Your Voice
READERS' FORUM
Another resource for ADHD patients
I would like to recommend that ADD Success Stories, a positive and useful book, be added to the list of books mentioned in the article by Dr. Gephart and Ms. Green, "ADHD: Resources for parents" (September 2000). Written and edited by Thom Hartmann, the book is a compilation of stories on survival skills and coping strategies contributed by adults and adolescents who have been given a diagnosis of attention deficit disorder and who lead a successful life. Several chapters offer brief self-reports on organizational strategies and social skills development, as well as insights into the driving forces of this problem and how to manage them successfully. A career counselor contributes the final chapter about "ADD-friendly" careers, including sales, law, the culinary field, the military, and medicine (think ER and ICU doctorshigh intensity, short-focus interventions with often novel problems and interactions).
The initial chapters explain Hartmann's thoughtful paradigm of people with ADD being "hunters in a farmer's world." In a previous book, the author discusses a study reported by Dr. Edna Copeland indicating that as many as 50% of successful American business entrepreneurs test out as having ADD. It is precisely because of high energy levels, creativity, spontaneity, and a willingness to take risks that these people are successful.
The problem I have with the majority of the books referenced in the article by Dr. Gephart and Ms. Green is the underlying assumption by many of the authors that this symptom complex is an actual disease and therefore a lifelong disability. I do not believe that this is an accurate assumption. One has only to look at some of the parents of our ADD kids to recognize many of the same traitsand these parents are often highly competent and successful, at work and as parents.
I have received excellent feedback about ADD Success Stories from many of my families. Published by Underwood Books, it is available in paperback at a modest cost.
George Starr, MD
Syracuse, N.Y.
The author replies: I am not familiar with the book ADD Success Stories, but it certainly sounds like a positive and encouraging resource for both parents and patients with ADHD. I would add that most of the books on our reading list, though they mention the possible negative outcomes of ADHD, do show strategies that can help one attain success.
I would concur that, for many patients, using the term "disorder" to describe ADHD seems a bit harsh, since many of them do very well with minimal interventions and become productive, responsible members of society. Yet, recent neuroimaging, genetic, and pharmacologic research certainly substantiates ADHD as a true medical entity.
We are all too aware that ADHD can be a very disabling and life-changing problem for many children with this diagnosis. For example, many studies show that, among patients who have the hyperactive-impulsive subtype of ADHD, 20% to 40% are eventually assigned a diagnosis of conduct disorder. And although 50% remit toward normal, the rest have continuing problems into adulthood, leading to a diagnosis of antisocial personality disorder.
Our experience (unlike that of Dr. Starr) after treating more than 4,000 patients during the past 10 years has supported the concept of ADHD being a potentially disabling condition. Fortunately, a multimodality intervention program that includes educational and behavioral interventions along with appropriate use of medication can, we believe, significantly alter those negative consequences.
Harlan R. Gephart, MD
Redmond, Wash.
Type 2 diabetes: When to screen?
Thank you for the helpful article, "Type 2 diabetes: Not just for grownups anymore" (January). Like many pediatricians, I feel rather unprepared to care for patients with this disease, since the last time I thought I would ever see type 2 diabetes was as a fourth year medical student doing my internal medicine subinternship!
One thing missing from the article was guidance on appropriate screening for children who fit the profile of someone at increased risk of diabetes. What would the authors recommend? For the last year or so, I have been screening my obese and overweight patients for diabetes if they have acanthosis nigricans or a family history of diabetes. I get a urinalysis in the office and then have the patient get a fasting glucose, glycosylated hemoglobin, insulin level, thyroid stimulating hormone level, and fasting lipid profile as an outpatient. So far only one of my patients has been found to have overt type 2 diabetes during a routine physical, and I prefer to think of this as a "serendipitous," not "accidental," finding.
Barbara L. Durso, MD
Dallas, Texas
The author replies: We appreciate Dr. Durso's comments. She expresses well the dismay felt by many of us who had assumed that choosing "Pediatrics" meant a practice free of the disorders we disliked during our internal medicine rotations. Regrettably, type 2 diabetes is only one of a group of disorders once considered the purview of the internist that the practicing pediatrician must now reeducate herself to address. Equally regrettable, the rapid increase in these disorders has taken the pediatric community by surprise, and there is generally very little research on which to base treatment decisions. With the recent advent of NIH-funded studies on natural history, epidemiology, and treatment, a great deal of useful evidence should become available over the next five to seven years. Until that time, our approach to these kids must be based on a pediatrics-informed reading of the adult literature.
