Evidence based pediatrics - part 10 ppt

and their own future. Nonverbal learning disabilities have been shown to persist into adulthood and even to worsen over time. The abnormal language characteristics, for example, poor prosody (intonation, accentuation, temporal variation, and voice quality) and prag- matics (the appropriate use of language in diverse social, cultural, or developmental con- texts), yet good vocabulary, and pronounced social difficulties of these children have led some investigators to question whether NLDS are part of a continuum with pervasive developmental disorders and Asperger’s syndrome. 8 Coexisting Conditions Attention Deficit Hyperactivity Disorder Hyperactivity occurs in 25 to 41 percent of children with learning disabilities. 9 Some investigators suggest that attention deficit hyperactivity disorder (ADHD) may be a consequence of learning disability, as children become inattentive, learn poorly, and perhaps tune out. Children with LDS experience frustration and may be unable to sustain attention because the academic demands are too heavy. Evidence exists, however, that learning disability and ADHD are distinct disorders that frequently occur together. 10 Both have strong genetic components but appear to be inherited independently. 11 Psychological Disturbances Depression and anxiety occur in one-third of learning-disabled children, especially in those with nonverbal disabilities. 12,13 This is not surprising since these children often have low self- esteem after years of failing at school and being labeled “dumb”by peers. 14 Children with LDS are not as socially competent as their peers and appear to have difficulty understanding others’ affective states, especially in complex or ambiguous situations. 15 Causes Heredity is a primary factor in language-based learning disabilities. Some 35 to 40 percent of close relatives of dyslexic persons have similar difficulties. 16 Linkage studies implicate loci on chromosomes 6 and 15 in reading disability. 17 As with ADHD, some children with LDS have mothers who abused alcohol and cocaine during pregnancy. Dyslexia is associated with left-brain dysfunction, the side of the brain specialized for language. Researchers have found that an area in the posterior portion of the temporal lobe, known as the planum temporale, which is normally larger on the left side than the right, is either the same size or smaller in dyslexic patients. 18 In adults with LDS, studies have shown functional changes on magnetic resonance imaging (MRI) 19 and areas of focal dysplasia in the language regions, 20 suggesting the presence of differences in the brain’s structural and functional characteristics. Learning disabilities have been found in children who have suffered severe head injuries, are hydro- cephalic, or have undergone radiation treatment of the head. Since these conditions entail destruction of white matter in the right hemisphere, some researchers attribute LDS of some children to early damage in this area. Differential Diagnosis of Learning Disability A child’s poor performance in school may be due to reasons other than learning disability. Table 22–1 lists some of the other causes of inferior school performance that physicians must differentiate from LDS. Diagnosis Early diagnosis is crucial to effective treatment of LDS. It is important that a diagnosis be made before a child’s skill levels and self-esteem slip to dangerous lows. Learning disabilities Learning Disabilities and Attention Deficit Hyperactivity Disorder 417 can generally be diagnosed on the basis of a careful and detailed history, physical examination, and, if necessary, a pyschological assessment. History The physician should take a history of developmental milestones to rule out mental retardation or autism and inquire about behavior and attention span. Medications such as antihistamines, anticonvulsants, tranquilizers, and asthma medications may affect attention and learning. Information about a child’s performance in school should be obtained from teachers. One should look for a history of delayed language development and problems with the sounds of words, for example, trouble rhyming or confusion of homonyms, and problems with expressive language, such as mispronunciations, hesitations, and word-finding difficulties. Children may have difficulty learning the letters of the alphabet, numbers, and days of the week, associating sounds with letters, or following directions or routines. Children may have trouble reading unfamiliar words; their oral reading may be inaccurate, slow, or labored and their spelling poor. They may also be slow to learn new skills and recall facts, relying heavily on memorization. Family history is important; the physician should obtain a history of reading and spelling difficulties of parents and siblings. Physical Examination The physician should look for neurologic dysfunction and assess hearing and vision to rule out any sensory or neurologic problem affecting learning. Physicians will vary in the detail and depth with which they wish to assess the academic skills of children. Simple screening tools may be used to evaluate comprehension of written and spoken language, mathematical skills, auditory memory, reading, spelling, and writing skills. 