program titled, "The ADHD Care Transition from Adolescence to Adulthood: Tips for Lifelong Management."

Joining me today are Dr Birgit Amann, who is the medical director and founder of the Behavioral Medical Center in Troy, Michigan, and Dr Greg Mattingly, who is associate clinical professor of psychiatry and behavioral neuroscience at Washington University School of Medicine in St. Charles, Missouri. And Jeanne Kelly, who is here to provide the parent perspective on attention deficit hyperactivity disorder (ADHD) and the challenges that patients and their families face over time. Welcome everyone.

Let's start with an overview of ADHD, and particularly as it pertains to transitions through the lifespan. As we know, ADHD is a highly genetic and heterogeneous disorder, clinically, as well as biologically. We know that disease burden as well as comorbidities, treatment considerations, and challenges change over the lifespan. For many patients, there's a lifelong need for care. The transition of care is what we'll be focusing on today, from pediatrics through adulthood, especially focusing on that difficult, challenging time of adolescence when there are so many transitions going on, as we'll hear about in a minute.

We know that we need to have a fluid sense of treatment -- we need to adjust our treatment to optimize outcomes and especially maximize adherence (which can be a challenge over time) for the treatments to be most effective. We know, as well, that there are many benefits of patients staying on their treatment as the patient ages over time, and we know that for many patients who are untreated, the negative outcomes can progress and become even worse over time.

In addition to the obvious morbidity that patients face and the impairments in function and quality of life, what is also surprising, and in some ways shocking, is the data that you see on this slide here, which shows that there is a significant mortality associated with ADHD. As a matter of fact, having ADHD alone increases your mortality rate by 1 1/2 times compared to the general population, and it gets worse when you add in comorbidities. For example, with ADHD and 1 comorbidity, the hazard ratio (HR) or the risk of mortality increases by more than 4 times. If you throw in a second comorbidity, it increases by 8 1/2 times and 3 comorbidities is over 15 times the mortality rate.

This again is very surprising data and I would say it should be clarion call to us, along with the impairments in function and quality of life, of the urgency to evaluate and manage and treat this condition aggressively.

Let's quickly look at an overview of ADHD progression, clinically and biologically. Clinically, what we know in childhood is ADHD is predominantly behavioral disinhibition, with emotional lability and predominant hyperactivity, as well as speech, language, and motor coordination problems. As patients age, you start to see psychiatric comorbidity, including depression and anxiety and oppositional and conduct disorders. We see problems with school, problems with peer rejection, and neurocognitive dysfunction.

Into adolescence, we start to see some other challenges as well, including the need to function more independently, manage a more complicated schedule, smoking and exposure to alcohol and drugs become issues, and driving becomes a challenge. As we move into adulthood, what we find clinically is that the cognitive demands become greater, and so the inattentive symptoms are especially challenging. Overt hyperactivity decreases and we still see some impulsivity, but the hyperactivity tends to go internally as a sense of restlessness. Substance abuse, low self-esteem, and social problems become an issue. Marital, relationship, family problems, forensic issues, poorer quality of life, and accidents and traffic violations are more common as we know.

As I mentioned earlier, if not treated, for many patients the outcome can get worse over time. As far as the etiology and pathophysiology, we know that ADHD is highly genetic. There's a great genetic predisposition, which can be modified by epigenetic and environmental factors. Also, we know that fetal exposure and birth trauma can be involved. We know from a biologic point of view that there are functional and structural brain abnormalities that can clearly be demonstrated even in childhood. We know also, as we follow over time, there's a persistence of cortical thickness, default mode network, and white matter track abnormalities. This is clearly a lifelong and progressive illness, so let's lay the groundwork for success during transitions. Jeanne, what kinds of things do we need to pay attention to during the different stages of life and the different transitions?

Jeanne Kelley: As a parent, you want your child to feel comfortable going to a doctor's office. When they are first told we're going to visit a doctor, and especially a psychiatrist or clinician, it's important to make them feel familiar and involved and communicate from day one. So, as they transition -- get older and have more issues in junior high and going through school -- they feel comfortable talking to the clinician, the doctor, the psychologist. That setting the grounds in the very beginning is starting the success that will continue throughout their high school and college if they choose to go to college.

