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June 1, 2000

A pediatrician for all seasons, Diagnosing ADHD, Hazards; Eye on Washington

 

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A pediatrician for all seasons

Sean Palfrey, MD, author of Contemporary Pediatrics' award-winning two-part article, "Overcoming ALTEphobia," is—as readers of this journal might expect—a distinguished academic. He is Professor of Pediatrics at Boston University School of Medicine and Professor of Maternal and Child Health at BU's School of Public Health. He has published widely on medical subjects, and his special interests within medicine range from teaching to the delivery of primary care to poor and multicultural communities, SIDS and infant apnea, lead poisoning, and immunization initiatives.

What readers might not expect are the many other hats Dr. Palfrey wears: as photographer, choral singer, soccer and tennis coach, and—most recently— author of a book about Anasazi children growing up in Canyon de Chelly and Chaco about 1,100 years ago. It's called Children of the Great Wall, and Dr. Palfrey hopes to publish it with illustrations by a Native American artist in the near future.

In his photographer incarnation, Dr. Palfrey has captured astonishing images from canyons in the Southwest to fishing villages in Nova Scotia and wildlife sanctuaries in South Africa. Using a medium-format camera he has modified to take more than one exposure on the same negative, he creates striking photographic compositions. For a sampling of Dr. Palfrey's photographs, go to www.palfrey.com.

Dr. Palfrey's Jesse H. Neal Award, presented in March, was given in the category of "Best how-to" article or series. The article received the additional honor of being third runner-up for the Grand Neal award, for the best article in any category. The series was published in the May and June 1999 issues of Contemporary Pediatrics.

Diagnosing ADHD

Attention deficit hyperactivity disorder (ADHD) continues to generate controversy, both within and outside the pediatric community. The controversy has become particularly acute in the wake of a recent review, reported in last month's Journal Club, documenting sharp increases in prescriptions for stimulant medication to treat ADHD in preschool children. To assist pediatricians looking for a reasonable approach to this disorder, the American Academy of Pediatrics has issued a clinical practice guideline on diagnosis based on a review of the literature and the consensus of experts in developmental pediatrics, psychiatry, psychology, and education (Pediatrics 2000;105[5]:1158). The guidelines are not intended as the pediatrician's "sole source of guidance," nor are they meant to replace clinical judgment or establish a protocol that will fit all children with this condition. A second set of guidelines on therapy for ADHD is to follow.

The recommendations are fairly simple and straightforward. Pediatricians should:

  • Initiate an evaluation for ADHD in a child from 6 to 12 years of age with a history of inattention, hyperactivity, impulsivity, academic underachievement, or behavior problems.

  • Use the diagnostic criteria for ADHD set out in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). These criteria are based on clinical experience and an expanding research foundation. Diagnostic criteria in the Diagnostic and Statistical Manual-PC are not as well tested, although the DSM-PC should be an additional option for pediatricians to consult.

  • Obtain evidence on core symptoms from parents or caregivers and from classroom teachers or other school personnel. Rating scales specific to ADHD have been validated for this purpose, and can be useful.

  • Assess for conditions often associated with ADHD, such as conduct disorder, learning disabilities, depression and anxiety disorders, and speech and language delays.

But a conscientious pediatrician following these guidelines is still left with considerable uncertainty. Although researchers continue to search for the holy grail of a definitive diagnostic test for ADHD, success has eluded them. Brain imaging, tests for lead and thyroid hormone levels, and computerized tests of continuous performance have all been touted as diagnostic, but none of them yield a definitive picture. Clinicians are still left with subjective assessments—their own, and those of parents and teachers—of whether a given child's behavior demonstrates an unusual degree of inattention, impulsivity, or hyperactivity and—even if it does—whether that behavior seriously interferes with the child's ability to function. It's still, as the guidelines point out, a matter of clinical judgment.

Hazards

Pediatricians routinely include safety warnings in anticipatory guidance.

They warn parents of the hazards of hot water heaters with the temperature set too high, car safety seats that are the wrong size or improperly installed, and putting infants to sleep on tummies rather than backs. Still, the most vigilant pediatrician can be ambushed by hazards she never even thought of. Here are two of the more outré dangers that have been in the news lately:

  • Baby chicks and ducklings, often given to children as Easter gifts. According to the Centers for Disease Control and Prevention, this is a practice parents should be warned against. The downy little creatures can carry Salmonella, as recent experiences in Michigan and Missouri have shown (MMWR 2000;49[14]:297).

