Lois Levine

It’s been more than 2 years since the COVID-19 pandemic first shut down schools across the nation. Contemporary Pediatrics® talked with Nathaniel Beers, MD, MPA, FAAP, executive vice president of Community and Population Health at Children’s National Hospital in Washington DC, and a general and developmental-behavioral pediatrician, about what this school year may look like for children and adolescents, and what pediatricians can do to help them play catch-up.

CP: It has been a couple of years since most children have had a regular in-person school year from beginning to end. What challenges await them?

NB: What we learned recently is that the impact of the pandemic on students across the country has been profound. We have seen scores in reading and math drop dramatically globally and disproportionately in minority populations. [Children in] schools that were slower to return to in-person learning showed even more of these academic losses compared with those who returned quickly. Certainly, the vaccines that are now available to children down to age 6 months increase the likelihood of being able to ensure that students can stay in class and have fewer days outside of class. 

Nathaniel Beers, MD, MPA, FAAP, executive vice president of Community and Population Health at Children’s National Hospital and a general and developmental behavioral pediatrician in Washington, DC.

But it means that coming into this school year, we have another year of catch-up to be doing and figuring out how we can help students and families, and create some stability in the educational space. This also comes at a time when we have been experiencing a huge turnover in the teacher and school principal workforce, which puts increased burdens on school systems to solve the academic challenges that students are facing.

CP: What about students with developmental disabilities?

NB: This is a group that has also shown worsening disparities. During periods of virtual instruction, there was a lack of specialized instruction such as occupational therapy, physical therapy, and speech therapy, that was needed in order to comprehend and learn the material. On top of that, this is largely a group of students who benefit from structure and routine. And so even when 

returning to in-person instruction, the frequency at which that was disrupted because of virus exposures in the classroom or in the school created breaks in education, and that was much more disruptive to them than to the general public. 

Having said that, there are some specific groups who actually excelled in those virtual spaces. And what we need to be doing is ensuring that we are looking at virtual educational opportunities and which populations actually do better. We know that there are groups of students who experience significant bullying during in-person instruction. And that virtual space created a safe space for them to learn, and they did well. We also have some anecdotal evidence of high-functioning students with autism who benefited from being able to have a more regulated environment and self-directed space of education, which allowed them to achieve things that they weren’t achieving with in-person instruction. And so we shouldn’t throw out virtual instruction completely. But we do need to understand who benefits from it, who doesn’t, and how to use it effectively during those periods of time that are going to come up. There are going to be times where the COVID-19 infection numbers are so high, there may be a need to reduce in-person instruction again for a period of time, hopefully a much more limited period. But we should make sure that the use of virtual instruction is really augmenting the learning and not creating gaps in education. That makes means making sure that students have access to broadband support, as well as the technology that they need in order to log on effectively at home, if that’s going to be where they receive educational supports.

CP: What about students who play sports or do group activities? After not being part of regular sports teams or recreational activities for more than a year, the football players, the swim teams—have any studies on how those students are doing been compiled? Is everyone jumping back in with gusto? Or are there problems in terms of getting students together for recreational group sports?

NB: There was a lot of interest in getting those activities moving quickly, because people recognize the value they had to students and their social/emotional development as well as their overall mental health. I think we certainly saw students who came back to sports and other physical activities excited about it, who then did develop injuries because of lack of conditioning. During the height of the pandemic, across the whole country, students were getting less physical activity than they had been previously by more than 20 minutes a day. There was also a disproportionate participation that existed that we need to look at as well. Children of minority families may not have been able to participate at the same rates as White families, perhaps because those families had fears about children returning to physical activities and group activities for fear of infection. How do we do reach out to those families and really welcome them back into activities as we plan for this school year? We need to start with a slow ramp up of these activities that acknowledges that not everyone had the same opportunity to maintain conditioning over the past 2 years.

CP: What can pediatricians do at this point? Do they need to advocate for additional help in the schools?

NB: There are several things that pediatricians can do to support children and their readiness for school. It’s about having conversations now about how to create a routine, so that students are ready to return instead of parents waiting for the night before school starts. Pediatricians can recommend that parents shift their children’s sleep schedule a few weeks before the start of the new year. Encourage children to do reading over the summer, play some math games on the computer….These can help create structure as well, which they need once the school year begins. It means creating a schedule where they do a little bit every week, and maybe spread that over several days during the week. Then there’s opportunity for them to have that ongoing learning and using of that brain. But children should be also having fun this summer: it has been a long 2 years of changing rules and changing spaces. And so making sure that they have a chance to unwind and visit with friends and be happy is really important to preparing for school.