21 Formal assessment, by a psy- chologist, of intelligence and educational achievement is occasionally necessary. Reports from teachers and/or IQ test results can provide information about cognitive strengths and weaknesses and help define how well a child processes information. Some of the more frequently used intelligence tests for school-aged children are the Wechsler Intelligence Scale for Chil- dren (WISC-III) and the Stanford Binet Intelligence Scale. Academic achievement can be assessed by tests such as the Peabody Individual Achievement Test-Revised (PIAT-R), Wood- cock-Johnson Tests of Achievement-Revised (WJ-R) and the Wide Range Achievement Test- Revised (WRAT-R). 418 Evidence-Based Pediatrics Table 22–1 Differential Diagnosis of Learning Disability • Mild and moderate mental retardation • Gifted children who are bored • Poor motivation, for example, from a family that does not value academic success • Psychiatric disorders such as anxiety and depression • Inappropriate expectations, for example, comparing a child to a high-achieving sibling or parent • Teacher-student mismatch • Attention deficit hyperactivity disorder • Family issues: separation and divorce, illness of family member, alcoholism and drugs, poverty, physical, emotional or sexual abuse • Physical illness: chronic or recurrent, for example, asthma, after-effects of head injury, brain tumor, very low birth weight sequelae, iron deficiency anemia, chronic lead poisoning • Medication effects: theophylline, anticonvulsants, antihistamines, ethanol and recreational drugs • Seizure disorders: absence or temporal lobe seizures • Fetal alcohol syndrome • Chromosomal syndromes: fragile X, Turner's, Williams, Down’s, and Noonan's syndromes • Nonchromosomal syndromes: Prader-Willi, Angelman's • Visual and auditory impairment Treat ment Educational Therapy The cornerstone of treatment of LDS is educational therapy. It must be tailored to individual needs and depends on the child’s learning strengths and weaknesses. To learn to read suc- cessfully, the child needs to master three component skills: phoneme analysis, visual memory, and comprehension. All children must first discover that spoken words can be broken down into smaller units of sound (phonemes) and that these are linked to specific letters and letter patterns (phonics). Once letter-to-letter decoding is achieved, whole words are usually committed to visual memory. Building up a sight-word vocabulary allows a child to read with increasing speed and automaticity. Speed in naming familiar symbols such as numbers or letters is slower in dyslexic children. 22 Comprehension is directly related to decoding skills but may present problems for students who are inattentive, have poor language skills generally, or fail to link the verbal information in words with nonverbal images of what they por- tray. 23 Many programs are available to teach reading skills, including intensive phonetic teaching programs. Reading remediation that emphasizes phonetic decoding has been shown to improve reading skills 24 (level I, recommendation A). See Table 22–2 for levels of LDS treatment, ranked on the basis of quality of evidence and perceived effectiveness. No evidence has been found, however, that any one reading technique is better than another. A number of protocols differing in method, format, intensity, and duration of intervention are now being tested to determine the most effective. 25 Several studies have investigated whether children with LDS should be mainstreamed (placed in regular classes and helped by teacher’s aides or tutors) or segregated in special classes with other learning-disabled children and a specially trained teacher. The studies suggest that with highly motivated teachers and aides, mainstreaming can lead to improvements in academic achievement, behavior, and self-esteem (level I, recommendation B) (see Table 22–2). Studies to determine whether children with LDS should repeat a school year (enabling them to acquire academic skills they missed the first time) or be promoted (retaining self- esteem) have proved inconclusive (level III, recommendation C). 26 Learning Disabilities and Attention Deficit Hyperactivity Disorder 419 Table 22–2 Summary of Treatments for Learning Disabilities Intervention Quality of Evidence Recommendation Reading remediation I A Repeating school year III C Teaching learning strategies I A (mnemonics, rhymes, visual images) Computer-based reading instruction II B Social skills training I B Psychotherapy III C Behavior management I C Medication (Piracetam) I C Orthomolecular therapies (diets, vitamins) I E Neurophysiologic therapies (sensorimotor I E integration, tinted lenses, eye muscle exercises) Besides using remedial reading techniques, educators have tried teaching general learning strategies to children with LDS. They have achieved some success in helping children improve the way they approach new tasks, memorize new information (eg, using mnemonics) (level I, recommendation A), 27 and organize information (eg, using rhymes or visual images to link specific bits of information) (level I, recommendation A). 