Greg Mattingly, MD: I know Jeanne felt this way with her own child, but it's building on the strengths of the child. It's easy to focus on the weaknesses, it's easy to focus on the struggles but, if you're not careful, you'll demoralize the kid and demoralize the parent. So, I'll quite often ask a parent, "Tell me the 3 things you love the most about your son. Tell me the things that you're most proud of with your daughter."

And then when we talk about school with the child, I'll talk about, "Okay, you're going from grade school to middle school. What are the cool things about middle school? Middle school -- you get to change classes. You're going to get to make other friends. Maybe you get to start choosing some clubs that you can be a part of. But what are some of the challenges that we have to think about with middle school? Multiple homework settings, having to keep things more organized."

Transitioning to high school -- all of a sudden, now, maybe I'm driving a car. I'm starting to date. There's peer influences. We know that in childhood, your parents are your primary influence but, by the time you're in high school, it's your peer group that's your primary influence. Then transition to college is a place where we lose a lot of our kids.

We know that 2 out of 3 kids who were in treatment in high school will get lost when they transition to the college age at times. So, how do we as practitioners and how do you in primary care think about who you are going to hand the care off to? Maybe it will be a university physician, maybe I'll continue the care, or maybe it's going to be an adult colleague who takes care of adult ADHD. Then, the transition into adulthood, when you're now a parent. You have to take care of your kids; you have to multitask. Maybe you have to learn how to parent with ADHD, and maybe you have a child with ADHD. So, kind of preparing for those transitions in a way that life can be successful.

Dr Cutler: I like it, but what are some of the barriers and concerns at these different stages? Birgit, what do you think?

Birgit Amann, MD: There are many barriers and concerns potentially with each of these stages. The disease burden itself, Andy -- it's a 24/7 condition, and the symptoms fluctuate throughout the course of the day. Depends on the demands of the day, depends on the structure or lack thereof, and the support or lack thereof. And then, there are a lot of patients who are apprehensive about starting treatment, and that can be at any age. It might be, "I don't want to go on a medication." or, "How long do I have to be on this medication? What are the side effects? What am I going to feel like? How much is it going to cost me? Wait a minute, these are medications are federally controlled. What does that mean?" There are a lot of rules and regulations around them.

We also have to monitor along the way for age specific co-morbidities. Things can change over time, so we should continually ask about them and then treat appropriately. Our patients tend to stop their medications, unfortunately. Meds don't work if we don't take them, and I remind patients all the time, often adolescents, "I can help you as much as you let me." So just reminding them that this is 24/7. The brain likes consistency. That's really important. In addition to general continuity of care, so making sure I have those properly placed follow-up visits to monitor appropriately.

Dr Cutler: Greg, what are some challenges and gaps specific to primary care?

Dr Mattingly: Once again, with challenges and gaps -- I would think that transitions can be a challenge. It's a place where the kid can fall apart. They get to middle school, and it's not just cognitive issues, but self-esteem issues. But those same gaps, those same transitions, are also the opportunities for success. So, how do I help the child now start learning about, "What does ADHD mean within my life? Up until now, it's been mom and dad helping to explain it to me, but now I'm starting to understand what's it like making friends while having ADHD? What's it like dating having ADHD? What are the things in life that I find rewarding to myself?" As a primary care physician, you think about it from the child's perspective and from the family's perspective.

Some of the challenges can be time constraints. We know that ADHD can be scary to some primary care physicians but, once you learn how to manage it, you can do it very effectively with rating scales, listening to the child, getting input from the parents, and thinking about medication changes. A little bit later, we're going to talk about how medication will likely change as a child grows and gets older. You may want a medicine that lasts longer. You may want to transition from a methylphenidate to an amphetamine. Most adults and most adolescents will take a long-acting amphetamine preparation.

I think the last challenge is that we go from a place where mom and dad give us most of our structure. Now, the child has to learn to provide their own structure as they become an adolescent, as they go to college, as they go off to university. So, the handoff in each of those transitions is really important.

Dr Cutler: Birgit, how can we address some of these challenges?

Dr Amann: Some of them are logistical challenges. The primary care provider has a very limited amount of time, as Greg mentioned. They may only have 10 minutes and, within that 10 minutes, they need to address both the medical, as well as oftentimes, the psychiatric treatment of ADHD. And because it's in such a short period of time, the patient or the parent of the patient, can feel like they've been dismissed. Or that the doctor isn't listening, and we talked about a side effect that we really are uncomfortable with.