  • Rides on "extreme" roller coasters, the thrilling finale of a trip to an amusement park. The newer, faster rides have caused severe brain injuries in growing numbers of passengers. The injuries appear to result from the forces unleashed by the ride itself, not from being hit in the head by a loose object, colliding with bars, or falling.

EYE ON WASHINGTON

Mother's Day was celebrated in the capital—and 60 other cities—with what organizers billed as the Million Mom March for "common sense gun control." As Mothers Against Drunk Driving (MADD) have demonstrated, mothers organized as a pressure group can muster considerable political clout. Even the National Rifle Association admits that a million moms pushing for gun-control measures like mandatory safety locks and licensing handgun owners will be hard for Congress to ignore.

At this time, however, Congress shows few signs of passing new gun control laws or any other major legislation that affects families and children. The education bill is bogged down in bitter partisan debate in the Senate, action on legislation to rein in the high price of prescription drugs is stalled, and managed care reform isn't getting off the ground, either. The ruckus caused by Representative Dan Burton (R-IN) with his charges that autism is caused by MMR immunization has died down; expert testimony in a hearing before Burton's House Government Reform and Oversight Committee made clear the lack of any scientific basis for the allegation and members worked out a compromise request for federally funded research—already ongoing—into the causes of the disorder. Donald Cook, MD, President of the American Academy of Pediatrics, issued a statement underscoring the lack of scientific evidence for the MMR-autism link and calling on pediatricians to continue educating parents about the great benefits of routine immunization for all children.

Away from Capitol Hill last month, family and children's issues were confronted in a variety of ways.

The White House held a Conference on Teenagers, an all-day session bringing together academic experts, advocates, parents, and young people to talk about the challenges of growing up safe and healthy in today's dangerous world. At the conference, First Lady Hillary Clinton announced the formation of a National Partnership for Women and Families to educate the public on the importance of making family time for teenagers.

The Department of Transportation announced new standards for automobile air bags, allowing manufacturers to equip cars with less powerful bags that would reduce the risk to children and small adults.

The Centers for Disease Control and Prevention (CDC) launched a Spanish language Web site, CDC En Espanol, at www.cdc.gov/spanish. It is not a translation of the CDC's English language site, the agency says, but a place where Hispanic and Latino health-care professionals and community members can get information in Spanish that is tailored to their needs.

The Food and Drug Administration approved linezolid (Zyvox), the first antibacterial drug in the new class of oxazolidinone drugs. The new drug was approved for the treatment of infections associated with vancomycin-resistant Enterococcus faecium, hospital-acquired pneumonia, and complicated skin infections, including cases due to methicillin-resistant Staphylococcus aureus. In another action, the FDA rejected proposals that would have forced producers to disclose genetically engineered ingredients on food labels. Instead, the Administration has decided to adopt a series of industry-backed steps intended to assure the public that the products are safe.

The Substance Abuse and Mental Health Services Administration launched an information campaign to alert clinicians and the public to the spread of methamphetamine abuse from the West Coast, where it has been concentrated in the past, to the Midwest and South.

CALENDAR

June 22-25, Super CME 2000: Advance and Thrive in Pediatrics, New York City. To register, call the American Academy of Pediatrics at 800-433-9016

September 9, Ketogenic Diet, Philadelphia, PA. For information, call Glorene D. Ford, Children's Hospital of Philadelphia, 215-590-5263

September 11-14, Adolescent Medicine Perspectives, Jerusalem, Israel. To register, call Mariam Malz at 972- 3-6910188

September 21-23, American Academy for Cerebral Palsy and Developmental Medicine Annual Meeting, Toronto, ON. For information, call 847-823-0536

September 22-24, Pediatric Infectious Diseases, Cambridge, MA. To register, call 617-638-4605

September 25-28, National Association of Children's Hospitals and Related Institutions, Philadelphia, PA. To register, call Jane Knops at 703-684-1355.

Judith Asch-Goodkin
Contributing Editor



Julia McMillan. Updates.

Contemporary Pediatrics

2000;6:13.