First Stop: Your Pediatrician

Our colleagues at the American Academy of Pediatrics (AAP) just released an extensive report aimed at informing their members of their important role in recognizing and helping to treat many problems that relate to learning and development,. Starting in infancy, long before a child is first enrolled in school, it is the pediatrician who often can spot a problem that can be addressed early to improve a child's chances of success in school. Screening for vision and hearing deficits, lags in motor and language development, and psycho-social family issues can all lead to interventions that can improve a child's chances of succeeding in school and in life.

As children reach school age, even before parents turn to their school system for help with learning or behavior issues, a child's pediatrician can pick up on a wide array of conditions -- genetic, neurological, medical, emotional -- that can have a wide ranging affect on how a child functions in and outside of school. While the AAP article is aimed at pediatricians, to guide them in their role in diagnosing issues that can get in the way of school success, it is also important that parents understand how their child's pediatrician can be an important first stop when things are not going well developmentally or academically.

There is a concept in medicine called "differential diagnosis" that plays an important role in helping to understand what is going on when children struggle. Pediatricians are trained to apply this concept when dealing with their patients and it is at the core of what we do here at The Yellin Center. As Dr. Yellin (a pediatrician and a member of the AAP) explains, you can use the analogy of a child with a cough. Before treating the cough, it is crucial to understand why the child is coughing. Does he have an upper respiratory infection, a bone stuck in his throat, asthma, or pneumonia? Only by looking for the cause of a problem can an effective solution be applied. Many learning or school problems require this same approach; only by looking deeply and ruling out many of the problems pediatricians are trained to consider can families begin to help their child get the help he or she needs.

Pediatricians are also excellent sources of referrals. They will be able to suggest educational evaluators (and many of our families are sent to us by their pediatrician for an evaluation for suspected learning or attention difficulties), or send a child to have their vision or hearing explored in depth, or recommend a therapist or other professional if there are signs of serious emotional or family difficulties. Parents should use their child's pediatrician, and the expertise and experience he or she offers, as an important resource when children are struggling in school.

Photo: Alex Proimos/Flickr Creative Commons

New Pediatric Concussion Guidelines

Watching the amazing players on the World Cup teams, we suspect that the high level of play and the drama of many of the games will help make soccer more popular here in the U.S., especially among young people. But we can't help but notice the frequent and often traumatic contact between the players' heads and the ball and the lack of any sort of protective headgear. Parents are understandably concerned about this.

We were particularly interested, therefore, when we learned of the release last week of the first comprehensive pediatric concussion guidelines from pediatric emergency medicine researchers at the Children's Hospital of Eastern Ontario (CHEO) together with the Ontario Neurotrauma Foundation (ONF). The guidelines were developed by an expert panel including over 30 members across Canada and the United States, and included representation from the full spectrum of pediatric health disciplines (emergency medicine, family practitioners, neurologists, rehabilitation professionals, etc.) which worked for over two years and reviewed more than 4,000 academic papers.

"These are the first comprehensive pediatric guidelines that we're aware of; they reflect the very best available evidence today," said Dr. Roger Zemek, who led the panel. "It was fascinating to see how recommendations have changed over time. Years ago, children were told to 'rest' after concussion, which means something entirely different today with the onset of technology – now, rest also includes a break from screen time."

The guidelines include numerous tools and instructions for parents, schools, physicians, and coaches. For example, the guidelines provide a pocket tool to be used by a coach or parent at the sideline to recognize concussion and offer advice on when to remove kids from play and when to seek emergent medical attention. For the emergency department physician, algorithms are provided to guide the decision whether or not to obtain CT scans, and examples of written discharge handouts for patients and families are included. For family physicians and nurse practitioners in the community, the guidelines provide recommendations for ongoing symptom management and decision tools to help navigate 'return-to-learn' and 'return-to-play'. For school boards, the guidelines provide an example of a policy statement regarding pediatric concussion.

We have long been concerned about the impact of concussions on learning  It is encouraging to see the expertise of so many researchers and clinical physicians come together to offer practical guidelines that reflect the best current knowledge. 

NIMH Notes Limits of DSM

We recently came across an excellent explanation of the limits of the American Psychiatric Association's DSM, the newly revised Diagnostic and Statistical Manual of Mental Disorders. We have not been fans of the DSM approach to attention difficulties, and have written before about how the DSM does not go far enough in understanding how attention impacts learning and behavior.

