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New ADHD guidelines: Get the child involved, Immunizations grab the spotlight, for the moment, The new new morbidity. Eye on Washington
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Last October, in a long-awaited follow-up to guidelines on the diagnosis of attention deficit hyperactivity disorder (ADHD) published in 2000, the American Academy of Pediatrics (AAP) released new recommendations for treatment (Pediatrics 2001;108:1033). The guidelines, based on a review of the scientific literature, were developed by a panel of medical, mental health, and educational experts. In developing the recommendations, the AAP worked in partnership with the Agency for Healthcare Research and Quality and the Evidence-based Practice Center at McMaster University in Ontario, Canada.
The guidelines include the following recommendations:
The treatment program should recognize that ADHD is a chronic condition and should incorporate a sustained system to monitor treatment effects and developmental changes.
Clinicians, parents, school personnel, and the child who has ADHD should specify the goals of treatment, related to the specific problems of the individual child.
If appropriate, the clinician should recommend behavior therapy with, or as an alternative to, stimulant medication to ameliorate specific symptoms. The guideline includes a review of the scientific evidence for recommending medication and behavior therapy.
When treatment does not accomplish its goals, the physician should reevaluate the original diagnosis, treatment, adherence, and possible comorbidities.
Periodic and systematic follow-up should be provided.
In ordinary times, keeping the immunization rate up is a never-ending effort that requires ceaseless reminders and public service ads. Not anymore. Demand is strong, and the problem is convincing people to be patient. Vaccine developments that made the news last month include:
An announcement at the annual meeting of the Infectious Diseases Society of America (IDSA) that postlicensure studies in 80,000 infants and children show PCV7 (the 7-valent conjugate pneumococcal vaccine) produced an 87% reduction in invasive pneumococcal disease. Meanwhile, the CDC warned of a temporary shortage of PCV7 and recommended deferring vaccination of children older than 2 years of age, except those at increased risk of pneumococcal disease.
Mixed messages about influenza vaccination, with some officials urging immunization as a way of preventing confusion of flu symptoms with those of anthrax while others caution that limited supplies should be reserved for those at highest risk.
Contention over contracts to produce more than 246 million doses of smallpox vaccine, regarding which manufacturer(s) the federal government will choose and how much the vaccines will cost.
Further delays in supplying anthrax vaccine, as BioPort, the only manufacturer, again misses a deadline for meeting federal safety requirements.
A new study questioning whether the removal of the rotavirus vaccine from the market because of an association with intussusception was really warranted. According to the new research, the risk is substantially lower than previous estimates (Simonsen L, Morens DM, Elixhauser A, et al: Effect of rotavirus vaccination programme on trends in admission of infants to hospital for intussusception. The Lancet 2001;358:1224).
Almost 10 years ago, the American Academy of Pediatrics expanded the purview of the specialty by delineating what the Committee on Psychosocial Aspects of Child and Family Health called "the new morbidity." Pediatricians were asked to widen their concepts of health and sickness to include psychosocial and socioeconomic impacts on children's development and behavior. Now, in a policy statement for the new century, the committee is asking pediatricians to broaden their focus still further, to include among childhood morbidities of concern:
School problems, including learning disabilities and attention problems
Mood and anxiety disorders
Increasing rates of adolescent suicide and homicide
Firearms in the home
Violence in schools
Drug and alcohol abuse
Human immunodeficiency virus infection
The effects of media exposure on violence, obesity, and sexual activity.
To assist pediatricians in tackling these issues, the committee suggests additional training in residency and continuing medical education; improving diagnostic, interviewing, and counseling skills; allocating sufficient time; and advocating for adequate reimbursement for such services. The policy statement is available in the December 2001 issue of Pediatrics.
The nation's capital last month remained almost entirely caught up in what might be called, in the language of tabloid journalism: All terror, All the time. President Bush was occupied with shoring up our sometimes reluctant allies and pursuing the war in Afghanistan. One wing of the Hart Senate Office Building remained closed, after efforts to decontaminate it were shelved pending a better approach than gassing the premises.
Access to government buildings was limited and tourists were scarce.
In Congress, legislation that got to the floor concerned securing the nation against terrorist attacks, rescuing the damaged economy, and paying for the war. To many observers, the interests of children in low-income families seem at high risk in this atmosphere. Health insurance is often the first casualty when the family breadwinner is out of work, and families that have made the transition from welfare to work are particularly vulnerable in times of economic downturn. Pressures on Medicaid and the State Children's Health Insurance Plan (SCHIP) are bound to increase, but funds to shore up these programs will be difficult to secure.
On the plus side, the current political mood accords new respect to the federal agencies that monitor and safeguard the public health. For instance:
The Census Bureau
reported that fewer women with babies under 1 year of age were in the workforce in 2000. Whereas working mothers of infants made up 59% of the workforce in 1999, the percentage dropped to 55% in 2000. If, as commentators think, the shift was a consequence of the economic boom times that are now over, the trend may be short-lived. The Census Bureau also announced the decision not to adjust the 2000 tally in allocating federal aida choice that is likely to harm minority, inner city, and working poor families.
The Departments of Education, Justice, and HHS launched the Safe Schools/Healthy Children program, granting $38 million to 20 communities for programs designed to make school safer, foster children's development, and prevent aggressive and violent behavior and drug and alcohol use.
January 1, American Association on Mental Retardation, Orlando, Fla. For information, call 800-424-3688.
January 1419, Society for Maternal-Fetal Medicine, New Orleans, La. For information, call the American College of Obstetrics and Gynecology, 202-638-5577.
January 26February 2, Update: Pediatric Emergencies, Maui, Hawaii. For information, call the American Institute for Postgraduate Education at 760-431-1670.
February 610, Sports Medicine: A Current, In-Depth Look. For information, call the American Academy of Family Physicians at 800-926-6890.
March 1213, First Annual Forum for Improving Children's Health Care Quality, Tempe, Ariz. Call the National Initiative for Children's Health Care Quality at 617-965-9847.
April 810, The Spectrum of Developmental Disability XXIV: A Review of the Science and Practice of Early Intervention in the 21st Century, Baltimore, Md. For information, call the Office of Continuing Medical Education of Johns Hopkins University, 410-502-9007.
April 1517, National Congress on Childhood Emergencies: Taking Action, Saving Lives, Dallas, Texas. For information, call 202-884-6859.
Updates. Contemporary Pediatrics 2001;12:13.