Diagnosing ADHD, with Dr. Mark Wolraich | EDB 260
Mark Wolraich, MD discusses his work creating diagnostic scales for ADHD, and how the medical community can better serve neurodivergent patients.
(VIDEO – 30 mins) Dr. Wolraich is CMRI/Shaun Walters Professor Emeritus of Pediatrics and the Chief of the Section of Developmental and Behavioral Pediatrics at Oklahoma University Health Sciences Center, and the former Director of the Child Study Center. He received his MD from SUNY Syracuse Health Sciences Center. His residency training in pediatrics was split between the SUNY Syracuse Health Sciences Center and the University of Oklahoma followed by a fellowship in the care of handicapped children at the University of Oregon. Dr. Wolraich helped create the The Vanderbilt ADHD Diagnostic Rating Scale (VADRS) – a psychological assessment tool for parents of children aged 6 to 12 designed to measure the severity of attention deficit hyperactivity disorder (ADHD) symptoms. He also worked on the Siperstein -Wolraich Adjective Checklist, which helps identify intellectual differences in kids.
Dr. Wolraich has authored 150 journal articles or book chapters including articles in the New England Journal of Medicine, Pediatrics, and the Journal of the American Medical Association. He has edited or written 22 books including three books on ADHD. Dr. Wolraich received the Lewis D. Hollaway Award for Research in Health Science Education from the University of Iowa, the Lee Salk Distinguished Service Award from the Society of Pediatric Psychology, induction into the CHADD Hall of Fame of the Children and Adults with Attention Deficit Hyperactivity Disorder, the Edith Kinney-Gaylord Presidential Professorship for meeting the highest standards of excellence in teaching and research from the University of Oklahoma, Mentor Award from the Department of Pediatrics at the University of Oklahoma, and the C. Anderson Aldrich Award from the AAP for outstanding work in the area of child health and human development.
AUDIO PODCAST VERSION:
Or look for us on your favorite podcast provider:
iTunes | Stitcher | SoundCloud
FULL TRANSCRIPTION
HACKIE REITMAN, MD (HR):
Hi, I’m Dr. Hackie Reitman, welcome to another episode of Exploring Different Brains. And today, I’m excited because we’re going to learn from one of the world’s authorities on ADHD, which I got some of that going on too. And Mark Wolraich is nice enough to join us. He’s written the books, He’s invented the categorization. We’re gonna learn all about it, Mark, welcome to Exploring Different Brains.
MARK WOLRAICH, MD (MW):
Thank you for having me.
HR:
How did you get involved in all of these different brains kind of things?
MW:
When I was in medical school, first, I got involved in pediatrics, because that was the only rotation I really liked, had the nicest people in addition to the children. And then I got involved with one of the faculty, Ted DeBono, who was interested in children with intellectual disability as well as children with what we call the bedtime minimal brain dysfunction, which is now ADHD. It was also when there was a big S experts say about the institutions for intellectually what was then called mental retardation, called Christmas and Purgatory. I don’t know if you remember the the book, it was one where they took pictures and went through one of the large institutions in Massachusetts, and showed how horrible that care was. And I got similar personal experience, because I was working with a geneticist who was getting blood samples from the Rome State School, which was a New York institution for intellectual disabilities at that time. And that got me interested in that.
And Ted got me interested in minimal brain dysfunction. And I continued to have interest on that during my residency, and then did a fellowship. Because that was before there was a subspecialty in developmental, behavioral pediatrics. So it was called on on on the handicapped child, at the time, and it’s always fascinated, fascinated me over over the years, part in with a lot of consistencies that really go back to the the time when I got started, that are still present with it. But it also got me involved. Coming from being the son of a Holocaust survivor, I’ve been very sensitive to how minorities and how individuals with disability are treated by society, and that it’s very important in terms of the services that you can have.
HR:
Well, I hope that we as humanity have learned from the Holocaust, I sometimes I wonder, and I certainly hope we have.
MW:
Yeah, I wonder too, given the current time.
HR:
Yeah. Tell us about the Vanderbilt ADHD diagnostic rating scale.
