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.

Tuesday, August 17, 2010

The Mess of ADHD Evaluation and Treatment

Two events today cause me to crash head-on into the terrible state of affairs that define ADHD diagnosis and treatment in our country. First, in my AAP SmartBrief, the daily listing I receive via email of important news stories related to pediatrics, I read this item Youngest in Class Get ADHD Label in USA today. The article states
Kids who are the youngest in their grades are 60% more likely to be diagnosed with ADHD than the oldest children, according to a study out today from Michigan State University, given exclusively to USA TODAY. A second study, by researchers at North Carolina State University and elsewhere, came to similar conclusions. Both are scheduled for publication in the Journal of Health Economics.
In my previous job,when the majority of my work consisted of seeing children who had been referred for "evaluation of ADHD" I commonly encountered children who were having their first structured school experienced. Many were among the youngest in their class. They were described as "impulsive." They found difficult to sit at circle time, and unfathomable to sit at a desk to do a written assignment. Yet parents would frequently tell me that the teacher had confided that while she wasn't supposed to make diagnoses, she was sure this child must have ADHD. The findings reported in this article confirm my suspicion that for many of these "ADHD evaluations" referred to me, it was the environment that didn't fit the child, rather than that the child had a "problem."

A few hours after reading this article, I received a phone call from the office manager from the pediatric practice I recently left. As I have written about in my blog, I changed practices to focus on working with young children and their parents in the setting of a community health center. This was in part because I was struggling with the expectation, in keeping with the standard of care in pediatric treatment of ADHD, that I fill many,many prescriptions without any opportunity to understand the complex life experience of these children.

I was sure to refer every child I had been seeing to an appropriate provider. Many of them would be followed, in keeping with the standard of care in pediatrics, by the other primary care clinicians in the practice. Some, who I felt needed more intensive help, I referred to an excellent child psychiatrist in my community. Just before I left, I learned that she had a new policy that she would only see patients for medication evaluation if they were engaged in psychotherapy. I thought this policy was very wise.

One patient, the office manager called to tell me, was very unhappy with this plan. (details,as always, have been changed to protect privacy) "He's never been in therapy before," his irate mother apparently told the office manager. I had a vivid flashback. Mother and father at opposite ends of the room, tense and angry. A small, thin 9 year old boy slumped into the corner of the exam table nervously chewing his nails. As his parents argued about his "laziness" he seemed to want to disappear into the wall. At our last visit together, however, his parents agreed that things were perhaps more complex than simply inattentive ADHD. They accepted my referral to the psychiatrist.

But apparently they had a change of heart. Just getting the prescription filled by their pediatrician was their preference. "He doesn't need any therapy." his mother said. Perhaps he doesn't. But I can be sure of what he does need. He needs someone to listen to him.

I am sad for these many children whose voices are not heard. It made me agitated to think about the state of affairs in children's mental health care that has led to a situation where countless children are mislabeled, their complex life experience tucked into vastly oversimplified categories.

Now I'm going to take a deep breath and go back to working on my book. In this task I immerse myself in describing a model of child development that acknowledges the importance of understanding children's feelings from the moment they are born. By letting children's voices be heard and recognizing the meaning of their behavior, we can facilitate their healthy emotional development. I can already feel my blood pressure going down!


  1. Hi, Dr. Gold,
    The model you describe (on which your book is based) reminds me of the philosophy of Magda Gerber. Janet Lansbury blogs about parenting using Gerber's philosophy. My view of child development is based on physical and physiological development. Here's a short conversation intersecting the two philosphies:

    Here's a rare post by me about child mental health: http://www.therextras.com/therextras/2010/07/school-responsibility-for-child-mental-health.html

    I came to your blog from twitter, and will be bookmarking to return. Thanks, Barbara

  2. One of the most difficult tasks in my job comes when I have to convince a room full of teachers and administrators why one of their "problem children" does NOT have an ADHD diagnosis. Try as though I might, many of them have decided that taking Ritalin would solve the child's behavior problems -- despite the fact that they are not mental health professionals. Trauma, depression, and other problems may look like ADHD to them, but treating the problem as ADHD won't help. Getting the schools to pay for therapy is often another battle. At first I thought the lack of an "MD" after my name made my task more difficult, but soon I found that even psychiatrists were having the same problem. The challenge of child mental health -- having enough trained professionals, and dealing with the stigma problem -- has reached epidemic proportions, unfortunately.