Lost Keys, Missed Appointments, and the Struggle of Treating Executive Dysfunction

Dinah Miller, MD

May 12, 2022

Maybe you know some of these patients: they may come late or not show up at all. They may have little to say and minimize their difficulties, often because they are ashamed of how much effort it takes to meet ordinary obligations. They may struggle to complete assignments, fail classes, or lose jobs. And being in the right place at the right time can feel monumental to them: they forget appointments, double book themselves, or sometimes sleep through important events. 

It's not just appointments. They lose their keys and valuables, forget to pay bills, and may not answer calls, texts, or emails. Their voicemail may be full and people are often frustrated with them. These are all characteristics of executive dysfunction, which together can make the routine responsibilities of life very difficult.

Executive dysfunction is a hallmark symptom cluster often seen in patients with attention deficit hyperactivity disorder (ADD or ADHD). Not everyone with attentional issues struggles with executive dysfunction, but it is quite common

Treatments include stimulants, and because of their potential for abuse, these medications are more strictly regulated when it comes to prescribing. The FDA does not allow them to be phoned into a pharmacy or refills to be added to prescriptions. Patients must wait until right before they are due to run out to get the next prescription and this can present a problem if the patient travels or takes long vacations. 

And although it is not the patient's fault that stimulants can't be ordered with refills, this adds to the burden of treating patients who take them. It's hard to imagine that these restrictions on stimulants and opiates (but not on benzodiazepines) do much to deter abuse or diversion.

I trained at a time when ADD and ADHD were disorders of childhood, and as an adult psychiatrist, I was not exposed to patients on these medications. Occasionally, a stimulant was prescribed in a low dose to help activate a very depressed patient, but it was thought that children outgrow issues of attention and focus, and I have never felt fully confident in the more nuanced use of these medications with adults. Most of the patients I now treat with ADD have come to me on stable doses of the medications, or at least with a history that directs care.

With others, the tip-off to look for the disorder is their disorganization in the absence of a substance use or active mood disorder. Medications help, sometimes remarkably, yet patients still struggle with organization and planning, and sometimes I find myself frustrated when patients forget their appointments or the issues around prescribing stimulants become time-consuming.

David W. Goodman, MD, director of the Adult Attention Deficit Center of Maryland in Lutherville, currently treats hundreds of patients with ADD and has written and spoken extensively about treating this disorder in adults.

"There are three things that make it difficult to manage patients with ADD," Goodman noted, referring specifically to administrative issues. "You can't write for refills, but with e-prescribing you can write a sequence of prescriptions with 'fill-after' dates.  Or some patients are able to get a 90-day supply from mail-order pharmacies. Still, it's a hassle if the patient moves around, as college students often do, and there are inventory shortages when some pharmacies can't get the medications."

"The second issue," he adds, "is that it's the nature of this disorder that patients struggle with organizational issues. Yelling at someone with ADD to pay attention is like yelling at a blind person not to run into furniture when they are in a new room. They go through life with people being impatient that they can't do the things an ordinary person can do easily."

Finally, Goodman noted that the clinicians who treat patients with ADD may have counter-transference issues. 

"You have to understand that this is a disability and be sympathetic to it. They often have comorbid disorders, including personality disorders, and this can all bleed over to cause frustrations in their care. Psychiatrists who treat patients with ADD need to know they can deal with them compassionately." 

"I am occasionally contacted by patients who already have an ADHD diagnosis and are on stimulants, and who seem like they just want to get their prescriptions filled, and aren't interested in working on their issues," says Douglas Beech, MD, a psychiatrist in private practice in Worthington, Ohio. "The doctor in this situation can feel like they are functioning as a sort of drug dealer. There are logistical matters that are structurally inherent in trying to assist these patients, from both a regulatory perspective and from a functional perspective. Beech feels that it's helpful to acknowledge these issues when seeing patients with ADHD, so that he is prepared when problems do arise. 

"It can almost feel cruel to charge a patient for a "no-show," when difficulty keeping appointments may be a symptom of their illness, Beech adds. But he does believe it's important to apply any fee policy equitably to all patients. "I don't apply the 'missed appointment' policy differently to a person with an ADHD diagnosis vs any other diagnosis." Though for their first missed appointment, he does give patients a "mulligan."

"I don't charge but it puts both patient and doctor on notice," he says.

And when his patients do miss an appointment, he offers to send a reminder for the next time, which is he says is effective. "With electronic messaging, this is a quick and easy way to prevent missed appointments and the complications that arise with prescriptions and rescheduling," says Beech.

Goodman speaks about manging a large caseload of patients, many of whom have organizational issues.  

"I have a full-time office manager who handles a lot of the logistics of scheduling and prescribing. Patients are sent multiple reminders, and I charge a nominal administrative fee if prescriptions need to be sent outside of appointments. This is not to make money, but to encourage patients to consider the administrative time.

"I charge for appointments that are not canceled 48 hours in advance, and for patients who have missed appointments, a credit card is kept on file," he says.  

In a practice similar to Beech, Goodman notes that he shows some flexibility for new patients when they miss an appointment the first time. "By the second time, they know this is the policy. Having ADHD can be financially costly." 

He notes that about 10% of his patients, roughly one a day, cancel late or don't show up for scheduled appointments: "We keep a waitlist and if someone cancels before the appointment, we can often fill the time with another patient in need on our waitlist."   

Goodman noted repeatedly that the clinician needs to be able to empathize with the patient's condition and how they suffer. "This is not something people choose to have. The trap is that people think that if you're successful you can't have ADHD, and that's not true. Often people with this condition work harder, are brighter, and find ways to compensate." 

If a practice is set up to accommodate the needs of patients with attention and organizational issues, treating them can be very gratifying. In settings without administrative support, the psychiatrist needs to stay cognizant of this invisible disability and the frustration that may come with this disorder, not just for the patient, but also for the family, friends, and employers, and even for the psychiatrist.

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