MW:
But to give you some background before getting to the scale, back in the 70s and early 80s, there weren’t there weren’t. What’s now the in terms of the mental diagnostic categorization, there was the DSM, but it was not widely used outside of psychiatry. So pediatricians who have had an interest in ADHD, had didn’t have necessarily the same criteria. And I really felt that to be able to communicate and coordinate services between the different providers of services for individuals with ADHD, there really should have more you define unified diagnostic criteria in the process. So I developed ADHD scale, and it wasn’t the first there have been there were other scales that similarly that were developed around that time, but that includes all the criteria from the age From the DSM system, and could be used more easily in primary care settings, as well. And so I initially developed it for research I was doing about how primary care clinicians were dealing with kids with ADHD, but then went on to make it so that it’s available through the American Academy of Pediatrics, but also that it’s in the public domain. So there’s no cost for the scale to now where the DSM criteria are pretty universally accepted as the criteria for making the diagnosis.
HR:
Well, that’s kind of a segue into your involvement in the Silverstein Wolraich, adjective checklist.
MW:
Well, that actually predates do doing the Vanderbilt rating scale. Gary Silverstein and I were interested, particularly the attitudes of clinicians, in dealing with kids with intellectual disability, and getting a sense that most clinicians don’t really know the capabilities of of individuals with disability and what they’re likely to be able to do or not do. Gary had developed for other reasons, what using what’s called the adjective checklist. And so we essentially took different items from very basic like, eats from spoon drinks from ricotta up to use as a telephone manages checking a checkbook to an Ask clinicians, what they what they thought someone and we would either have a case or level of intellectual ability for them to say what they thought that those individuals would be able to do by adult adulthood. We surmise, which was what you found is that they tend to be more pessimistic about the conditions and the more severe you’re that you describe the disability, the more pessimistic they are in the cases. And so we did, and also so that it affects then decisions about treatment. Involve that if they’re very pessimistic about how well they could do they tend to be not as open to treatment. So we use a combination of cases. One of the examples would be children with spina bifida, it was for a while I was run for 14 years ran the spine a benefit of program in at the University of Iowa, that if the case was severe, they were a lot less eager to provide aggressive treatment for the kids. So we would give a case that we would describe as more severe and then asked what they thought they those individuals would likely be able to do when they were adult. And if there were a mild case they would be able to do.
HR:
Well, you know, if you bring back memories of part of my orthopedic rotations at Boston University with the Shriners Hospital for Crippled Children out in Springfield, Mass, and you know, there was a wide range of those patients, and there’s a lot to be said about names and the effect they have on people. What would you say that most people don’t understand about the way that ADHD and similar differences are diagnosed?
MW:
The diagnosis for ADHD is really based on observed behaviors. But it’s observed behaviors, not like you’re taking a intelligence test where you see what’s done. It’s behaviors you observe within the setting within the family with how they’re doing in school. And so it’s more complex, but it’s basically when behaviors particularly around difficulties, being able to pay attention and to think through things about being impulsive, and and, and overactive. And it’s been interesting that the behaviors for what was called minimal brain dysfunction and then now ADHD have been constant over the years. If you go back to Around the turn of the century, surgeon in London describe describe the condition very much as it occurs today. And there is also a German primary care physician in the 1850s. He wrote a book we’re, that has Harry who looks in the air, and fidgety Phil, both who come to no good as as part of it as children’s books at the time. So the elements of inattention, hyperactivity, and impulsivity have really been constant now over 4050 years.
HR:
And my my daughter, Rebecca was doing some tutoring in a school. And she would take the, the kids in some of the special ed classes who were really disrupting the class, take them separately and try to tune in on what their deal was. And I remember once this, this kid who was in math class kept getting thrown out because he was fidgety and wouldn’t do this. And that was disrupting, and kept getting up to walk around and all that took him in a separate room. And he was really kind of nasty and acting out. And she said, Would you like to pace around while we do this work? And he said, you’ll let me pace and say, Yeah, as long as you do the work, PACE threat was a pleasure, you just had to be pacing, because his brain was different. And that’s just an example of, I guess, considerations. I’m not saying everybody should do something like that. But like, you’re saying, you look at the individual’s brain, because every brain is different. And it’s not like, well, he’s got ADHD, therefore, XYZ, it’s, what is that individual doing?
MW:
But you do have to function within a society.
HR:
Yes!
MW:
You really have to have some skills that enable you to do that.
HR:
Yep. So you have to learn the tools that will let you get along with society. And likewise, society, for its own benefit has to learn how to make some accommodations. Talk about the importance of having a team approach to the individual with ADHD.
