Doctors Train to Spot Signs of A.D.H.D. in
Children
By ALAN SCHWARZ FEB. 18, 2014
Jerry, 9 years old, dissolved into his Game Boy while his father described
his attentional difficulties to the family pediatrician. The child began
flitting around the room distractedly, ignoring the doctor’s questions and
squirming in his chair — but then he leapt up and yelled: “Freeze! What do
you think is the problem here?”
Nine-year-old Jerry was in fact being played by Dr. Peter Jensen, one
of the nation’s most prominent child psychiatrists. On this Sunday in
January in New York, Dr. Jensen was on a cross-country tour, teaching
pediatricians and other medical providers how to properly evaluate
children’s mental health issues — especially attention deficit hyperactivity
disorder, which some doctors diagnose despite having little professional
training.
One in seven children in the United States — and almost 20 percent of
all boys — receives a diagnosis of A.D.H.D. by the time they turn 18,
according to the Centers for Disease Control and Prevention. It narrowly
trails asthma as the most common long-term medical condition in
children.
Increasing concern about the handling of the disorder has raised
questions about the training doctors receive before diagnosing the
condition and prescribing stimulants like Adderall or Concerta, sometimes
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with little understanding of the risks. The medications can cause sleep
problems, loss of appetite and, in rare cases, delusions.
Because the disorder became a widespread national health concern
only in the past few decades, many current pediatricians received little
formal instruction on it, sometimes only several hours, during their seven
years of medical school and residency. But the national scarcity of child
psychiatrists has placed much of the burden for evaluating children’s
behavioral problems on general pediatricians and family doctors, a reality
that Dr. Jensen and others are trying to address through classes that
emphasize role-playing exercises and spirited debate.
“Most continuing medical education is somebody standing up at a
podium transmitting facts,” said Dr. Jensen, the former associate director
of child and adolescent research at the National Institute of Mental
Health. “But with A.D.H.D. that’s like showing a slide show of how to
swim the butterfly, and expecting people to go home and swim the
butterfly. It takes real hands-on training.
“If all we change is residency, we won’t see benefits for 20-30 years,”
he added. “We have the problem now, and it needs to be addressed now.”
Pediatricians and family doctors handle the majority of office visits for
children being medicated for A.D.H.D., according to a 2012 study in the
journal Academic Pediatrics. Most experts blame the relative rarity of
child psychiatrists: There are only 8,300 in the United States, compared
with 54,000 board-certified general pediatricians, according to their
professional organizations’ statistics. The result is that some rural families
must drive 100 miles or more for an appointment with a child psychiatrist
or neurologist, who often have long waiting lists and accept insurance less
often than a family pediatrician.
Yet many practicing pediatricians, family doctors and certified nurse
practitioners say they have received little training to prepare for today’s
rising number of families asking that their children receive mental-health
evaluations. Pediatric residency programs since 1997 have been required
to include a month on developmental-behavioral pediatrics, a category
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into which A.D.H.D. can fall. But many doctors say the actual programs
can vary widely and cover too many conditions too briefly.
“When I trained, most of pediatrics was treating infectious disease,”
said Dr. William Wittert, 57, a pediatrician in Libertyville, Ill. “But we
don’t treat bacterial meningitis anymore. We are being asked to evaluate
and handle mental-health issues in kids like A.D.H.D. We have to get up to
speed.”
Dr. Wittert acknowledged that for years his handling of the disorder
was inadequate. He said he often would run down a list of vague
symptoms — like distractibility and forgetfulness. “If you had enough
yesses, then you pretty much got the diagnosis of A.D.H.D.,” he said.
Harriet Hellman, a certified pediatric nurse practitioner in
Southampton, N.Y., who is licensed to make mental-health diagnoses, said
that there were times she would identify the disorder through mere
instinct, a “hair-on-the-back-of-your-neck feeling.”