Last year, teachers were dealing with huge numbers of behavioral health  issues that were showing up in their classrooms in all kinds of different ways. Students are dysregulated because of lack of routine, because of anxiety and stress that they have of their own. And we need to make sure that school systems have the behavioral health supports that they need in order for teachers to be able to successfully teach students. We also need to have schools ready to acknowledge that there’s been learning loss and that students haven’t learned everything that they should have learned over the past 2 years. Make sure there’s extra support for teachers and students, make sure that it’s not just drilling students to catch up. Really think about how they are doing differentiated learning where they are accelerating students to catch up, but also acknowledge that there are some skill gaps that students need to have filled…. Advocate for classroom teachers who may need some additional instructional support beyond what is typically required. 

We also can’t forget to spend time making sure that we are identifying students with disabilities. The most critical piece that pediatricians can help advocate for is going to be to make sure that there are behavioral health supports both in the school and outside of the school so that students really can be ready to learn when they’re in the building.

Articles

Many students are returning to a regular schedule for the first time since 2020. How will they fare?

What does back to school look like this year?

According to Erin O’Connor Prange, MSN, CRNP, of Children’s Hospital of Philadelphia in Pennsylvania, drugs for attention-deficit/hyperactivity disorder (ADHD) have been on the market for more than 45 years, beginning with methylphenidate (Ritalin), which was approved in 1955. [

Editor’s note: Although not included in the

 Diagnostic and Statistical Manual of Mental Disorders 

until 1968, methylphenidate was originally prescribed for fatigue and depression.

1] According to a 2016 study, roughly 6 million children in the United States have ADHD, said Prange. Boys receive a diagnosis twice as frequently as girls, but overall, 77% of these children were receiving treatment, with roughly 32% of them having both behavioral and medication treatment.

What is a snapshot look at a child with ADHD? Prange, who was speaking at the 43rd National Conference on Pediatric Health Care in Dallas, Texas,

 in March 2022, explained that the main component of this developmental learning disorder is poor executive functioning in tasks. These include planning, time management, attention, organization, and self-control. Additionally, during the months that children were learning remotely due to the COVID-19 pandemic, impaired communication, eye strain, distractions, and anxiety were also reported, largely as a result of the struggle with virtual and hybrid learning.

Nonmedication treatment for ADHD includes cognitive behavioral therapy, extra time for test taking, creating lists (eg, what to put in the school backpack), and bouncy bands and wiggle seats for desks. The newest (those that have become available over the past 5 years) and most commonly prescribed drugs for the disorder include the nonstimulant viloxazine (Qelbree); for stimulants, there are now several methylphenidates (Cotempla, Adhansia, Aptensio, Jornay) and amphetamines (Dyanavel, Adzenys, and Mydayis).

Before starting a patient on stimulants, the American Academy of Pediatrics recommends a thorough cardiovascular assessment, including patient and family health histories; evaluation of all medications being used; and a physical exam focused on cardiovascular disease risk factors. Prange also reviewed the adverse effects for stimulant medications, which include, but are not limited to, decreased appetite, trouble sleeping, headache, weight loss, and mood swings. She also encouraged audience members to seek out a copy of the ADHD medication guide, available at addwarehouse.com, which provides books, assessment products, and training programs for ADHD and related conditions.

This article was published by our sister publication Drug Topics. 

1. Epstein JN, Loren REA. Changes in the definition of DSM-5: subtle but important. 

. 2013;35(5):455-458. doi:10.2217/npy.13.59

2. Prange EO. ADHD treatment explosion: new meds are here! Presented at: 43rd National Conference on Pediatric Health Care; March 23,2022; Dallas, TX.

Nonstimulant drugs and even nonmedication options are available for use.



Quick look: The newest drugs for ADHD

Amy Paller, MD, MS, is the Walter J. Hamlin professor, chair of Dermatology and professor of Pediatrics at Northwestern University's Feinberg School of Medicine in Chicago, Illinois. Here she discusses exciting takeaways from her panel, "Indications of AD, Alopecia and Vitiligo (Practical Pearls)" at this year's Society for Pediatric Dermatology Meeting.

At the SPD 2022 47th Annual Meeting, we talk with Amy Paller, MD, about her panel session on Indications of AD, Alopecia, and Vitiligo

Talking with Amy Paller, MD, about the Society for Pediatric Dermatology Meeting

Researchers Sabrina Dahak, MS, University of Arizona College of Medicine in Phoenix; Jennifer M. Fernandez, MD, RD, University of Nebraska Medical Center, Omaha; Jenna E. Koblinski, MD, Emory University School of Medicine, Atlanta, Georgia; Clara Curiel-Lewandrowski, MD, University of Arizona, College of Medicine, in Tucson; and Rebecca Thiede, MD, University of Arizona College of Medicine, Tucson, evaluated gender differences in both presentation and survival of pediatric and adolescent patients with melanoma.

The investigators used a retrospective cohort study, conducted using the National Cancer Database to identify biopsy-confirmed invasive primary cutaneous melanoma cases diagnosed in patients aged 0 to 21 years, between 2004 and 2018. The study yielded 4645 cases.

