The Doctor Is Not In: ADHD’s Pediatrician Problem
America’s pediatricians are increasingly expected to diagnose and treat ADHD and other mental health conditions in their patients — even though many lack the expertise and confidence to do so. Here’s how to solve the patient-provider mismatch.
Reviewed on September 28, 2018
Stephanie Berger always knew that her granddaughter struggled with inattention and hyperactivity, but she couldn’t get a diagnosis until Nadia was nine.
“When she was four, I went to our pediatrician and told him she was having trouble,” Berger said. “He’s the first one who said it ‘could be’ ADHD.” Berger, who lives in Brandon, Florida, didn’t know much about ADHD, but she could see that Nadia was struggling. She asked the pediatrician what he could do to help.
“I asked him, ‘Can you handle this?’ but he demurred. ‘I could, but I shouldn’t.’ He said that they covered [ADHD] a little bit in his medical school training, but it was minute.” He would refer Nadia to a specialist.
The specialist was unaffordable, however, so Berger took Nadia to another pediatrician — and, after that, several more. Most said that Nadia likely had ADHD, but each was reluctant to diagnose her. “I couldn’t get any of them to say, ‘She has ADHD,’” she said. “They kept sending me someplace else.”
Years passed; Berger grew frustrated. “I saw so many people, and no one would help her,” she said. Most of the pediatricians she tried said they lacked the expertise to handle Nadia’s challenges. Getting the diagnosis would require her to look elsewhere.
The Training Gap
In theory, Nadia’s pediatricians should have been qualified to diagnose and treat her ADHD and co-occurring anxiety. In practice, however, their hesitation may have been justified — because most pediatricians are woefully undertrained in the most basic mental health issues.
The problem starts in medical school, said psychiatrist Peter Jensen, M.D., where the breakneck pace and extensive material too often prioritizes physical ailments over mental health. Though curriculums vary, most medical schools spend the first two years on life sciences. Third-year students start working with patients, usually by rotating through hospitals and shadowing doctors on their rounds. There’s a lot to cover, Jensen said, so students get just a brief sense of each department as they go.
The sole psychiatry rotation lasts two months — and “to call it ‘training’ would be an overstatement,” Jensen added. Most medical students see only adult psychiatry patients in an inpatient ward. “If I’m a pediatrician,” he said, “it’s highly likely I was never exposed to any [children’s] mental health cases during medical school.”
After graduation, pediatricians dive into internships and residencies. Pediatric residents who don’t specialize — about 20 percent — are given broad training, Jensen said, so they “can see pretty much [the kinds of cases] that walk in the [doctor’s] door.” Time constraints and competing priorities, again, result in limited attention paid to mental health.
“We got one month of developmental and behavioral pediatrics,” said Mary Gabriel, M.D., a child psychiatrist and former pediatrician. “That was it.” When most pediatricians enter practice, they’ve received only three months of hands-on psychiatric training — most focused on adults with severe disorders.
The realities of day-to-day practice come as a shock, then, when pediatricians learn that 25 to 50 percent of their patients are seeking treatment for mental or behavioral health. The shortcomings of their training are inescapable, Gabriel said. “I was not adequately trained,” she realized.
“Most pediatricians come out of their pediatric training thinking, ‘Yeah, I learned about ADHD,’” Jensen agreed. “But when they look back on it, they say, ‘I didn’t learn nearly enough.’”
A Nationwide Shortage
Pediatricians who lack mental health training might not appear to be the ideal place to turn for help. But data consistently show that parents turn to them. A 2015 study found that 35 percent of children receiving mental health care saw only their pediatrician, and only 26 percent ever saw a psychiatrist at all. The reason? There aren’t enough child psychiatrists to go around, said Harvey Parker, Ph.D. — meaning that parents “have to rely on primary-care doctors to provide this initial treatment.”
According to the Child Mind Institute, more than 17 million U.S. children are affected by mental health issues annually. Child psychiatrists in full-time practice — along with developmental pediatricians and child psychologists — number at about 7,000, Jensen said. If all 7,000 split their time evenly among the children who need them, each child would receive less than one hour of care each year — not nearly enough for diagnosis or treatment.