So, just try to make sure that they're comfortable communicating their concerns but that they understand that that primary care doctor does have to do many things within that short time. It is definitely a challenge. Remind them that we shouldn't stop medication in the summer or on the weekends -- those transitions in life are critical to continually address throughout the year. And then look at, as Greg said, what changes are needed in their medications -- if they need a longer-acting medication, for example -- as the challenges get greater and their days get longer.

Dr Cutler: Birgit, how can we help families anticipate and prepare for these transitions and changes?

Dr Amann: I think it's about setting expectations. We have to talk to them about helping their child turn into an adolescent and into an adult. When they're younger, parents are much more involved and should be, such as, in elementary school, looking at the school website and making sure assignments are handed in and helping things be very organized. But as they transition into middle school, the expectation is that middle schoolers should be more involved. I like a 50/50 where mom and dad should be looking, and the adolescent should be addressing and monitoring things that need to be turned in and everything else to optimize their success.

By high school, parents should do more of a once-a-week check -- kind of that safety net -- while that high schooler should be taking care of most of that on their own. If the parents do most or all of it, they are not really helping them and are doing them more of a disservice because, by the time they're adults, they really need to be able to do all of that on their own with their job or whatever else is involved in being an adult.

Patients need to talk about and make sure with their provider that their medication is doing what it needs to for the amount of day that they need coverage for, which is most of the day. Fortunately, there are a lot of different pharmacologic options but, Andy, there are also a lot of important non-pharmacologic strategies and coaches to help them with organization, which is important at any age.

Dr Cutler: Certainly is.

Dr Amann: Telemedicine has really become a critical part of physician and provider care for patients during the COVID-19 pandemic, but many of us feel that, moving forward, this will actually be very important. For example, as our college students go back to school, we will now be able to utilize telemedicine to have better continuity of care where, prior to now, we might've had to secure a provider on campus. We may need that, on occasion, but less often because we can utilize telemedicine.

Dr Mattingly: Telemedicine, in one form or another, is probably here to stay, and I think we're going to use it to bridge the gaps in transitions. I've been a part of a number of different task forces, with the World Health Organization and with the American Psychiatric Association, during this time. We know that, especially in the pediatric arena, visits are dramatically down. People aren't coming in for live visits. They're afraid of their child contracting something. The good news is, ADHD treatment has actually gone up during this period of telemedicine. 85% of prescriptions during the COVID pandemic, over the last 3 months, have been prescribed by telemedicine. As Birgit said, I'm going to use telemedicine for kids that can't come to see me. I'm going to use telemedicine for my university students -- I'm going to see all my kids going off to college 2 weeks into their first semester. I'm going to use it as a tool to help bridge the gap in a way that is very preventative for a lot of my university students.

Dr Cutler: COVID-19 has changed the way we deliver healthcare, and I think we're entering a hybrid world where there'll be some combination of live visits and telemedicine, as you're saying. Greg, you published an article highlighting some of the different ways of thinking about treating during these various transitions in life. Could you summarize for us a little bit of what you found?

Dr Mattingly: Certainly. This is an article that just came out this year, so this is breaking news for the group. But we just talked about it -- from a clinical perspective, what should we think about as a pediatrician, family medicine doctor, or as a child psychiatrist that changes over time? We know that in young school-aged children, ADHD is more common in boys vs girls (~2:1). We know that changes so that, by the time you're an adolescent, it's almost 1:1. And during adult years, we actually see more women coming in for treatment with ADHD than men. So, the misnomer that it's only boys, we know that's not true, but we know that boys are a little more common when they're younger. We know that a lot of times what is observed at first is school performance and or comorbidity with temper. "I can't control my temper, I can't modulate my temper" -- we may call this thing oppositional defiance disorder -- or "I'm falling behind in school" can quite often be the presenting complaint.

The recommended treatment for school-aged children in the grade school setting is psychotherapy plus medication. It's been shown consistently to give the best outcomes in some large studies, such as the MTA study. We want to have family therapy on how to manage this, but then we also want ADHD treatment. Given the variety of treatment options, what is considered first-line treatment for school-aged children is methylphenidates, a long-acting methylphenidate, because it has a little bit lower side effect ratio vs amphetamines. So, we tend to go with methylphenidate first, and then we progress to amphetamines or non-stimulants when the methylphenidate isn't giving us our desired outcome.