The pediatric and adolescent age groups that were used are defined by the American Academy of Pediatrics: infant (birth to 2 years); childhood (3 to 10 years); early adolescence (11 to 14 years); middle adolescence (15 to 17 years); and late adolescence (18 to 21 years).

Of the 4645 pediatric melanoma cases studied, 63.4% were females and 36.6% were males. The researchers noted a significant relationship between primary site on body and gender. For example, for 34.3% of females and 32.9% of males, primary sites included trunk; for 16.4% of females and 30.09% of males, primary sites were head and neck; 19.5% of females and 16% of males exhibited melanoma on upper extremities, while 27.9% of females and 16.5% of males exhibited on the lower extremities.

Females had higher rates of superficial spreading melanoma, and males were more affected by nodular melanoma. Additionally, more females were likely to be diagnosed with stage 1 disease (67.8%) than males (53.6%).

The 5 and 10 year overall survival rates were higher for females (95.9% vs 93.9% respectively) than they were for males (92% vs 86.7%, respectively). The data ultimately showed that, although melanoma was less common in males than in females, males were more likely to have a higher stage at the time of diagnosis and OS rates, information that could be useful for the practitioner when creating a diagnosis and treatment plan for these populations.

Dahak S, Fernandez JM, Curiel-Lewandrowski C, Thiede R. An anaylsis of gender differences in 4645 cases of pediatric and adolesecent melanoma. SPD 2022 47th Annual Meeting. Poster presentation, July 7 and 8. Indianapolis, Indiana.

At an SPD 2022 47th Annual Meeting poster session, researchers look at gender and age differences in pediatric patients with melanoma.

An analysis of gender differences in 4645 cases of pediatric and adolescent melanoma

Back in 2017, the National Rosacea Society (NRS), the world's largest organization dedicated to improving the lives of the estimated 16 million Americans who suffer from this widespread but poorly understood disorder, proposed updated diagnostic criteria for rosacea. The guidelines included transitioning from subtype to phenotype classification. It was not clear if these new guidelines can now also pertain to patients aged less than 19 years.

Olive Osuoji, MD department of Dermatology, University of California, San Diego, California; Elana Kleinman, BS, department of Dermatology, Rady Children’s Hospital, San Diego; Helen Park, BS, department of Dermatology, University of California, San Diego; Margaret M. Appiah, BS, Rady Children’s Hospital, San Diego; and George Hightower, MD, PhD, Rady Children’s Hospital, San Diego, compared photo-documentation in peer-reviewed publications of adolescents diagnosed with rosacea with the National Rosacea Society updated diagnostic criteria to see if the new criteria was applicable to the pediatric population.

The investigators performed a PubMed search using the terms “rosacea (and pediatric OR adolescent)” and limited the search to peer-reviewed publications between October 2017 and March 2022. All articles were reviewed by one or more members of the team to identify the presence of facial photos with a written description that included ages between 12 and 19 years. Identified photos, along with text descriptions were then evaluated using a rubric including phenotype description terms which corresponded with the rosacea diagnostic criteria that was outlined by the National Rosacea Society in 2017.

The search terms produced 106 articles. Six of the articles were not publicly accessible, and 2 articles were not in English. Of the remaining articles, there was a total of 76 images. Only 2 articles included facial photography of patients aged 12 and 19 years. Only 1 of these articles met the 2017 National Rosacea Society diagnostic criteria.

Researchers concluded that there were very few peer-reviewed articles with photos of adolescents diagnosed with rosacea. Furthermore, the search indicated that the 2017 National Rosacea Society diagnostic criteria are not widely used in peer-reviewed studies of adolescent patients. The researchers determined that age-targeted publications showing appropriate use of diagnostic criteria in adolescent patients can help dermatologists in an accurate diagnosis of rosacea for this population.

Osuoji O, Kleinman E, Park H, Appiah MM, Hightower, G. Adolescent rosacea in peer-reviewed publications and the use of the 2017 National Rosacea Society Updated Guidelines. SPD 2022 47th Annual Meeting. Poster presentation. July 7 and 8, 2022. Indianapolis, Indi

At the SPD 2022 47th Annual Meeting, a poster session looks at the updated guidelines for rosacea, and whether they are inclusive of children.

Adolescent rosacea in peer-reviewed publications and use of the 2017 National Rosacea Society Updated Guidelines

Albert Yan, MD, professor of Pediatrics and Dermatology at the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, also a past president of the Society for Pediatric Dermatology, shares highlights of his fascinating presentation on how pediatric dermatology is benefiting from technologies that include crowdsourcing, artificial intelligence and machine learning, and no-code and low-code software building platforms. 

At the SPD 2022 47th Annual Meeting, we chat with Albert Yan, MD, of Children's Hospital of Philadelphia on the latest trends in technology for pediatric dermatologists.