Many postgraduate and web-based continuing medical education
classes are staffed and shaped by pharmaceutical companies, raising
concern about bias toward encouraging diagnoses and subsequent
prescriptions. Wary of this, Dr. Wittert and Ms. Hellman said they were
immediately drawn to Dr. Jensen’s seminars, held by the Resource for
Advancing Children’s Health Institute, the nonprofit he founded in 2006.
About 2,000 health providers have paid about $2,000 for intensive threeday
sessions, which Dr. Jensen holds about 10 times a year across the
United States.
The recent event in New York focused on A.D.H.D. But the day’s key
acronym was D.J.D.S.: “Don’t just do something.” It was a reminder to the
audience to resist the urge to simply prescribe medication and that a
proper diagnosis requires far longer than the 15 minutes some health
providers spend.
The institute’s team staged doctor’s-office visits in which a child
comes in for an A.D.H.D. evaluation. A pushy father, played by Dr. Ned
Hallowell, demands an Adderall prescription for his daughter to improve
2/19/2014 Doctors Train to Spot Signs of A.D.H.D. in Children – NYTimes.com
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her grades. A distracted and fidgety boy might not have A.D.H.D. but
rather might be the victim of bullying at school. A teenage girl might have
been sexually assaulted.
When Dr. Hallowell, a prominent A.D.H.D. psychiatrist, climbed
under chairs and rolled aimlessly on the carpet, the audience appeared
both amused and somewhat disturbed.
As the role-playing continued, Dr. Jensen called from afar, “Dr. Jones,
you have six patients waiting!”
Trainees consulted symptom evaluation forms submitted by teachers
and parents. They evaluated family histories. They debated whether the
child’s behavior was likely to be a result of depression, A.D.H.D., sleep
problems or family tension.
They rarely reached a consensus.
With Jerry, the 9-year-old boy, some suspected he had A.D.H.D.,
while others wanted to learn more about whether his parents were
providing enough structure at home or if Jerry had a different learning
disability.
“Doctors aren’t trained to say, ‘I don’t know what to do,’ ” Dr. Jensen
said.
The institute’s program does not stop with the three-day seminar.
Attendees are allowed 12 hourlong conference calls with institute trainers
and other trainees over the next six months to discuss real-life cases. A 9-
to-5 hotline allows for further consultation with an expert on call.
Although the training does not discourage diagnosing the disorder or
using medication — left untreated, the disorder carries significant risks for
academic and social struggles — most graduates interviewed said they do
so less often after taking the course.
Dr. Nina I. Huberman, a pediatrician in an underprivileged section of
the Bronx, was among the doctors who said the class allowed them to
begin providing care to those who otherwise would not get it. Once averse
to handling A.D.H.D. and its medications because of her lack of training,
Dr. Huberman said she no longer sent families to specialists they might
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never see because of cost, geography or perceived stigma. She used a thirdgrade
girl as an example of someone whose life was turned around by what
Dr. Huberman called a straightforward diagnosis.
“She didn’t have any learning issues, she just had that textbook
A.D.H.D. issue where she could not sit still or focus,” Dr. Huberman said.
“Now she’s reaching her potential. Her whole way about her has changed.
I don’t think that the parents would have ever brought her to a
psychiatrist.”
The impact of the institute’s program is limited. Each training session
is capped at about 40 health care providers, whose attendance is
voluntary. So there is some question as to whether the sessions can
improve the handling of the 400,000 children in the United States who
receive an A.D.H.D. diagnosis each year.
But its ethos may be spreading. Dr. Robert A. Jacobs, the chief of
general pediatrics at Children’s Hospital Los Angeles, a premier teaching
hospital, said he has sent 24 instructors to the institute so they can learn
its methods, particularly role-playing. He plans to double the number of
hours residents spend on depression, anxiety and A.D.H.D.
“The scope of pediatrics has changed,” Dr. Jacobs said. “For many in
the elementary-school population, A.D.H.D. is the primary concern.”
NYTimes: Doctors Train to Spot Signs of A.D.H.D. in Children