The more recent criticism of the DSM was prompted by the release of a complete revision of this Manual, after much consideration, this past May. It comes from Thomas R. Insel, M.D., Director of the National Institute of Mental Health (NIMH), who discussed the limitations of the DSM in a blog post in which he described the DSM as, "at best, a dictionary, creating a set of labels and defining each."

Dr. Insel notes that the DSM diagnoses "are based on a consensus about clusters of clinical symptoms," not on laboratory measures or scientific studies. He goes on to explain that the NIMH has been engaged in a project to move beyond such diagnoses by focusing on research into areas such as imaging, genetics, and cognitive science.

This project, Research Domain Criteria (RDoC), will form the basis of how the NIMH, and presumably the extensive network it influences, looks at diagnosis, moving beyond the limits of the DSM. As the NIMH notes, "Rather than starting with an illness definition and seeking its neurobiological underpinnings, RDoC begins with current understandings of behavior-brain relationships and links them to clinical phenomena." This approach is very much in keeping with the approach we apply at The Yellin Center, and we look forward to the day when this project results in a universal understanding of the need for looking at the science behind labels.

Thinking about ADHD

An article in last week’s New York Times, "A.D.H.D.Seen in 11% of U.S. Children as Diagnoses Rise," raises some important issues. The article concerns data from a CDC study which interviewed more than 76,000 parents between February 2011 and June 2012 as part of a wide-ranging look at children’s health issues. The CDC has not yet published its findings, but the Times used the raw data as the basis of the article.

According to the Times, diagnoses of ADHD in the U.S. have risen some 41% in the past decade, and 11% of school-age children have received a diagnosis of ADHD. It also reported that about two-thirds of those diagnosed received a prescription for stimulant medication. 

The article continued by noting that the criteria for ADHD -- a checklist of symptoms occurring across situations (for instance both at home and at school) over a period of time -- was due to be expanded in the new Fifth Edition of the DSM, due out this May. This is expected to add to the numbers of teens and adults who are diagnosed with ADHD. 

So, what does this mean for you, for your child, and for clinicians? 

First, parents need to understand that just because a child has difficulties with attention does not mean that he has ADHD. There can be many reasons for attention issues and children can fidget for many reasons. Thoughtful clinicians need to apply the time tested medical approach of “differential diagnosis” when they look at the symptoms commonly associated with ADHD. "Why," they should always ask, "are these behaviors present?" Does this student have a language difficulty, so that she has trouble understanding what is going on in class? It can be hard to pay attention when you can’t follow the classroom discourse. Does he have a problem with memory, so that he jumps and shouts out so that the teacher will call on him before he forgets what he wants to say? Or, perhaps, does she have a true deficit of attention which may or may not be accompanied by hyperactivity?

Even when children have ADHD, we must be thoughtful about what the best strategies may be to deal with this problem. There are many interventions that can and should be tried before using medication. In fact, medications are NEVER sufficient alone. They must always be prescribed in the context of a comprehensive educational plan that includes strategies students, educators, and parents can implement on a daily basis.

Building self-awareness must also be part of the treatment. A child can have ADHD without being ADHD. They must learn about their strengths, and understand that attention weakness exists within the context of their strengths, and perhaps other weaknesses. Attention is a multi-faceted function that appears to involve at least three different parts of a child’s brain. A child needs to know what parts of attention are the sources of their difficulty, and perhaps what parts of attention are working well for them. Attention problems rarely exist in isolation. We owe it to our children to ask, “What else might be contributing to their difficulty?” 

We understand that medication can be enormously helpful for many children for whom the benefits greatly exceed the risks. However, as is the case with every medical treatment, the risks and benefits must be considered on a case-by-case basis. I believe our role as clinicians is to provide parents with the best information that we can and with our best judgment. However, I worry when I hear that parents had their child “tested for ADHD.” I am not saying that the possibility of an ADHD diagnosis shouldn't be considered. What I am saying is that it must be considered in the context of thoughtful consideration of all of the possible causes of a child’s symptoms. And once a diagnosis has been made, medication must be examined in the context of all of the potential interventions.

Illustration: Life Mental Health