By adolescence, things started to change. By age 13, we know in the United States, it's a 50/50 world between methylphenidates and amphetamines and, from age 13 onwards, it's primarily long-acting amphetamines that are going to be your treatment of choice for your patients. So, 50/50 at age 13. Part of that is cognitive challenges increase. We know the day gets longer. We know that inattentive symptoms start to dominate. You're not as hyperactive -- Andy, you brought it up -- you're not as restless, you're not running around the room.

What I will say that we can miss a lot in adolescents is impulsivity: "I blurt things out. I do things without thinking about it. I take risks before I think about the precautions." So, difficulties with driving accidents, unwanted teenage pregnancies, blowing up at the boss and telling them off before I think, "Hey, maybe I should stop and think before I do that." So, inattentive and impulsivity symptoms. We also noticed that adherence becomes increasingly difficult during adolescence so, for first line-therapy, a long-acting amphetamine preparation is considered by the time you get into your high school years. If your patient can't tolerate a long-acting amphetamine, then you're going to consider a long-acting methylphenidate. And if that isn't the treatment of choice, you're going to think about the nonstimulant preparations by college age.

Now, we're thinking about kids going off to college and having to self-actualize -- "I have to manage my own day. I have to get up. I have to structure my day, and I'm exposed to a lot of risks." Peer group has changed. Living independently has changed. The biggest mistake I see made in the college age setting -- and I know Andy I've talked with you about it and, Birgit, we've talked about this -- this is not a group in which to use short-acting stimulants.

Short-acting stimulants get misused and get diverted. It's not a matter of if they're going to, it's just what percentage of bad things will happen to them. You put your kid at risk of having their dorm room broken into and having somebody take their medicines. So, consider long-acting once daily medications to make things easier. And it's not just the medication but also structuring your day. Get up at a certain time, get to bed at a certain time, and chunk your classes and your learning. But your medicine is a tool that's going to help you to be successful.

Finally, by the time we get to adulthood -- and I think Andy brought this up and Jeanne brought this up -- at this point, I'm talking about relationships. I'm talking about holding a job. Comorbidities start going up, and I think one of the most important slides we've talked about today is, as comorbidities go up, it's not just about feeling bad, but mortality rates go up. So, if I let somebody become demoralized and they develop depression on top of ADHD (eg, a mom that develops anxiety on top of ADHD), it's not just that she struggles, but her rate of not making it go up -- mortality rates due to suicide, accidental injury and, for women, domestic violence.

All of those things go up as you start stacking comorbidities. So, treatment is not only about the here and now, it's about helping prevent negative outcomes in the future, especially when we talk about adults. Long-acting once daily amphetamines have been shown to have the best efficacy versus side effects. If those don't work, we typically go to long-acting methylphenidates and, for people where we can't use stimulants at all, we'll think about the nonstimulant medications.

Dr Cutler: And of course, as people age, medical comorbidities start coming in and more and more as well as medications with the risk for drug-drug interactions. This is where primary care doctors are ideally placed to monitor and perhaps manage the whole patient, as we've been talking about. So, getting comfortable treating ADHD or certainly getting comfortable with having a referral relationship to a specialist would be very important. Speaking of that, Birgit, can you talk a little bit about the roles of the team in this comprehensive management and coordinated care?

Dr Amann: Absolutely. Coordinated care and shared decision-making are really critical in comprehensive patient management. For example, when we have a child or an adolescent seeing their pediatrician, that pediatrician and the prescriber -- whether it's a psychiatrist or a nurse practitioner -- should be in regular contact. Additionally, we can't minimize that the psychiatrist or nurse practitioner should be in regular contact with the therapist, and both should be in regular contact with the schools, or the coaches, or whoever is working with the patient, as a multidisciplinary team.

And, because we've said many times that this disease or condition continues into adulthood, it's critical for that continuity of care and communication to also continue. So, that child or adolescent will turn into an adult and has to transition from the pediatrician to internist or family practice doctor and needs to make sure that all providers are still in communication. Jeanne, I'd like to ask you to share a little bit about the challenges that you experienced with your son as it relates to that transition.

Ms Kelley: I think it's hard for every parent to release their child to help them make their own decisions and, as they get older and especially in high school and college, this is something that will be really helpful for them in life. I think setting small goals in the beginning. I mentioned earlier about getting your child involved with going to the doctors and feeling comfortable with doctors; from my experience, having that communication is key.

