TOW #14: ADHD

As we get fully immersed in the school year, assessment for Attention Deficit Hyperactivity Disorder (ADHD) may be on the agenda for more patient visits. Fortunately, we have more data and tools than ever to diagnosis and treat ADHD.

Materials for this week:

Take-home points for ADHD:

  1. Epidemiology: Estimates by the CDC are that 8-10% of youth in the US have been diagnosed with ADHD. Prevalence increased by ~1/3 between the 1990s to 2000s, but this coincided with increased marketing of ADHD medications. Concern remains about overdiagnosis, particularly among younger children where behavior may be developmentally appropriate. For example, children who are the youngest in their classrooms are more likely to be diagnosed with ADHD. However, girls with ADHD may be underrecognized, and most children with ADHD go under-treated.
  2. Risk factors: Both genes and environment contribute to ADHD risk. Twin studies suggest a strong genetic component, with up to 76% heritability. Environmental risk factors include perinatal and early childhood stress from toxins, compromised prenatal nutrition or birth complications, chronic deprivation, and early childhood adversity. Up to 2/3 of youth with ADHD have a comorbidity including anxiety, mood disorders, autism, ODD, tics, and/or substance abuse.
  3. Diagnosis: ADHD has 3 primary components: inattention, hyperactivity, and impulsivity, present to varying degrees. To diagnose ADHD, these must be present beyond appropriate for developmental stage, must cause significant impairment, should be present before age 12, and should be present in 2 or more settings (school, home, day care, camp, etc). In diagnosing ADHD, we should use clinical assessment along with ADHD rating scales (e.g., Vanderbilt), and also assess for co-morbidities with broad symptom checklists (e.g., Pediatric Symptom Checklist).
  4. Treatment: Behavioral (parent and/or classroom) and pharmacological treatments have been shown to work well, especially in combination. Usually, one of the two stimulant classes of medicines will be tried first: methylphenidate products (such as Ritalin, Concerta and Daytrana) or amphetamine products (such as Adderall and Vyvanse). Both stimulant classes are generally tried before switching to one of the non-stimulants: atomoxetine (Strattera), clonidine, or guanfacine, which have shown lower efficacy. However, atomoxetine would be considered first-line for treating ADHD with concurrent anxiety, or when there’s a risk of medication abuse with a stimulant. As above, given the high prevalence of co-morbidities, we must also screen for and treat these conditions.
  5. Local resources: Our state has terrific resources through the Partnership Access Line and SCH. For more complex cases and/or those where diagnosis / treatment is in question, consult the SCH Psychiatry and Behavioral Medicine team including ADHD specialists Mark Stein PhD and Will French MD. Dr. Sam Zinner’s developmental-behavioral screening tools webpage is a great resource to bookmark.

TOW #13: Scoliosis

We have a role in screening and diagnosis of scoliosis in primary care, with the AAP recommending screening for teenagers between 12-14 years old. This week we will review this key orthopedic topic.

Materials for this week:

Take-home points for this week:

  1. Epidemiology: Scoliosis is the most common abnormality of the spine. Idiopathic scoliosis is present in 2% of adolescents. There is a genetic basis with first-degree relatives at increased risk (10% prevalence).
  2. Definition: Scoliosis is defined as a lateral curvature of the spine that is 10 degrees or greater on a coronal radiographic image while the patient is in a standing position. It is measured by the Cobb angle.
  3. Types: Most cases are idiopathic and defined by age at recognized onset: before age 3 (infantile), age 3-10 (juvenile) and older than 10 (adolescent). There are also congenital forms due to malformations of the spine in utero that progress with age, and neuromuscular scoliosis associated with neuromuscular diseases.
  4. Work-up: Classic findings of scoliosis on examination are shoulder and scapular asymmetry and rib prominence on forward flexion. We can use an inclinometer tool to help assess the degree of asymmetry. Typically, referral is recommended if >= 7 degrees on inclinometer. Physical exam is also used to help rule out hereditary connective-tissue disorders (e.g., Marfan’s syndrome), neurofibromatosis, or neurologic conditions. Obtain scoliosis spinal radiography in standing position and request measurement of the Cobb angle.
  5. Treatment: Most adolescents can be monitored in primary care for curves <20 degrees. If >20 degree curvature, we would refer to ortho and they may consider bracing when >25 degrees, but data are not conclusive. If >40-45 degree curvature, surgery is usually recommended.

