CCPR: Dr. Diller, you have published widely on the overdiagnosis and overtreatment of ADHD. Today I want to focus on alternatives to medications for these kids—but first, do you still think that stimulants are being overprescribed in the US?
Dr. Diller: I think stimulants are underprescribed, misprescribed, and overprescribed. There’s no question that stimulants work and that they are relatively safe, and I prescribe them often, especially for kids who have severe symptoms—who are at the end of the bell curve. But for the vast majority of children, the issue isn’t so much hyperactivity or impulsivity, the issue is a temperament or personality that finds it difficult to do things that they are not interested in—that’s how we’ve come to define ADHD in our country. So yes, my overall sense is that we are overprescribing in the US. We are 4% of the world’s population, yet we produce 70% of all stimulants (International Narcotics Control Board report, http://bit.ly/1iOCX6z). In 2013, 194 tons of legal stimulants were produced in the US (see Aggregate Production Quota History for Selected Substances, http://www.deadiversion.usdoj.gov/quotas/quota_history.pdf). In addition, according to a telephone survey by the US Centers for Disease Control and Prevention (CDC), 10% of all parents have been told by someone that their child has ADHD (Visser SN et al, J Am Acad Child Adolesc Psychiatry 2014;53(1):34-46). In certain states, such as North Carolina, that figure goes up to 30% of parents who have been told their son has ADHD.
CCPR: How do these figures compare to the actual prevalence of ADHD?
Dr. Diller: That’s hard to say, because the diagnosis is subjective. The ability to self-regulate falls in a bell-shaped curve. Where you draw the line between variations in “normal temperament” and a “disorder” will vary depending on who’s doing the evaluating. But the vast majority of kids with ADHD have the mild to moderate variety. And these are kids who deserve a trial of non-pharmacologic interventions first.
CCPR: So how do you approach your comprehensive evaluation?
Dr. Diller: First, I’ll let parents know that I won’t necessarily be prescribing any medications immediately, and give them a little background on how there is an overreliance on medications for ADHD because in our culture there is pressure on parents, teachers, and children to perform. They appreciate that. Many families who come to me, see that I am an MD and they expect medications, and when they hear a doctor talking about non-drug interventions, 95% of the parents are very pleased to be given that option.
CCPR: Do you start your evaluation by talking to the family or the patient, or both?
Dr. Diller: The first session is a meeting with the parents, and I can’t overemphasize the importance of involving both parents. Even in divided households with a non-custodial parent, who is often the father, including that parent is critical. Even if he only sees the kid every other weekend, my experience is that an uninvolved father, who disagrees with a behavioral or a medication plan, can undo in a weekend what the mother and I have set up over a three-month period.
CCPR: And after that first meeting, do you meet with the patient?
Dr. Diller: Usually I’ll first meet with the patient during the second session, which will be a conjoint family meeting. Everybody who lives in the household is invited, including the parents, the patient, the siblings, the grandparents, etc. I find that this is the single most valuable 45 minutes I spend with the child, because I can see the child’s behavior within the primary social system.
CCPR: Why is that so valuable?
Dr. Diller: I’ll give you an example. One scenario in a conjoint meeting is that the identified patient sits reasonably well in the office but his younger sibling is out of control, and the parents are ineffectually trying to deal with that sibling—this gives me a great deal of insight into the family system. For one thing, I know that the parents are having to deal with a lot of stuff besides the patient. You just can’t get that insight through regular history taking.
CCPR: And how do you structure the conjoint family session?
Dr. Diller: We start out doing a little talking where I have the parents ask the children why they think they’ve come to see the doctor. I have some toys in my office and I’ll generally allow a brief time for family play. I always assign the family a drawing game. The instructions are, “Here are some markers and paper. I’d like you to do something together with the markers and paper for five minutes, but there’s no talking.” This turns out to be a very revealing five minutes. For example, a common scenario is that the parents hesitate, and the children start drawing their own pictures, even though I said, “Do something together.” The parents then start to draw on their own, but then mom tries to join Johnny’s (the patient) picture, but he hits her hand and she backs away. What has happened very quickly in the office is that the children have created the rule system in the family, and Johnny experiences mom’s efforts to be involved as a violation of his territory. I ask them if they’ve experienced this dynamic outside of the drawing game, in which there’s a power void that is filled with the child. I explain that in life, 90% of what kids do requires that they comply with someone’s rules, and that if you leave it up to kids to establish these rules, there are going to be some negative consequences. This is a prelude to working with the parents on basic parenting skills, such as providing immediate consequences and time outs when needed.
CCPR: Do you also have an individual session with the patient?
Dr. Diller: Yes, that’s usually the third session. I start by asking a few questions, engaging with him, which gives me a sense of what his social abilities are and whether he can stick with me on a subject. Then, for kids under 12, I give them 10 or 15 minutes to play, which is usually going to the sand tray in my office, and using toys to create a story. The majority of kids who aren’t on the extreme of hyperactivity do fine in this task. But the kid who is really struggling is overwhelmed by the number of choices, and might put toys randomly into the sand, and then change them abruptly, with little organization. After that, if the child has not already had a recent educational evaluation by the school, I’ll spend 20 to 30 minutes and go through some graded reading paragraphs, a math test, and a screen for auditory processing. I do this not to document a learning disability, but because this will give me a clue if there is a significant learning problem. A kid might look fine during play but once I give him a pencil, he starts showing symptoms, rocking, and yawning, or feel overwhelmed by some simple processing tasks. If I see some obvious learning issues, I make sure to have the parents initiate an educational evaluation through the school.
CCPR: It really sounds like you’re providing a one-stop shop for these families.
Dr. Diller: Yes, certainly other providers could do some of these things, but the key issue is whether the MD wants to do or know anything else besides deciding on medicine. There are economic issues that drive the MD in how he or she maintains the practice, because you can make twice as much money doing four med checks as you can spending 45 or 50 minutes with the family or the kid.
CCPR: So overall, your typical evaluation requires three sessions?
Dr. Diller: Yes, three billable sessions, because you can’t really make the diagnosis in 15 minutes. I do one other thing which is important, and that is I talk to the teacher on the phone rather than rely on a form. Many clinicians will have the teacher fill out a Vanderbilt Assessment Scale, which is certainly better than nothing, but I find that it’s much more valuable to actually get the teacher on the phone. The problem is that this is not billable through insurance. The way I handle it is, I don’t charge unless the conversation lasts longer than 15 minutes, and then I’ll bill the parents for my time.
CCPR: Why is actually talking to the teacher so important? What do you find out?
Dr. Diller: Talking is important because the teacher questionnaires only ask about negative behaviors—does the child fidget, blurt out things, etc. When I talk to teachers, I ask in an open-ended way, “Tell me about this child in your classroom in terms of both strengths and weaknesses.” I find that many teachers are trained these days to describe every type of misbehavior in the language of ADHD, especially using the word “focus”—as in, “He doesn’t focus in the classroom.” If so, I tell the teachers, “Not focusing is an interpretation of behavior, but can you tell me what he’s doing or not doing that’s the problem.” Because there are multiple reasons why children don’t do what they are supposed to do.
CCPR: So once you are done with this evaluation, what’s the next step?
Dr. Diller: In the fourth visit, I sit down with parents and go over the findings. I lay out what I feel I can do for them. I make sure
they know that I’m not talking about weekly visits over the next year, but maybe three or four visits over the next two months, and that primarily I’ll be working with the parents.