Managing ADHD at Hadassah Hospital
In the United States, more than a quarter of the children affected by it are expelled from school for disruptive behavior and over a third are involved in theft. Untreated, many of these children will grow into underachieving adults who are involved in four times more car accidents than average, have difficulty holding down a job, are at high risk for substance abuse and have criminal or suicidal tendencies.
These disturbing statistics from the Centers for Disease Control and Prevention and the American Academy of Pediatrics are for the condition known as ADHD—attention deficit hyperactivity disorder. The most common neurodevelopmental deficit of childhood, it affects up to 10 percent of the world population.
“While you can turn the figures around and say that 9 in every 10 people do not have ADHD, the fact is that it is so common it impacts on us all, from the schoolroom to the workplace to the roads,” explains Dr. Itai Berger, director of the Neurocognitive Center of the Hadassah Medical Center’s pediatric division on Hadassah’s Mount Scopus campus.
This, he says, is one reason why ADHD was an immediate focus for the center that he opened three years ago. A second is that the condition, while chronic, can be effectively managed—and the earlier and better it is managed, the better off the child, family and classmates. “The wheel for managing ADHD had been invented,” says Dr. Berger. “What was needed was getting it to turn early and to keep turning smoothly and regularly, so that today’s difficulties are effectively handled and tomorrow’s are minimized.”
The approach that Dr. Berger and his team have developed was among 20 innovations selected from 2,000 Israeli practices for presentation at the TEDMED international biomedical conference’s Great Challenges Day in May 2013. Billed as “Faster Adoption of Best Practices,” the Hadassah model was enthusiastically received and continues attracting attention—with a Ugandan medical team the most recent in a succession of those interested in adopting it.
“Our model focuses, first, on early and accurate diagnosis and, second, on compliance with prescribed therapy—tested behavioral, psychological and pharmaceutical interventions,” says Dr. Berger. “This may sound obvious, even simplistic, but, believe me, it is far from that.”
For diagnosis, there is no definitive test, scan or marker. “Not every child with poor social skills who is disruptive at home or at school has ADHD,” he says. “Nor are all those who are afflicted hyperactive. An accurate diagnosis needs thorough and expert evaluation, with input from parents and teachers.” But less than half of children with ADHD are seen by specialists, he points out. Even with specialists, the 10- to 15-minute appointments scheduled by health funds, sufficient for diagnosing many medical problems, are inadequate for an ADHD diagnosis. Hence long waiting lists, despite the critical importance of early intervention.
The second part of managing ADHD is eliminating the often wide gap between diagnosis and treatment. “No single gene for the syndrome has been found, but it has a clear genetic basis, with three quarters of affected children having a parent or sibling with the same condition,” says Dr. Hanoch Cassuto, a pediatric neurologist and researcher at the neurocognitive center. “Such parents find it harder to adhere to treatment schedules—appointments are missed, medication forgotten. And many parents, with or without ADHD, are reluctant to medicate otherwise healthy children.”
To clear the obstacles, Dr. Berger’s team has brought in the community. “[Hadassah is] aware that community services play a major role in day-to-day management of chronic conditions,” he says. “We thus approached ADHD as a clinical condition involving the patient, his or her family, the community and the health system and developed a way for them to collaborate for diagnostic accuracy and for compliance with evidence-based treatment.”
Step one, started three years ago, was mapping the situation. Using a wide-ranging questionnaire, the Hadassah team ascertained the needs and perspectives of parents, teachers, school psychologists—all those caring for children with ADHD. Step two was to create gatekeepers to the medical system.
“Faced with the urgency of diagnosing children with ADHD as soon as possible—ideally by age 4—we teach teachers…psychologists and occupational therapists to do the preliminary screening, enhancing early identification,” explains Dr. Berger. “They, along with the children and their parents, complete our intake forms and questionnaires and forward them to our center. As appropriate, we then schedule a one-hour appointment, sometimes asking for further information, tests or scans beforehand.”
On days dedicated to ADHD patients, the child comes to the center clinic with all necessary paperwork and with his or her parents and teacher and, sometimes, psychologist as well. “Because everything is in place, we can make an evidence-based assessment and recommend treatment tailored to the specific needs of the child at this first meeting, speeding intervention and cutting waiting lists,” says Dr. Berger.
“With the school representative as part of the process, parents are helped practically and supported emotionally,” says center pediatrician and ADHD specialist Dr. Einat Yaari. “And if there is a gap between our medical language and the school’s understanding of it, the school intermediary who was at the consultation can verify that recommendations are followed, ensuring a two-way flow of information.”
In 2012, the first year this model was applied, 89 youngsters, ages 6 to 18, were identified by community gatekeepers and attended the clinic. Chana (not her real name) is the mother of a bright, impulsive 11-year-old boy. “Since seeing you, we have known the best days since he was born,” she told Dr. Berger at a follow-up appointment. “He is a sweet child, but living with him has been unrelenting hell. If he didn’t like his food, he’d tip over the table. He was always sorry and promised never to do it again…but he always did. Behavioral therapists worked with him for years. Nothing helped until you saw him and put in place your system, medication schedule and psychology.”
“This clinic has changed—even saved—the lives of many children, enabling them to live normal lives with their families,” says Rabbi Shimon Orlansky, one of the community gatekeepers.
Approval rating among the center’s first-year intake was 87 percent. Last year, the team saw 70 new patients each month, and the numbers continue to grow. In November, at the request of Israel’s Education Ministry, the Hadassah team taught its gatekeeper course to school psychologists countrywide.
“It is not that ADHD is a new syndrome or a growing one, it’s that the context has changed,” says Dr. Berger. “Youngsters no longer leave school at 12 to work on the farm or help in the shop. They remain in academic settings, where attention deficit and hyperactivity are more visible and problematic.”
It has taken almost 100 years since ADHD was first identified (and labeled “minimal brain damage”) for it to be recognized as a neurobiological disorder with small changes in the shape and functionality of the brain.
One recent breakthrough in understanding its neurobiological basis is the discovery of reduced dopamine activity in the brain, a chemical that signals nerve cells and influences behavior such as the ability to concentrate. Another is a recent National Institutes of Health study that has shown a two- to three-year delay in certain areas of brain development in children with ADHD: The prefrontal cortex, the brain’s all-important neural tissue or gray matter, is thinner than appropriate for their age, and their attention span and inhibitory control are thus underdeveloped. Dr. Berger’s team found the same in a study they made of 124 children ages 6 to 11.
Along with the impact it has made on diagnosing and managing ADHD, Hadassah’s rapidly growing center has, in its three years, also focused on autism, epilepsy, cerebral palsy, very-low-birthweight infants and, most futuristically, neonatal neurology—advising pregnant couples when brain development in their unborn child is abnormal.
“Much of what we do at the center is care rather than cure—as in our work with ADHD,” says Dr. Berger. “For me, care and cure are two sides of the same coin, and both are why I chose to practice medicine.”