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 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 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.”
This article first appeared on ‘The New York Times’ on 18 February 2014.