Lawrence Diller, MD. Behavioral/Developmental Pediatrician in Private Practice. Assistant Clinical Professor University of California, San Francisco.
Dr. Diller has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
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://1.usa.gov/1sg2LJw). 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.
CCPR: Do you ever start medications right away?
Dr. Diller: For a small percentage of kids, about one-eighth of my practice, I find that they are so hyperactive that they need to be on medications immediately before we can do anything else. But the vast majority of kids get a trial period of from two to three months where behavioral and educational interventions are tried. Of this group, about 50% will end up on meds, eventually, but 50% will be fine without medicines.
CCPR: What are the specific behavioral interventions that you usually recommend?
Dr. Diller: My first point is usually to address the common misconception that the child is incapable of doing certain things because of ADHD. I’ll say, “You should throw out the idea that Johnny can’t do this or that, because based on my experience, certain things are just harder for him to do, and require specific strategies.” The key behavioral strategy is immediately linking demands and consequences, and this leads right to my main recommendation, which is a parenting skills intervention based on the book “1-2-3 Magic” (Phelan TW. Glen Ellyn, IL: Parentmagic Inc.; 2014). This is a deceptively simple technique, in which parents count kids to three and then give them a time out if the behavior continues. I’ll often introduce this by saying to parents, “You know when Johnny hit his sister and he immediately looked at you to see your reaction? That’s called a test.” I ask if they agree, and they usually say “yes.” Then I say, “Why do children test their parents? They test boundaries to develop consistent responses because it makes them feel more secure.” A child has huge anxiety when he thinks, “I’m too little to take care of myself but I’m stronger than my parents.” Most parents understand that this is a reasonable justification for enforcing limits.
CCPR: What’s so magical about 1-2-3 Magic?
Dr. Diller: Parents only need to explain it to the kid one time, and that’s it. Sometimes while they are explaining it, the kid starts mouthing off, and the parents say, “That’s ONE.” I tell the parents that for the first 72 hours it will be horrible torture as you make the shift from being powerless to having consistent power. But I’ll say, “If you stick with this plan, I guarantee (I’ll sound like a car salesman) improvement in 72 hours. If you don’t see improvement in 72 hours, then you are to call me, even on the weekend, because you must be doing something wrong.” The magic is that after the kids have been sent to time out once or twice, the parent says “ONE” and the kid freezes like a lightning bolt has hit him. The other part of the magic is that over a period of a couple of weeks, especially with the younger kids, it looks like they are on Ritalin, because the behavioral change can be quite profound. However, for some of the parents, it’s not a natural way of acting. Down the line, for these families the “magic” compliance wears away as they do what is natural to them.
CCPR: Are there other behavioral interventions?
Dr. Diller: The other intervention is to make sure the parents go to the school and get a basic educational evaluation rolling. An SST (Student Study Team) evaluation has to be completed within two weeks, whereas an Individualized Education Plan (IEP) evaluation, which is much broader, can take up to 120 days. I also recommend a school-based behavioral intervention, appropriate mainly for children fifth grade and younger, which is called the daily report card. This is just a piece of paper on the kid’s desk, and when he completes a task without any or only one reminder, then the teacher puts a dollar sign or a sticker in one of the boxes immediately upon completion. I tell the kids, “This is an opportunity for you to win fabulous cash prizes and trips to the Bahamas.” The stickers equal computer time, or trips to the ice cream store, or his choice of a DVD at the end of the week if he gets enough of them. It’s even better if the teachers have lottery boxes or treasure chests at the end of the week—you wouldn’t believe what the kids are willing to do get an extra ticket to put into the lottery box.
CCPR: After your evaluation, as you follow the family, are there any tips that help the parents be successful in their behavioral interventions?
Dr. Diller: I use the “swordfish” technique. This helps parents support one another in effectively using 1-2-3 Magic. If one parent is trying to engage the child in setting limits, but is not doing well, the observer parent says “swordfish” to remind the disciplining parent to get back on track. “Swordfish” is from the Marx Brothers’ Horse Feathers movie. It’s the password Groucho uses with Chiko to get into the speakeasy.
CCPR: I like the thoroughness of your evaluation process. But there are certainly some doctors who are either unable or unwilling to budget their time this way. If we did want to farm out some of these aspects of the evaluation, how do you recommend that we find someone who works well with parents and the schools in this way?
Dr. Diller: Unfortunately, it’s hard to find. In my middle/upper middle class community, I can think of only two or three therapists who will do a conjoint family interview or talk to the teacher. Most therapists do individual work with kids, which often will not lead to much improvement in ADHD symptoms. In fact, in my practice a typical pattern is for parents to send their kids to therapy for six to 12 months, see no change, and then to come to me. Sadly, child psychiatrists in my area are typically not doing conjoint family interviews, because the field has moved to a medication model.
CCPR: Thank you, Dr. Diller.
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