You had mentioned earlier about the different medications as you get older. I have a story. When my son started college, he got really bad anxiety -- he was already taking Adderall, but the first day of college he felt really anxious, and it was important for him to be able to call his doctor right away to stop him from getting more anxious. He got on some medication that stopped his anxiety and, after a couple of weeks, he stopped it but was still taking his Adderall.

I want to stress that a lot of times we say that kids stop taking medication because they think they're doing okay -- but that's not always a negative thing. My son took medication in junior high, and he took it in high school. He did stop, but then on his own he found out, "Hey, this really is helping me." That was good for him to find out on his own instead of adults and parents and doctors saying, "You need this, you need this." Sometimes they really need to say, "This is what's happening to me, and they're right.", and that helped him throughout college and the rest of his life because he did learn that maybe what doctors are telling him is true.

Dr Amann: Absolutely. Thank you for sharing that. It's wonderful that he had the wherewithal to understand that the medicine helps him and that he really needs it. I think a critical part of that is really involving him much earlier in the conversation at the doctor's office.

I'd like to share a little bit more about that. For me, for example, with every office visit I start with the child or adolescent giving input. It's so critical to ask them -- when they're able to give sentences back to you, say to them -- "what is working well for you?" Or just, "How are you today? What are you good at?" Help them find some of their strengths. "What could improve? What are 1 or 2 things that you hope could get better with your medication or with your therapy?" Start with them. I've done that since I started my practice.

Then ask the parents. They'll give you plenty of wishes that they'd like to have improve, but it's the child or adolescent's body. They need to understand why they're taking a medication and what the goals are and, as they get older, it really helps to set the stage for when they come to those medication visits alone. They've done it, they've practiced it, and mom or dad aren't there to help manage that visit.

If we look at a slide that looks at pediatrician visits, you can see that 64% of words spoken were typically by the pediatrician, 28% by the parent, and only 8% by the patient, despite it being their body and them that everybody was talking about.

Andrew, you mentioned that earlier, how you thought it was very critical to include your son in his treatment regimen so that he could understand it and be involved in it. When the pediatrician questions the parent, 71% of the conversation is directed at the parent and only 29% at the patient. So, I think we can all take a step back and remind ourselves who the patient is, and make sure you're getting input from them and include them.

Dr Cutler: Greg, you were involved in this study. Maybe you could share a little bit of your experience here.

Dr Mattingly: Yes. I've done hundreds of studies in the last 25 years. This is probably the study that has changed my practice more than anything else. We videotaped really good pediatricians and child psychiatrists doing ADHD evaluations with families, and it hit us over the head that we were all making the same mistake. Instead of talking to the kid, we were talking to the parent, and you'd see the child almost shrink as they were sitting during the visit listening to mom and the doctor talk about all the kid's mistakes (eg, where he wasn't doing well, where he was struggling). We'd see these kids pulling away.

Jeanne, I thought about -- if you start a visit with the doctor and the mom talking about all the things you're not good at, all the places you're having problems -- how do you feel about it when you're a teenager and now you get to have a voice about staying on medication? How do you feel about coming back to see that doctor? How do you feel about yourself? How do you feel about having ADHD?

What we found is the best outcomes were the ones where the ratio was flipped, as Birgit said. So, instead of directing the questions to the parent, direct the questions to the child. "Jimmy, Susie, tell me about you. What do you like doing? What are you proud of within yourself? What's a good day like? What's a tough day like? When do you struggle? What are the things that are challenging that you want to work on together?" So, directing the question to the child.

Then, when you're done with that, come back and let the parent tie it together for you. Even there, when you're tying it together with the parent, if the parent starts with a series of negatives -- "Well, Jimmy is in trouble. He blurts out. He's not doing well in school." -- pause and say, "Okay, but tell me the 3 things you love most about your son or daughter. Tell me the things that you really love about your child." to set the tone in a way that's going to be successful as we go through these transitions in life with our kids.

Dr Cutler: I'm hoping that some of this information we're providing will help our primary care colleagues to manage ADHD but, Birgit, there are times when they must think about referral. Can you give some tips for a PCP as to when they might think about referring?