TOW #12: Iron deficiency anemia

One of the major nutritional deficiencies worldwide is iron deficiency (ID) and iron deficiency anemia (IDA), so it’s an important area of pediatric nutrition for us to review and understand.

Materials for this week:

Take-home points:

  1. Epidemiology: Since the 1970s we have made significant progress identifying and screening for iron deficiency, but it remains the most common nutrient deficiency worldwide. In the US it is estimated that about 8% of infants and toddlers have iron deficiency. Some believe this may be underestimated (see Magge et al).
  2. What are the effects of iron deficiency? Iron deficiency is associated with poorer cognitive and social-emotional outcomes and has  persistent effects, but treatment can improve outcomes. Unfortunately, most of that data is from developing countries; in a systematic review for the USPSTF, data were lacking in developed countries, and no RCTs were available for routine screening to prevent IDA.
  3. Who should we screen? Iron deficiency screening is recommended by the AAP for all children between 9-12 months: labs recommended vary. At a minimum Hct/Hgb identifies anemia and adding Zinc Protoporphyrin to Heme ratio (ZPPH) (an inexpensive and widely available test) can help identify iron deficiency that precedes anemia (but note ZPPH is also elevated from lead and anemia of chronic disease).
  4. What are important risk factors for iron deficiency? Risk factors include prematurity, cow milk consumption before 1 year of age, drinking more than 24 oz/day of cow’s milk per day after 1 year, low income status, and restricted diets for any reason.
  5. What is the recommended treatment? Treat iron deficient children with 3-6 mg/kg of elemental iron daily until sufficient and then 2-3 months after to ensure adequate iron stores. Typically we repeat blood tests 1-3 months after starting therapy (some test at 1 month, others wait until further in) to ensure response and compliance and/or do additional work-up if not improving.

TOW #11: The Medical Home & Children with Special Needs

One of the most fulfilling aspects of primary care is longitudinal relationships with families and addressing comprehensive, holistic needs over time. There is a growing body of data on the health benefits of medical homes, especially for children with special health care needs, and also for typically developing children. As we take care of more complex pediatric patients, the need for pediatricians to provide a medical home takes on even more importance.

Materials for this week:

Take-home points:

  1. What are the principles and goals of a “medical home”? The “medical home” (sometimes referred to as the “health care home” to include health maintenance and health promotion) is a model promoted by national agencies including the AAP to provide comprehensive, family-centered, community-based care for patients, especially Children with Special Health Care Needs (CSHCN). The medical home model seeks to provide care that is accessiblefamily-centered, continuous, comprehensive, coordinated, compassionate, and culturally effective. A key part is to overcome barriers of fragmented service delivery and provide care that is proactive and preventative, not always reactive.
  2. How many children qualify as “Children with Special Health Care Needs (CSHCN)? Large population-based surveys estimate that 13% to 20% of children and youth meet the definition of CSHCN, as defined by parent report using the Children with Special Health Care Needs Screening Tool. This is probably an underestimate, and many children have two or more conditions.
  3. How does socioeconomic status affect prevalence of CSHCN? Unfortunately, there remain large inequities in chronic health conditions, access to health care services, and unmet specialty care needs based on SES. National data indicate higher odds for special needs in children living in poverty.
  4. Who needs to be included in providing effective care within a medical home?  Providing comprehensive and coordinated care requires a team approach. The primary care physician often directs the plan of care, and implementation and coordination of services is managed by other personnel, including nurses, care coordinators, or social workers, as well as the child’s family. Collaboration with school nurses, visiting nurses, and home health aides is also crucial to implement care and monitor progress.
  5. What does a care plan include? One of the recommended strategies to help coordinate services for CSHCN is to develop care plans. Suggested care plan components include diagnoses/problem list, care team contact information, patient and family strengths and challenges, prior surgeries and/or procedures, recent lab and other diagnostic studies, assistive technology, and patient and family goals.