28 Computer-based reading instruction has advanced recently with the use of interactive talking storybooks that encourage children to persist in the reading task and provide help in reading (eg, a child may select an unknown word to hear it read aloud). This method has been shown to improve skills in word recognition and decoding but may be less effective in improving comprehension. 29 Adding speech to text is a valuable addition to reading software and has been shown to double the rate of acquisition of decoding skills. 30 Children may have problems with written work because of poor spelling, weak fine-motor skills, or expressive language delays. Use of word processors has been shown to lead to positive changes in writing quality and the quantity of text written 31 and increased accuracy in spelling and gram- mar, 32 but these changes are not always found in all students. Children with writing disorders may be helped by using a classmate’s notes, taping lectures, being assigned “homework bud- dies,” and being allowed to take examinations orally. Thus, computer-based reading instruction has resulted in improvement in some aspects of reading and writing skills (level II, recommendation B). Other Therapies Social skills training. Many children with LDS are not well accepted by their peers, have social skill deficits, and do not make and keep friends easily. Various interventions have been tried to help solve these problems, and some of them have proven effective. 33 Interventions with students in special programs have been less effective than with those who are mainstreamed, perhaps because the latter have more opportunities to observe desirable social behavior. Longer interventions (4 to 25 weeks of training) were more successful than shorter ones (1 to 14 weeks). Small groups of students achieved better results than larger groups, and students chosen because of significant social difficulties responded better than those selected simply because they were in an LDS class. Many studies that used techniques such as coach- ing, modeling, role-play, feedback, and problem solving had positive effects, although behavior changes occurring in controlled settings often did not generalize to natural settings. Nor was there evidence that peer acceptance increased as a result of these social skills interventions. 33 Social skills training has resulted in improvement in these skills in selected groups of students (level I, recommendation B). Counseling. Individual, family, or group counseling sessions may be required to treat psychological disorders. However, there is no good evidence that learning-disabled children treated with psychotherapy experience long-term benefits (level III, recommendation C). 34 However, counseling may deal with issues of the child’s self-esteem and help relieve guilt about his or her problems. Education and information about LDS is important. One of the most valuable supports for parents is the Association for Children with Learning Disabili- ties. It provides parents with information about local services and new discoveries and helps organize support groups in which parents can compare notes and provide mutual encour- agement. Behavior management. Behavior management is often used with children diagnosed with LDS or ADHD. Reinforcing on-task behavior in children with LDS has been shown to improve academic performance in the short term. 35 The essentials of a behavior modifica- tion program have been extensively described, 36 with the expectation that it may produce desired behaviors and a positive parent-child relationship (level I, recommendation C). Medication. In the child with combined LDS and ADHD, stimulant medications have been shown to improve classroom performance, not only through greater attentiveness and 420 Evidence-Based Pediatrics concentration, but also in the way the central nervous system processes information. In reading tasks, this effect is seen in improved word-finding abilities and a resultant improvement in reading vocabulary. 37 A different class of drug, pyrrolidine acetamide (Piracetam), was found to produce a significant improvement in the reading and writing ability of dyslexic boys, taking both rate and accuracy into consideration, compared with a placebo group. 38 This medication is still considered experimental (level I, recommendation C). Alternative therapies. Patients with LDS and their families often seek out unconven- tional approaches to improving reading difficulties and behavior. Various diets have been advocated: additive-free, oligoantigenic, low-sugar, allergy-free, megavitamin–added, and trace mineral–added. Other therapies purported to help include anti–motion sickness medication for vestibular dysfunction, patterning, optometric training, sensorimotor integration, chiropractic manipulation, discontinuing fluorescent light, Irlen (colored) lenses, and neg- ative ions. Few credible data are available to support the claims made for these therapies. 