MW:
Well, there are multiple challenges for kids with ADHD. So you’re talking about certainly school as a as a big one, in terms of it. And there are and have a large number that kids with ADHD will also have learning problems as part of it. And language problems and there’s a high CO occurrence of anxiety disorders or depression. As part of it, they frequently have a motor challenges in terms of again, coordination of what they’re working with. So you’re dealing with a number of different people that can be professionals that can be of help from them from the clinician to treat because the, the the medications are effective in helping kids to concentrate. Particularly teaching parents in behavior management that psychologists do. Particularly for the younger kids, is an important factor dealing with the educational problems they deal with. One of the things for me, that enticed me when I was in my last year of medical school was dead de Bono, who was one of my mentors had set up a clinic in combination between the medical school and Syracuse University and included speech clinicians and psychologists and educators as part of it. And it was fascinating seeing how they look at children differently than the physician. Looking at and bringing them together really came up comes up with a much more effective way of trying to address the, the needs.
HR:
Tell us about your involvement with Reach.
MW:
Okay, and you’re going to be interviewing Peter Jensen. In the future Peter Jensen’s a child psychiatrist had worked with in NIMH National Institute of Mental Health, for a number of years, particularly for a lot of the large studies that that were done to give us gives us the evidence, and really felt that what was needed was that is to be able to train primary care clinicians to better manage mental mental illness in in their patients. Because there are only about 7000 child psychiatrist in the country. And if you figure it out, based on the number of children, that means that that have challenges that comes out to they would get about 36 minutes a year, per patient, that it really needed additional coverage, and that there’s poor communication that goes on between the people. So I got involved with with him in some of the early development of the program and became a more active teacher over about the last eight years. What’s been fascinating for me is it uses a very much of an adult learning method. In my earlier studies, I was trying to look at how we could improve training for pediatricians and found that lecturing really doesn’t do the trick. for them. We tried doing what the pharmaceutical companies do of having someone come to the office of it, but that works, okay, if all you want to do is get them to realize the name of the particular drug that they would like to promote, it doesn’t really help them with the skills they need to provide the services that they do.
So the REACH program developed what’s basically a two and a half day program that is very interactive, it has role plays, it has table exercises, as part of it. And then it’s followed up, which is an important element of it, with six months of twice a month, case conference calls where those who’ve participated in the course, then get a chance to present a case and there’s discussion about the case, but I’ve sort of been knocking my head against the wall now for years, trying to convince pediatrics that the training of pediatric residents has to have more training in development and and behavior which it still doesn’t the requirements in most residency, it’s it’s only one month out of three years. And it’s sort of ironic, because over half of the kids that the physicians that are going to be taking care of have some men mental illness as part of what they’re dealing with ADHD is the most common, and that’s what they do, but they’re certainly providing also the primary care for kids with autism. They’re providing it for kids who are having anxiety or depression as part of it. And they get very little training in that, that they still the residency still is primarily focused on hospitalized patients. And in reality of them primary care. They may not have any hospitalized patients because now there’s a sub special team of hospital physicians taking care of it. So they go into practice with over half of their kids having chronic illness and developmental and behavioral problems without the skills to really treat it well. The REACH program does help in terms of the behavioral and mental illness conditions.
HR:
I gave probably the only lecture they ever had at the American Academy of Orthopedic Surgeons on neurodiversity. An attack I took with the my fellow orthopedic surgeons was whose it’s not their fault then in medical school in North Korea. residency, you get zero training in this stuff. But I said, Look, you you’re already treating x percent of your patients are on the spectrum or have different things. And I said, Let’s just take what isn’t. If you start to look at everybody a little differently, I said, Remember that patient who it took you 45 minutes, just getting the fiberglass cast off and the kid was screaming, and you thought it was just a poorly brought up kid. And that’s because they’re hypersensitive to vibration, you could have saved yourself 45 minutes of your office time, if you use plaster, and have them start to soak it off at home, okay, because that, but you can’t know that you got no training in it. But if you start to look at it like that, then you can make those little things. And I think that got their ear only in the sense that it was something tangible that could be taught, and would help them in the office and also converts to a better bottom line in their practice, too. Because let’s face it, you tell you spent 45 minutes on a patient that could have taken your 15 It’s a big difference. So and I know that our friends at the AADMD, in the dental area, getting the dental students and they finally got the Dental Board to change the rules that you have to get that much more training of disabled individuals.
