Two great articles appeared in the NYTimes in the last week- highlighting the confusion, misinformation and frenzy surrounding what is behavior versus sensory issues in children. Check them out – this is a great segway for pediatric therapists to lead this discussion, consult with parents, schools and physicians on this issue. Share your knowledge and expertise and be the “go to” person on this issue.
Expand Pre-K, Not A.D.H.D. – Op Ed Piece NYTimes
By STEPHEN P. HINSHAW and RICHARD M. SCHEFFLER
BERKELEY, Calif. — THE writing is on the chalkboard. Over the next few years, America can count on a major expansion of early childhood education. We embrace this trend, but as health policy researchers, we want to raise a major caveat: Unless we’re careful, today’s preschool bandwagon could lead straight to an epidemic of 4- and 5-year-olds wrongfully being told that they have attention deficit hyperactivity disorder.
Introducing millions of 3- to 5-year-olds to classrooms and preacademic demands means that many more distracted kids will undoubtedly catch the attention of their teachers. Sure, many children this age are already in preschool, but making the movement universal and embedding transitional-K programs in public schools is bound to increase the pressure. We’re all for high standards, but danger lurks.
The American Academy of Pediatrics now endorses the idea that the diagnosis of A.D.H.D. can and should begin at age 4, before problems accumulate. In fact, Adderall and other stimulants are approved for treatment of attentional issues in children as young as 3.
Early intervention for children with A.D.H.D. could provide great relief. Children who go untreated have major difficulties in school and with their peers, and they have higher-than-normal rates of accidents and physical injuries.
The problem is that millions of American children have been labeled with A.D.H.D. when they don’t truly have it. Our research has revealed a worrisome parallel between our nation’s increasing push for academic achievement and increased school accountability — and skyrocketing A.D.H.D. diagnoses, particularly for the nation’s poorest children.
For example, we found that in public schools, A.D.H.D. diagnoses of kids within 200 percent of the federal poverty level jumped 59 percent after accountability legislation passed, compared with under 10 percent for middle- and high-income children. There was no such trend in private schools, which are not subject to legislation like this.
Families and physicians must take special care in medicating very young children. Today’s push for performance sets us on a troubling trajectory. A surge in diagnoses would mean more prescriptions despite guidance from professional organizations, including the American Academy of Pediatrics, which recommend that behavioral therapy rather than medication be used as first-line treatment for children under 6.
Too many kids are identified and treated after an initial pediatric visit of 20 minutes or even less. Accurate diagnosis requires reports of impairment from home and school, and a thorough history of the child and family must be taken, to rule out abuse or unrelated disorders.
Yes, this would be more time consuming and costly in the short term. But just like investing in preschool, spending more today on careful diagnosis and treatment of A.D.H.D. will lead to lifetimes of savings. As the early childhood education movement builds, let’s make sure we proceed with caution. We should fundamentally rethink how we diagnose and treat A.D.H.D., especially for our youngest citizens.
Doctors Train to Evaluate Anxiety Cases in Children – Alan Schwarz 2.19.2014 NYTimes reprint
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.
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 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.
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 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 three-day 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 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 never see because of cost, geography or perceived stigma. She used a third-grade 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.”