When the American Academy of Pediatrics came out with new guidelines a couple of years ago extending the age of diagnosis of ADHD (attention deficit hyperactivity disorder) down to age 4, it seemed as if Pfizer might have been waiting in the wings. Soon after, a new preparation of ADHD medication in an oral suspension, for kids too young to swallow pills, became available.
I was a lone voice expressing opposition to this change in the guidelines. As a primary care pediatrician I saw up close how the diagnosis was made based on symptoms alone, missing complex underlying problems. As the standard of care is to treat what we call "ADHD" with medication and/or "behavior management" these problems, which can include a history of abuse and neglect, family substance abuse, ongoing marital and family conflict, and history of significant loss, are not addressed. As the standard of care is also to see these kids every three months for brief follow up, these issues can go unaddressed for many years, as the focus of care becomes adjustment of dose and preparation of medication.
The reason this happens is not because these primary care clinicians are unaware of these underlying problems. It is because the burden of care for children with the constellation of the symptoms of dysregulation of attention, behavior, and emotion, that we now call ADHD, falls almost exclusively on their shoulders.
The economic reality of primary care practice, due in large part to the administrative costs of managing a huge array of different health care plans, is that clinicians are under pressure to see more and more patients in less and less time. Add to that the severe shortage of quality mental health care services, and the primary care clinician is really stuck. The appeal, both for parent and clinician, of a drug that can be very effective in controlling the symptoms of an out-of-control 4-year-old, is understandable.
Whenever I write about this subject, I get a barrage of comments from parents saying things like, "but my child really has ADHD." Therefore, I want to state clearly that I am referring to a public health problem, not to one specific child. In fact, if the system were not broken, I would not need to be writing all these blog posts about the misuse of the ADHD label. Children who are struggling in the ways I have described would be able to get the care they need.
If a broken health care system is the problem (a problem that extends beyond my level of expertise), what can we do for these symptomatic 4-year-olds?
Here is where a model of preventive mental health care comes in. When a child is symptomatic at 4, it is very likely that the roots of the problem were present at three, two or even in infancy. Recently, after I gave the Dewald lecture at the St Louis Psychoanalytic Institute on this proposed model, I had the opportunity to have breakfast with a group of infant mental health colleagues. We spoke about what we termed "the nice lady (or man) down the hall" model.
A primary care practice would incorporate in to their team a mental health clinician trained to work with young children and parents together. The primary care clinician would have easy access to this clinician, who would work in collaboration with the primary care team. Ideally there would also be a team of such early childhood mental health specialists, including an occupational therapist.
When children are young, and their brains are rapidly growing, a brief intervention, such as several hour-long visit over a several month period, can go a long way towards placing that child and family on a different developmental path. It makes sense, both clinical and economic sense, to invest the greatest resources in care for this age group. By the time the child is in school, the problems have become more complex and entrenched.
There has been a lot of work lately on screening for mental health concerns in the 0-5 age population. It is imperative that we develop adequate model of treatment before screening is put in place. If such treatment is not in place first, large scale screening will likely insure that the folks at Pfizer who developed this new liquid form of ADHD medication will do very well.
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