Not every child who needs care seeks it, but child psychiatrists in the U.S. are overburdened. Some have years-long waitlists, while others turn away new patients altogether. After Berger switched insurance to take Nadia to a psychiatrist, she encountered a waitlist that was three months long — an eternity to a child who’s so anxious about school that she often can’t get out of bed.
“There’s a huge mental health crisis,” Jensen said. “And it can’t be solved simply by increasing the number of professionals.” According to estimates from the U.S. Bureau of Health Workforce, the country would require a total of 13,000 child psychiatrists to meet the current need.
But there is a group of medical professionals who could step up to the plate, Jensen said — if given the resources to do so. “We have about 50,000 pediatricians out there,” he said. “If we had each of them trained [in mental health] — now we’re talking some serious numbers.”
If pediatricians could be trained to handle the three-quarters of child mental health cases that are “mild to moderate,” it would free up psychiatrists to tackle the severe cases. And since families are going to their pediatricians anyway — because they trust them, or because they’re the only providers around — it’s an ideal setting to get basic comprehensive care.
That’s why, in 2007, Jensen founded The REsource for Advancing Children’s Health (REACH) Institute, which aims to train pediatricians to handle the “Four Horsemen” of children’s mental health: ADHD, anxiety, depression, and aggression.
“Many [pediatricians] are desperate to help kids, but don’t have any child psychiatry resources,” Jensen said. By completing REACH’s “mini-fellowship” — a three-day mental health intensive, followed by six months of bi-monthly conference calls — they get the confidence they need to handle cases themselves, instead of referring them to child psychiatrists.
When faced with a patient who has ADHD, for instance, “they could do that in a heartbeat — and they could do it well,” Jensen said. REACH has trained approximately 2,500 pediatricians over the last decade — and a forthcoming online version of the program will allow more pediatricians to be reached at a much lower cost.
Despite REACH’s successes, however, the cost (in both money and time) is prohibitive for some. It’s important that these pediatricians have access to mental health resources too, said David Kaye, M.D., project director of CAP PC, a program of New York State’s Office of Mental Health’s Project TEACH. CAP PC partners with REACH to provide free in-person training to New York-based pediatricians. It also provides real-time phone consultations and referrals to doctors by pediatricians who are faced with challenging cases.
If a patient comes in with ADHD-like symptoms, for instance, the doctor can call CAP PC’s toll-free number and be immediately connected with a child psychiatrist, who can help work through the diagnosis. If the child is presenting more severe symptoms, CAP PC will connect the pediatrician to the nearest mental health professional who is equipped to handle those specific symptoms. In some cases, CAP PC will provide face-to-face evaluations.
“We’ll see a kid who we think — with a little more specific direction — a primary-care person would feel capable of managing,” Kaye said. As doctors build competence, they’ll start to make diagnoses and treatment decisions independently.
“Formal education and phone consultation support really work synergistically,” Kaye said — and access to the latter is growing exponentially. So far, 25 states have consultation programs similar to New York’s CAP PC. Each state’s contact information is available at nncpap.org.
No matter how many practicing pediatricians are trained, however, it won’t be enough to solve the crisis, since about 2,000 pediatricians graduate from medical school annually. Many experts agree that changes in the medical school curriculum must be made, so that new graduates will have the training to work with patients in their practice.
“Training programs have to change to reflect what happens in a pediatrician’s practice,” Jensen said. “If every one of our doctors in pediatric residencies were coming out with the same kind of training we’re doing for practicing doctors, the country would change dramatically in the next 10 years.”
Changing the medical school curriculum is a “complicated food fight,” Kaye said. “Every [specialty] is…saying, ‘We need more of this.’” But as the medical community begins to recognize mental health’s importance, he said, pediatric programs are taking steps to implement a new model of care. Rainbow Babies and Children’s Hospital in Cleveland, Ohio, for instance, introduced a mental health track for pediatric residents — allowing them to integrate mental health into their practice right away.