39,40 They are not considered useful and cannot be recommended for the treatment of LDS (level I, recommendation E). Prognosis Many follow-up studies have shown that some features of reading disabilities persist into late adolescence and young adulthood. 41 Although reading comprehension and word recognition skills may improve, many adults continue to have difficulty with spelling, reading unfamiliar words, and reading with reasonable speed. 42 Adults with untreated LDS have higher rates of unemployment, and many have difficulties in at least one activity of daily living, such as banking, using maps, and time management. Their frequent lack of organizational skills is reflected in unpredictability, inefficiency, poor punctuality, untidiness, and procrastina- tion. 43 The outcome in children with LDS is determined by the severity of their learning deficits, the extent to which these are counteracted by their areas of strength, and the supports available to them. On an optimistic note, many people with LDS, such as Winston Churchill and Thomas Edison, went on to achieve high levels of academic and professional success. ATTENTION DEFICIT HYPERACTIVITY DISORDER Attention deficit hyperactivity disorder (ADHD) is now recognized as the most common neurobehavioral disorder affecting children. It is characterized by inattentiveness, impulsiveness, and hyperactivity that significantly impairs a child’s functioning at home, at school, and with peers. 44 The prevalence of ADHD has been estimated to be between 1.7 and 16 percent, depending on the population and diagnostic methods used. 45,46 Recent reports indicate that 3 to 5 percent of school-aged children have ADHD. 44,47 On average, then, about one child in every classroom is affected. Some 40 percent of the children who cause problems in school likely have ADHD. This disorder is 2 to 8 times more frequent in boys than in girls. 48 Its symptoms persist into adolescence in 70 percent and into adulthood in 10 percent of those diagnosed with ADHD in childhood. 49,50 Symptoms The current and most widely used criteria for ADHD have been defined by the American Psy- chiatric Association (Table 22–3). 44 The symptoms of ADHD may vary substantially between home and school, structured and nonstructured settings, and large and small groups as well as in situations that make high or low demands on the child’s performance. Children with ADHD can pay attention in situations they find novel, fascinating, or scary, or in a one-to- one situation with an adult. For example, a child with ADHD has difficulty concentrating when faced with routine, monotonous activities but has no problem when engaged in cer- tain activities of his or her choice, like watching television or playing Nintendo. Most chil- Learning Disabilities and Attention Deficit Hyperactivity Disorder 421 dren with ADHD have trouble concentrating on activities that other children enjoy, like col- oring, pasting, and doing puzzles. They may also show signs of the free flight of ideas, difficulty feeling satisfied, social immaturity, inconsistent performance, and mood swings. As these children get older, they exhibit excessive fidgeting and restlessness rather than gross motor activity. Attention deficit hyperactivity disorder forms part of a more comprehensive diagnosis called attention deficit disorder (ADD), which is classified by the Diagnostic and Statistical Manual, 4th edition (DSM-IV) into three categories: 422 Evidence-Based Pediatrics Table 22–3 DSM-IV Criteria for Attention Deficit Hyperactivity Disorder Either (1) or (2) 1. Six or more of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with the developmental level. Inattention • Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities • Often has difficulty sustaining attention in tasks or play activities • Often does not seem to listen when spoken to directly • Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure of comprehension) • Often has difficulty organizing tasks and activities • Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) • Often loses things necessary for tasks or activities at school or at home (eg, toys, pencils, books, assignments) • Is often easily distracted by extraneous stimuli • Is often forgetful in daily activities 2. Six or more of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with the developmental level. Hyperactivity • Often fidgets with hands or feet or squirms in seat • Often leaves seat in classroom or in other situations where remaining seated is expected • Often runs about or climbs excessively in situations where it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) • Often has difficulty playing or engaging in