Welcome to my blog, which speaks to parents, professionals who work with children, and policy makers. I aim to show how contemporary developmental science points us on a path to effective prevention, intervention, and treatment, with the aim of promoting healthy development and wellbeing of all children and families.

Sunday, March 28, 2010

My Shrinking "ADHD" Practice

I consider my most successful cases to be the ones that do not seem me any more. Not that they are "better", but they and their families have come to realize the full complexity of the problems they are struggling with, and are getting appropriate help.

I inherited my "ADHD practice" from another pediatrician. He was wonderful man, a larger than life, toss babies in the air pediatrician with a hearty laugh. He never had an unkind word to say about anyone. He had retired from general pediatrics and was only seeing "ADHD patients," when he died suddenly in a tragic accident. His patients were devastated. I had recently started my own behavioral pediatrics practice, and his practice, where I had worked previously, asked if I would return and take over his "ADHD patients." Out of loyalty to him, I agreed.

I learned that he was seeing his 170 or so patients once every three to six months for a 30 minute visit. This was pretty much the standard of care in pediatrics. But I felt that if I were going to prescribe a mind altering drug to these children, I wanted to learn what was going on in their lives. I particularly tried to open things up when kids were doing poorly. I didn't focus on adjusting the dose of medication when they were failing in school, but explored other possible reasons for their academic struggles. This meant uncovering some pretty difficult problems, including complex family conflict. Some families got angry and left. "We thought you just weighed and measured Johnny and then refilled the prescription."

But a few families welcomed this chance to talk. I encouraged one mother(details have been changed to protect privacy) to meet with me alone because at our visits with her 12 year old daughter, Kaitlin, she would speak so harshly and critically that it made me uncomfortable. "She's just lazy, " she would say. "She's always been impossible." When we met alone, she described a deeply troubled relationship with Kaitlyn since she was an infant. Kaitlin had been on medication for ADHD since she was 9, but her mother revealed to me that she had always questioned the diagnosis, saying, "its more complicated than that."

We worked together for a year. I met with them for a 60 minute visit every three months. I would ask about the medication, while also talking about other aspects of Kaitlin's life. I started to meet for half the visit with Kaitlin alone. It each visit I suggested that talking with someone on a more regular basis would probably be helpful, but they did not follow through. Finally, at the end of one session Mom said to me, "Kaitlyn feels that she would like to talk with a therapist." I referred them to a wonderful colleague who fortunately took their insurance and had time.

It proved to be a great match. Kaitlin has now been in therapy for 2 years. Recently my colleague and I met for lunch. She filled me in. Kaitlin is off her medication. While she does need extra help, she is doing well in school. She is developing a strong sense of herself. She has many friends and interests. Perhaps most importantly, her mother, who also meets regularly with my colleague, is happy and very proud of her daughter.

Some of my patients have what I refer to as "straightforward ADHD." They likely have a neurobiologically based difficulty with focusing and attention. Stimulant medication allows them to learn. There are no other issues. If I can get all of my patients to receive the help they need, as I did with Kaitlin, my practice would consist of only these children. It would be a fraction of the size it is now.

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