A lot of this work, though, is happening “under the surface,” Gabriel said — and it’s hard for parents to take the long view when their child is struggling now. Berger, for instance, never got a diagnosis from a pediatrician, or from any other medical professional. In desperation, she enrolled Nadia in a research study at the University of South Florida (USF). She waited for more than a year, but the results — which secured diagnoses of ADHD, anxiety, and dyslexia — were worth it, Berger said. “Once I had a piece of paper that said, ‘These are her issues,’” Nadia was able to get much-needed support and treatment.
Nadia still struggles, and “it was frustrating that it took so many years,” Berger said. The most discouraging part was the reluctance of anyone to step up. “I’ve been told it’s ‘not my job.’”
But it could be, Kaye said — and should be. “As we integrate physical and mental health,” he said, “we’re breaking down some of the silos. Asthma used to be taken care of only by pulmonary specialists — now, it’s part of bread-and-butter primary care.”
Basic mental health, he said, “should be bread-and-butter primary care,” too. When we reach that point, “We’ll be making inroads on a much bigger scale.”
What Can Parents Do?
So what can you do if your child is struggling and you can’t find help? Here’s what caregivers and experts suggest for anyone who feels that their pediatrician isn’t up to speed — or that adequate care is out of reach:
1. Look to other parents. “You’ve got to find a doctor who really cares about you,” said Peter Jensen, M.D. “If you don’t think your doctor [does], you have to keep looking — and the best source is other families.” Jensen writes each parent a “prescription” to attend two CHADD (chadd.org) meetings — they provide an opportunity to ask other parents which doctors really “get” ADHD.
2. Look to other professionals. Psychologists, nurse practitioners, and LCSWs can diagnose ADHD and oversee treatment — either on their own or in partnership with a psychiatrist or pediatrician. Therapists can’t prescribe meds, but they can be trained to perform other interventions, like behavior therapy. The REACH Institute, says Jensen, has trained about 1,000 so far.
3. Find care wherever you can. “Mental health support comes in so many forms,” said child psychiatrist Mary Gabriel, M.D. “It can come through mentorship; it can come through Girl Scouts. Look in your community and see what’s out there.”
Simplify ADHD Guidelines
The American Academy of Pediatrics (AAP) released guidelines in 2011 that outline best practices for diagnosing and treating childhood ADHD. But studies have shown that pediatricians aren’t following them — often because they lack the confidence or feel time doesn’t allow it.
“For most doctors, it’s difficult to do what the AAP guidelines are suggesting they do on a regular basis,” said Jeff Epstein, Ph.D., director of the Center for ADHD at Cincinnati Children’s Hospital. “Primary-care doctors just don’t have the time to do all the things that are required. Particularly, the collection of rating scales can be a tedious process.”
Epstein studied a sample of Ohio-based pediatricians, and found that a mere 50 percent collected rating scales during diagnosis — and less than 10 percent collected follow-up scales to assess the effects of treatment.
To reverse this trend, Epstein’s team designed web-based software that streamlines this process for busy doctors. Teachers receive — and complete — rating scales online; the program scores them automatically and sends doctors the results.
“It made them able to do the things that the AAP was requiring,” Epstein said. “But without those tools, it’s hard to do that — and that’s why we don’t see very high rates of this behavior happening.”
Shrink the Shortage
Even if pediatricians could be trained to handle routine cases, experts say, the lack of true mental health professionals — particularly in rural areas — is concerning. One solution, then, seems obvious: train more child psychiatrists and send them where they’re needed.
Mary Gabriel, M.D., practiced as a pediatrician for nine years. But she realized that her training hadn’t prepared her to deal with the mental health issues she faced on a regular basis. Anything beyond “very basic issues, like ADHD or simple depression,” she said, seemed above her skillset.
She went back to school to specialize in psychiatry, but saw that the seven-year process was onerous for pediatricians like herself who discovered their passion for mental health later in their career. So, she instead enrolled in — and now serves as Training Director for — the Post Pediatric Portal Program (PPPP) at Case Western Reserve Hospital in Cleveland, Ohio, which aims to train pediatricians to become child psychiatrists in three years.
The PPPP trains pediatricians in both child and adult psychiatry. “Most [graduates] go into child psychiatry,” Gabriel said. “Some practice both pediatrics and psychiatry.” One recent graduate went into practice in rural Nebraska — becoming the only child psychiatrist serving a vast area of the state.