leisure activities quietly • Often talks excessively • Is often “on the go” or often acts as if “driven by a motor” Impulsivity • Often has difficulty awaiting turn in games or group situations • Often blurts out answers to questions before they have been completed • Often interrupts or intrudes on others, for example, butts into other children's games Onset Before the Age of 7 Years • Some impairment from the symptoms present in two or more settings (eg, at school or work or at home) • Clear evidence of clinically significant impairment in social, academic, or occupational functioning • ADD with predominant hyperactivity and impulsivity with minimal inattentiveness • ADD with combined hyperactivity and inattentiveness • ADD with predominant inattentiveness and minimal hyperactivity (ADD-H) The first two groups are nearly indistinguishable from each other and will be referred to as children with ADHD. 51 Children with ADD-H function at a slower cognitive speed, appear more confused, apathetic and lethargic, show increased social withdrawal, and are more likely to suffer from anxiety or depression than children who have ADHD. 52 Children with ADD-H tend to be female and are diagnosed in later grades of elementary school, when they begin to fall behind academically. This group of children is often underdiagnosed, since their behavior and conduct problems are not as common or conspicuous as those in the ADHD group. These children are disorganized, inattentive, distracted, forgetful, and often labeled lazy or underachieving. In contrast, children with ADHD are described as more noisy, aggressive, disruptive, messy, irresponsible, immature, and less successful in establishing relationships with peers. The paragraphs that follow describe the coexisting conditions, diagnosis, causes, and treatment of ADHD, by far the most prevalent condition among children with ADD. Coexisting Conditions In addition to exhibiting the core symptoms of inattentiveness, impulsiveness, and hyperactivity, some children with ADHD have learning problems and delays in speech, language, and motor skills. 53 Behavior disorders, low self-esteem, and psychiatric conditions such as anxiety disorders and depression are also common. 54 The prevalence rates of these comorbid conditions vary according to whether the patients are seen primarily by psychiatrists or pediatricians: conduct and oppositional defiant disorders seem to be higher in psychiatric studies and learning disorders higher in pediatric studies. Academic Problems and Learning Disabilities From 25 to 30 percent of children with ADHD also have a learning disability, 55 and the fre- quency is even higher in those with ADD-H. 56 Despite having normal or even superior intelligence, the ADHD child is often a chronic underachiever. By adolescence, up to one-third of these children have failed at least one grade. Both ADHD and reading disabilities have strong genetic components but appear to be inherited independently. 57 Psychiatric Disorders As many as 50 to 65 percent of children with ADHD referred to psychiatrists have at least one additional psychiatric disorder. 43 Virtually all childhood psychiatric disorders are more common in children with ADHD than in those who are unaffected. Tics may also be seen in some school-aged children with ADHD. 58 Problems with poor self-esteem are common; depressive disorders occur in 9 to 38 percent of children with ADHD, especially after they reach about 10 years of age. 45,59 Bipolar disorders have also been associated with ADHD. 60 Anxiety disorders resulting in fears and worries occur in up to 25 percent of children with ADHD. 43 These disorders are unlikely to worsen school performance but do cause more social difficulties. 61 Children with anxiety disorder and ADHD also respond less favorably to stimulant medication than those without anxiety. 62 Conduct Disorder Conduct disorder, or antisocial behavior, is characterized by cruelty, violence, and disregard for the rights of others. Affected children are aggressive, destroy property, and frequently lie and steal. They often skip classes and run away from home regularly. Approximately 25 percent of children with ADHD seen by psychiatrists have a conduct disorder. 45 The disorder is manifested less often in children and adolescents with ADD-H than in those with more pro- Learning Disabilities and Attention Deficit Hyperactivity Disorder 423 nounced hyperactivity. Children with both ADHD and conduct disorder come from families of lower socioeconomic status than ADHD children without conduct disorder. 63 They also have higher rates of reading disorders 64 and show an increased incidence of adult antisocial personality and criminal convictions. 