Dr. Durso requests recommendations for the screening of children considered at high-risk of type 2 diabetes. We're sorry to admit that this omission was not "accidental,"or even "serendipitous," but reflects the authors' inability to agree on the issue and the lack of data on which to base a recommendation. Many advocate measurement of fasting blood glucose and glycosylated hemoglobin. This is certainly defensible and relatively easy in practice, and has high specificity for diabetes. But changes in these measurements occur relatively late in the natural history of type 2 diabetes; it seems preferable, using the classical pediatric approach, to identify the disorder earlier in its course. Because impairment of glucose tolerance precedes impairment of fasting glucose, it can be argued that testing postprandial glucose would be more sensitive and permit earlier intervention. This can be done as a formal oral glucose tolerance test (OGTT) or by measuring blood glucose two hours after a carbohydrate-rich meal.
The caveat, of course, is that we have no data to indicate whether intervention before impairment of fasting glucose is as good an idea as it seems. Therefore, whether the benefit to the patient outweighs the greater inconvenience and cost of a formal OGTT remains to be determined. Because of the lack of data on which to base an authoritative recommendation, we mustat least for nowleave the choice of screening approach to the discretion of the primary physician.
The utility of measuring the insulin or C peptide level, or both, during screening is even more uncertain. In epidemiologic studies, elevated insulin and C peptide levels have been clearly associated with risk for subsequent development of diabetes. Their utility in the care of an individual patient is less clear, however. Though we routinely measure these levels, we do so in an effort to identify children who have evidence of insulin resistance and normoglycemia for inclusion in studies designed to explore approaches to preventing progression to frank diabetes. While the information can provide some ammunition to the physician when counseling about the risk of type 2 diabetes if the patient doesn't make a lifestyle change, the appropriate therapeutic response to an elevated insulin or C peptide level in an adolescent has yet to be determined. Again, the decision to measure the insulin or C peptide level as a screening tool remains at the discretion of the primary physician until more evidence is available one way or the other.
Last, the patient mentioned by Dr. Durso who has a diagnosis of overt type 2 diabetes following screening nicely demonstrates the value of focused screening. The accidental patient we refer to in the article is the surprisingly common patient who is noted to have glucosuria or hyperglycemia during an unrelated evaluation, such as a school physical or contraceptive counseling. We would argue, therefore, that Dr. Durso's patient is neither "accidental" nor "serendipitous," but rather the result of a physician actively and thoughtfully dealing with a disorder of rising importance in her practice, despite her fervent wish that the disorder, and its compatriots, would return to the internal medicine ward.
Philip Zeitler, MD, PhD
Denver, Colo.
Puzzling over Puzzler
In "Five-week-old with a blue spell: Catching a link to the diagnosis" (February, Pediatric Puzzler), I think the head circumference of 43.3 cm that was noted would have concerned me and could have provided initial clues in an infant with a cyanotic spell. Because this clearly represents macrocephaly and yet was not elaborated on, I do not know if the head circumference was a misprint or if there was an oversight in both the newborn nursery and the infant's evaluation at 5 weeks. The physical exam was otherwise unremarkable, but I wonder if the primary hypomagnesemia and the clear macrocephaly could be associated, or if this child suffered from familial megalencephaly, aqueductal stenosis, or some other isolated cause of macrocephaly. Thank you for clarifying this dubious yet interesting link in the chain.
Hal E. Crosswell, MD
Greenville, S.C.
The author replies: Dr. Crosswell is to be congratulated for careful reading of the growth parameters. The head circumference was my error. It should have read 34.3 cm, not 43.3 cm. The latter would have been clearly abnormal. The link in the chain that was weak was my typing. Good pick-up!
Walter W. Tunnessen, Jr., MD
Chapel Hill, N.C
Readers' Forum. Contemporary Pediatrics 2001;5:21.
