Barbara Hale-Richlen, M.D.

My wheels turned into the parking lot of the new medical office building that was still under construction. I walked into the expensively tiled hallway to see workmen putting the finishing touches on what will certainly be a beautiful office. Impressed by the professional appearance, I walked down the soon-to-be-busy hallway excited to meet my potential employer.

I was ushered into a cozy waiting room and soon found myself in a plush office. I rose to shake hands with the social worker who owned the group and was introduced to an office manager and a Ph.D. who were also working there. My initial first impressions of a well run mental health practice were soon dashed as the conversation turned to talk of “expanding revenue streams,” and the lack of “money to be made” in mental health. My thoughts of talking about treatment philosophies to see if we were a “good fit” soon turned to thoughts of “how fast can I get out of here?” During the 45-minute interview, I was exposed to a side of medicine I had not yet seen but always knew was out there — the businessman with no medical training who seeks to capitalize on new technology solely for the purposes of profit.

He quickly dominated the conversation with talk of how he planned to “capture the market on attention-deficit/hyperactivity disorder (ADHD)” within 18 months, and then “franchise” his model out to other businesses. When I pointed out that ADHD was a relatively straightforward diagnosis to make and treat, he disagreed, stating that it was often misdiagnosed and was really post-traumatic stress disorder (PTSD) or some other disorder. He then launched into his grand plan: SPECT scans of children’s brains to “prove” the diagnosis of ADHD. Several thoughts tumbled through my mind including that he might be pulling my leg.

“Who will pay for this treatment?” was the first question I managed to ask.

“It’s $3,500 and will be all out of pocket,” he replied.

Incredulously I looked at him and said, “Do you believe there will be people willing to pay that amount of money for something that a Conners form and a good clinical interview could diagnose for one tenth that amount?”

“They certainly will!” he retorted. “They are doing it right now in California and Colorado.”

I asked if he really felt this would be helpful to families and pointed out that there is no evidence to show that SPECT scanning has any diagnostic validity.

“Well, I’d do it if it were my kid! I wouldn’t want to expose them to those drugs for nothing!” he replied rather defensively. “Besides,” he added, “we’ve partnered with a pediatric radiologist and he’s looked at the data and he feels it’s there.”

I listened patiently for a while and then realized that this “interview” had to end. I interrupted to tell them a little about myself. I spoke of my enjoyment treating complex cases involving significant social problems, medical and psychiatric issues that required a dedicated team approach, and added that often those families have little to no money. I pointed out that finding new “revenue streams” was not an interest of mine. I soon found myself back in the waiting room needing to knock on the glass divider to ask the receptionist for my coat.

As I hurried to my car, I thought of all the families that would feel they weren’t giving their child the best treatment possible if they didn’t use this fancy new technology. I’m sure they would be impressed, just like I was initially, with the expensive exterior and the slick marketing. All this helps to lend credibility to what all my years of training have taught me is a sham. For the amount of money they want for one SPECT scan, a child psychiatrist could diagnose and treat that child for two years, including medication costs.

I knew it would be useless to explain that the ADHD-specific questionnaires and rating scales have been shown to have an odds ratio greater than 3.0, which is equivalent to sensitivity and specificity of greater than 94 percent. In fact, the American Academy of Pediatrics Clinical Practice Guideline for the Diagnosis and Evaluation of Children with ADHD states that, “ADHD-specific rating scales accurately distinguish between children with and without the diagnosis of ADHD” (AAP 2000).

Joseph Biederman, M.D., program director of the Pediatric Pharmacology Research Unit at Massachusetts General Hospital, stressed that SPECT scanning is a valuable research tool but cannot be used diagnostically. “Although brain-imaging studies have documented both structural and functional pathological changes in frontal-subcortical-cerebellar circuits, imaging methods cannot be used as diagnostic methods” (Biederman 2005).

But perhaps utmost in my mind that day were the ethical concerns I had. Principle I of the American Academy of Child and Adolescent Psychiatry Code of Ethics states that professional judgment and the behaviors or actions which arise from that judgment must be based on scientific knowledge and collective and personal experience (emphasis added). Principle III acknowledges the unique relationship that a child and adolescent psychiatrist has with children, adolescents, and families. The potential influence based on that relationship should be used to foster “optimum development and well-being of children and families.” Principle III further states “any action that involves exploitation of children, parents, or others involved for the physician’s personal gain or aggrandizement, is clearly unethical.” At this point in time, it is hard for me to imagine a child and adolescent psychiatrist ethically recommending SPECT scans as a diagnostic tool.

I fear that our patients’ families, with already stretched budgets, will be dazzled by fast talk and fancy equipment, and will fall prey to those who want to use the hard earned credibility of the medical profession to fatten their wallets. We need to be aware that these practices are occurring so we can educate our patients as well as our colleagues to not fall prey to this “new revenue stream.”