65 Oppositional Defiant Disorder Oppositional defiant disorder, a term often used for younger children, involves negativism and hostility but, unlike conduct disorder, does not involve the violation of societal norms. The disorder is characterized by stubbornness, tantrums, disobedience, and defiance of authority. If the disobedience becomes a way of life for a child, he or she has an oppositional or defiant disorder. About 65 percent of ADHD children in one psychiatric study had this disorder, but it did not necessarily develop into a conduct disorder later on. 66 Causes Most experts believe that ADHD is an inherited neurobiologic disorder. Heredity plays a role, since children with relatives with the disorder are at high risk for ADHD, comorbid psychiatric disorders, school failure, and learning disability. One in every four children with diagnosed ADHD has a biologic parent who is similarly affected. 66 Identical twins are more likely to share ADHD than fraternal twins or other siblings. 67 Recent studies suggest an association between the dopamine transporter gene and ADHD 68 and differences between control subjects and ADHD patients in the D4 dopamine receptor gene (associated with novelty seeking). 69 The frontal lobes of the brain, which have long been known to play a critical role in reg- ulating attention, activity, and emotional reactions, may have a role in ADHD. Positron emis- sion tomographic (PET) scans have shown that adults with ADHD have lower brain glucose metabolism in the frontal lobes than non-ADHD subjects when told to concentrate on a task. 70 This pattern of underactivity is thought to be due to abnormalities in the neuro- transmitters in the frontal areas. Stimulant medication is postulated to compensate for these abnormalities, since ADHD subjects show increased activity in the frontal areas when treated. High concentrations of dopamine metabolites in the cerebrospinal fluid have also been shown to correlate with high degrees of hyperactivity and with good response to treatment with stimulant drugs. 71 Magnetic resonance imaging (MRI) studies have revealed structural differences in the brain in patients with ADHD. Non-ADHD boys showed an asymmetry of the caudate, the right side being larger than the left, whereas boys with ADHD demonstrated no asymmetry; subjects with the least asymmetry performed worst on tests of response inhi- bition. 72 Also, MRI has shown abnormal frontal lobes 73 and reduced volume in the rostrum and rostral body of the corpus callosum in patients with ADHD. 74 Birth injuries associated with fetal distress and difficult labor play a negligible role in ADHD, but damage before birth may be a factor. Mothers who abuse drugs or alcohol during pregnancy may have children who suffer from ADHD and learning disabilities. 75 Some have blamed environmental toxins, including lead, and artificial flavors, dyes, preservatives, and other food additives for ADHD, while others have singled out sugar, food allergy, and food additives as the causes.Anecdotal evidence and testimonials have been used to support these claims; however, double-blind controlled studies have not substantiated them. 76 Differential Diagnosis Physicians must distinguish between ADHD and other disorders or conditions that mimic its symptoms. Fidgeting, distractibility, and impulsiveness have many causes, only one of which is ADHD. If these behavioral problems have only recently begun to show up or are related to a particular event, a child may not have ADHD. For instance, a child who becomes 424 Evidence-Based Pediatrics distractible in grade 4 may be suffering from emotional problems, such as those caused by a divorce. Or if a child starts having trouble in mathematics, a problem that affects 5 to 10 percent of school-aged children, 77 a learning disability could be the cause. Many of the conditions that coexist with ADHD may, on their own, cause hyperactivity in a child. Table 22–4 lists some of the other causes of hyperactivity that physicians must differentiate from ADHD. Diagnosis Physicians who see children with ADHD differ in their opinions about how to diagnose ADHD. Some recommend a large battery of tests, whereas others simply have the parent complete a brief rating scale for the child, then make a quick diagnosis and prescribe treatment. Neither extreme is in the patient’s best interest. No single medical, laboratory, or psychological diagnostic test definitively identifies ADHD. 44 The diagnosis is a clinical one made on the basis of a picture that begins early in life, persists over time, pervades different settings of the child’s life, and impairs functioning at home, at school, or in leisure-time activity. The diagnosis is made through interviews with people who know the child, a physical examination, use of rating scales, and a review of pre- vious psychological test results, if available. History The history of a child’s longstanding problems with attention, impulsivity, and hyperactivity is the best source of information for identifying ADHD. The physician should obtain separate accounts of the child’s behavior from parents and teachers, as symptoms are specific to situations. When interviewing parents, the physician should take a full developmental history to rule out developmental delays, learning and language