Dr Amann: Absolutely. We need our primary care clinician colleagues to be comfortable treating simple ADHD or maybe ADHD and one comorbidity. But it's very reasonable for them to say, "Okay, at this point, I've exhausted the medications that I'm comfortable with," or "I know that as the number of comorbidities increase, the mortality increases. I really need to refer this patient out." Maybe the patient has autism traits or autism spectrum disorder, and they don't feel comfortable with that. Or they don't have the resources that the patient needs. Perhaps there's a strong family history of mood disorder and they're concerned, "What if I miss a bipolar disorder?" That could be quite serious. What if the patient has suicidal ideation? Then, of course, you want to make sure that you refer out, and they get the proper treatment.

It can be a variety of things, but it's important to understand that it's okay to make that referral. Make it when you feel you've exhausted your comfort level or skill set. Maybe suggest it a couple of months early, as a tip -- only because schedules can be hard to get into -- so that they can make that transition as smoothly and quickly as possible.

Dr Mattingly: Birgit, that referral can be, not just to a psychiatrist but to the school team who can do testing with the child or to a therapist in the community who can provide family therapy, which is quite often needed with these children. It can be for speech and language. I have a child with developmental disabilities, so speech and language therapy and occupational therapy. That's how you coordinate care for your child to help give them a chance for the best success going forward.

Dr Amann: Absolutely.

Dr Cutler: Jeanne, as we think about the totality of what we've been talking about here, what would you like healthcare providers who treat ADHD to know from a parent's perspective or based on your son's experience?

Ms Kelley: Well, I just thought of something. You were saying that when the child visits the doctor, you have him speak. I think besides mentioning the positive things and the things that can help him, there's a lot of other things that doctors can mention. I know my son was told about exercise and diet, to give him the whole perspective, and exercise made a big difference for him. When a doctor told him, "If you exercise every day, it will really help you release a lot of your anxiety." that just clicked. He thought, "Well, I will do that every day.", and he was adamant about sticking to it and the diet too.

I said he was very anxious when he started college and having the medication, in combination with all the other helpful things, made him feel more confident and made him feel like he could succeed because he had good help -- a good doctor and a good organizer. I found a college organizer who helped him take little steps in his life. People get overwhelmed -- everyone, but especially people with ADHD -- thinking, "Oh my gosh, I have to tackle this big thing." Even in high school, baby steps really helped, and I think having the right people in his life made him feel confident. He had more self-esteem, and ADHD was not a bad thing.

I also learned that kids and adults who have ADHD have an insight into themselves. They probably know themselves better than somebody who doesn't have ADHD because they've had to work hard to find out what works for them, and it's really important to have that understanding.

Dr Mattingly: Andy, you and I have talked about the myths of ADHD. It's something we haven't mentioned, but I think it's important. One of the myths of ADHD is to try a test dose of medicine or, "I know I have ADHD because I took my roommate's medicine." That is not a diagnosis.

The other big myth that we haven't talked about is only taking your medicine when you think you need it. Studies have now come out showing that the best outcome is consistent, ongoing treatment of ADHD. I was taught when I was in medical school to take medication holidays, to not take it on the weekends, and maybe don't take it in the summers. What we found is that tends to lay the groundwork for disaster.

The best outcomes are with consistent treatment. ADHD doesn't go away when you're driving a car, when you're going on a date, when you're holding a job, or in your relationship and your marriage. Consistent, ongoing treatment has been shown to decrease morbidity, accidental injuries, and car wrecks. Adults who are impulsive are 4 times less likely to have a car wreck when they're taking their medicine versus when they're not taking their medicine. So, consistent, ongoing treatment is really important.

Dr Cutler: Yeah, I agree. This has been a fascinating discussion but, unfortunately, we're out of time.

I'd like to summarize by saying that ADHD is a lifelong disorder in which the clinical presentation, comorbidities, and impairments can change over time, and life can become more complicated. The transition from childhood to adulthood, particularly in the adolescent phase, is challenging, and continued treatment, as Greg said, must be considered. As Birgit has told us, we need to really think about adjusting and tailoring this treatment to the individual's needs and to their situations in life. Impairments and negative outcomes, unfortunately, can get worse if not addressed as well.

I think it's also helpful to anticipate and prepare for transitions, as Jeanne told us. And, as Jeanne also helped us to understand, communication between primary care provider, specialists, patient, and caregiver, including shared decision-making and involving the patient, can really improve outcomes.

Well, I'd like to thank my colleagues, Birgit, Greg, and Jeanne, for this really important therapeutic discussion. Thank you all so much. And I want to thank you for participating in this activity. Please continue on to answer the questions that follow and complete the evaluation.

This transcript has been edited for style and clarity.