MW:
While I’ve been pushing for 30 some odd years in terms of pediatric training, part of the problem is how training is funded. residencies are funded through government funds to a great extent that come to the hospitals. And so what they get trained on is still primarily hospital care in the severe conditions, they spend a number of months in the neonatal intensive care unit. And when they get out in practice, they’re not likely to be using any of that on their own, because that’s become very much of the specialty center. But it’s been very frustrating, you know, we really, really worked, I What was very much involved in defining helping to develop the subspecialty of developmental and behavioral pediatrics. And we have pushed to try to get that to be more of the residency. And I just learned in the program that I retired from, that they’re actually going back the other way that even that month is divided up. So it’s really not as effective training and it’s not surprising they get out and they don’t know how to handle the cases that we teach in the meet reach Institute or to how to best develop or deal with kids with with autism or other conditions.
HR:
I used to have these discussions with one of my old classmates was the head of the National Institute of Mental Health for a while Tom Insel. You know, it’s it’s tough to turn around the elephant, you know, it’s tough to get it going. But there’s got to be a way to do it. But I guess we’re not going to figure it out today.
MW:
We’re not figuring it out today. The REACH program has now had training of over 5000 primary care physicians. So it is making a dent in the program in how well they’re able to handle cases. And so that’s been encouraging. But until we also get a eliminate the separation of mental health from physical health, so that it’s all it’s all one person that we’re dealing with. You know, there is not a good way that conditions are handled or coordinated between it and when you have when you’re limited to 1520 minute visits on patients. Those patients that are need a lot more help really have difficulties.
HR:
Well, I think the the odds have improved paradoxically for getting the education out thanks to COVID with the rise of virtual learning, like we’re doing now, and I think that makes it much more possible in a very limited fashion to educate the already, you know, out there practicing bunch.
MW:
Yeah, that’s what the the reach Prout program right now is has been all virtual and actually they’ve been able to maintain, which we had some concern over what all of the things that we’re doing with table exercises role plays, on doing it virtually, and it still has worked. And the least the feedback we get has been very successful. But it’s also, you still need more time, two or three days or a virtual goal doesn’t replace what would be a much better training program for physicians in particularly during their residency.
HR:
Sure, Mark, is there anything we haven’t covered today that you would like to cover?
MW:
Well, I think we’ve talked about it, but is a really emphasize the issue of getting of getting clinicians to communicate with each other on patients and, and across disciplines. What we talked a lot with, when we have the case conference calls is have Have you spoken to the child’s therapist, their, their or their counselor, as part of it, and and how well, you know, the we don’t have the structure in place to get communication between clinicians that they need to, we hear continually, particularly when you have the walls up between what is mental health and what is physical health, that there isn’t the communication and coordination that’s really needed as as part of it. And I, it would take too long to talk about just that how corporate the whole healthcare system has become, over the years there. You know, all healthcare now is through large health corporations be their medical schools or private things, and that has some benefits, but it’s also had a lot of drawbacks.
HR:
Well, we’re gonna have you back another time to explore all that because a while it’s not just in what we’re talking about, as you said, it’s affecting everything. And I could not have practiced orthopedic surgery the way I did today, wouldn’t be allowed to do it. The structure wouldn’t put up with it. And I, but that’s a that’s a subject for another day.
MW:
And you can’t you can’t manage kids with ADHD solely by 15 minute visits, as pediatricians are required to do in most practices.
HR:
Well, Dr. Mark Wolraich, it’s been such a pleasure to have you I learned so much and I’m sure our audience did. How can they learn more about you?
MW:
They can probably Google my name and see it. I’ve been active in the American Academy of Pediatrics over the years. So there’s that and also through the Society for developmental and behavioral pediatrics that I embedded. That is the with with subspecialty, that’s relatively new subspecialty that I was involved with informing are probably the most they can look, I spent the last 20 years at the University of Oklahoma. And they can certainly look at that. One of the things I think that you may have been interested is I will will develop a service navigation program with county coordinators and involving primarily families in Oklahoma that is still active and continuing to grow. It’s not statewide yet, but we’re it was it’s in about 13 counties.
HR:
So that can serve as a template for other states as well.
MW:
Yes.
HR:
That’s great. All right, Mark, we hope you’ll come back again soon. Keep up the great work you’re doing. And thanks for all you’re doing not just for ADHD, but for everything. Thank you so much.
MW:
Thank you. I’ve enjoyed it.