disabilities, and pervasive developmental disorder. The physician should • ask about the child’s behavior in infancy, such as resistance to cuddling, high activity levels, and sleep and feeding disturbances. Behavior at this stage is sometimes corre- lated with future ADHD behavior; Learning Disabilities and Attention Deficit Hyperactivity Disorder 425 Table 22–4 Differential Diagnosis of Hyperactivity • Age-appropriate overactivity • Anxiety disorder • Conduct disorder • Oppositional defiant disorder • Learning disability • Speech or language disability • Tourette's syndrome • Affective disorder: mania, depression • Schizophrenia or psychosis • Inadequate environment or parenting • Mental retardation • In-utero exposure to alcohol, cocaine, lead • Neurologic disorders: post-traumatic, postencephalitic • Iatrogenic effects of medication: theophylline, barbiturates, steroids • Eczema and other irritating skin conditions • Endocrine disorders: hyperthyroidism, pheochromocytoma, hypoglycemia • Chromosomal disorders: Down’s syndrome, fragile X syndrome, Klinefelter's syndrome (XYY), Turner's syndrome • elicit information about what the child’s behavior is like in various settings, for example, when alone, playing with other children, or while shopping; • review the behavior-management techniques the parents have used to ensure that they are appropriate for the child’s age and not overly punitive or indulgent; and • ask about the child’s academic performance and peer relationships. A family history of hyperactive behavior or learning difficulties is important because of the role played by heredity in ADHD. The physician should evaluate the child’s emotional status to rule out depression and anxiety disorders and to distinguish ADHD from other disruptive behaviors, such as conduct disorder and oppositional defiant disorder. Reports from teachers about the child’s ability to finish work, stay on task, and respect others form an important part of the evaluation. As well, because of the association of ADHD with learning difficulties, these reports may help assess the child’s level of academic achievement and general intelligence. Since underachievement is a hallmark of the child with ADHD, his or her grades usually do not match estimated ability levels. An in-depth clinical interview with the child is necessary to rule out more serious disorders such as psychosis and to determine his or her degree of maturity and verbal skills. The physician should ascertain the child’s feelings about home, school, and social life and ask whether the child feels sad, anxious, or fearful. Because the symptoms of anxiety or depression overlap those of ADHD (agitation, impulsivity,decreased concentration), these comorbid conditions may go unrecognized. The most common mistake physicians make when taking a history is forgetting to ask about coexisting conditions. It is important to remember that to be diagnosed with ADHD, a child must fulfill the DSM-IV criteria (see Table 22–3). Symptoms must be present before the age of 7 years and cause impairment in two or more settings. Rating Scales Various rating scales have been used to assess children’s behavior at home and in school. The Conners Teacher Rating Scale 78 rates children on several aspects of behavior, as does the ADD-H Comprehensive Teacher Rating Scale, which allows separate evaluation of four areas of child behavior: attention, hyperactivity, social skills, and oppositionality. These scales help in making an initial diagnosis of ADHD, estimating symptom severity, and monitoring a child’s response to treatment. However, none of them can provide a diagnosis. There are also performance tests that assess a child’s ability to sustain and focus attention and to refrain from responding impulsively. These include the Matching Familiar Figures Test and the Con- tinuous Performance Test. 79 Although these tests provide useful information, their results are not infallible and should be interpreted in the context of all available information. 80 Physical Examination Observation of the child’s behavior in the physician’s office can be helpful; however, only about 20 percent of children with ADHD exhibit overt hyperactivity during an office visit. 45 A physical examination is done primarily to rule out visual and hearing problems, which may impair attention and memory. It should also exclude physical illness, medication effects, and major neurologic or developmental problems. The examination may reveal some dysmor- phic features characteristic of syndromes associated with ADHD, such as fragile X (an inherited condition associated with mental retardation) or fetal alcohol syndrome. As well, the physician should look for evidence of motor or vocal tics, which may indicate the presence of Tourette’s syndrome as well as ADHD and influence the choice of medication. The physician may pick up soft neurologic signs, such as fine-motor coordination problems and choreiform and motor-overflow movements. However, these are not diagnostic of ADHD, since normal children may also have them. The electroencephalograms (EEGs) of some children with ADHD may also show abnormalities, such as an increase in slow-wave activity. However, since many affected children 426 Evidence-Based Pediatrics [...]... disorder: participant workbook New York, NY: SCP Communications 1994; p 4–20 89 Kavale K The efficiency of stimulant drug treatment for hyperactivity: a meta-analysis J Learn Disabil 1982;15:280–9 436 Evidence- Based Pediatrics 90 Ahmann PA, Waltonen SJ, Olson RA, et al Placebo-controlled evaluation of Ritalin side effects Pediatrics 1993;91: 1101 –6 91 Gillberg C, Melander H, Von Knorrins AL, et al Long-term... the studies they reviewed were well-designed prospective RCTs, which calls into question the ability of these reviews to guide future work in HIV prevention and intervention However, since the mid-1990s, several RCTs96 ,100 105 have been published Orr and colleagues100 tried to determine whether condom use among high-risk female adolescents could 448 Evidence- Based Pediatrics be increased through a brief... Seattle; the two cities are otherwise very 452 Evidence- Based Pediatrics similar demographically For the 1 5- to 24-year-olds in the study, the non-firearm suicide rate in both cities was similar However, the total suicide rate in Seattle was significantly higher (Seattle 15.72 versus Vancouver 11.43 deaths per 100 ,000, relative risk, 1.38) because Seattle had a three-fold increased risk of suicide by firearms... to 19-year-olds .107 Males comprise the majority of suicide completers; 81 percent of 15 to 19-year-old suicide victims were males in 1994 The suicide rate for males in this age group was 20.39 per 100 ,000, and suicides accounted for 24 percent of all 15 to 19-year-old male deaths that year In the United States, suicide ranks third as a cause of death, after motor vehicle injuries and homicides .108 According... significant finding was no longer present at the 6- and 12-month follow-up assessments The safer-sex group, however, did show sustained decreases in sexual intercourse at the 6- and 12-month followup assessment, as well as less unprotected intercourse at all the follow-up assessments, compared with the other two groups Although the adolescents in the peer-facilitator groups gave more favorable evaluations... to increase with the generation of highquality, easily accessible evidence In this chapter, we present some common clinical scenarios often encountered in the practice of adolescent medicine that illustrate the potential use and the limitations of evidence- based approaches based on the currently available literature EXAMPLES OF EVIDENCE- BASED APPROACHES IN ADOLESCENT MEDICINE Confidentiality Background... rates for 10 to 19-year-old Caucasians were 42 percent higher than those for African Americans Nonetheless, the suicide rates for African American youth has been increasing faster than that of Caucasian youth In addition, aboriginal populations in both Canada and the United States have youth suicide rates much higher than the general population.116,117 450 Evidence- Based Pediatrics The best evidence. .. knowledge available from clinicalcare research that involves young people The direct application of this growing body of evidence from research on adolescents to everyday clinical decisions is an opportunity for health-care providers to practice evidence- based adolescent medicine Evidence- based adolescent medicine can help clinicians deal with diverse adolescent health issues and make successful clinical... children J Learn Disabil 1994;27:144–54 8 Semrud-Clikeman M, Hynd GW Right hemispheric dysfunction in nonverbal learning disabilities: social, academic, and adaptive functioning in adults and children Psychol Bul 1990 ;107 :196–209 432 Evidence- Based Pediatrics 9 Holbrow PL, Berry PS Hyperactivity and learning difficulties J Learn Disabil 1986;19:426–31 10 Shaywitz B, Fletcher J, Shaywitz S Attention... (allergy-free, yeast-free, sucrose-restricted, salicylate-free) 108 Neurophysiologic therapies include alpha-wave conditioning, patterning, sensory integration training, optometric training, eye muscle exercises, and tinted lenses Other therapies include anti–motion sickness therapy and chiropractic manipulation None of these therapies have been shown to be effective when subjected to double-blind controlled . Individual Achievement Test-Revised (PIAT-R), Wood- cock-Johnson Tests of Achievement-Revised (WJ-R) and the Wide Range Achievement Test- Revised (WRAT-R). 418 Evidence- Based Pediatrics Table 22–1. ADHD may also show abnormalities, such as an increase in slow-wave activity. However, since many affected children 426 Evidence- Based Pediatrics 2.5 percent of all school-aged children in North. attentiveness and 420 Evidence- Based Pediatrics concentration, but also in the way the central nervous system processes information. In reading tasks, this effect is seen in improved word-finding abilities

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