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|Friday, October 29, 2010
|ADHD Diagnosis: The Debate Continues
|by Pediatric Perspectives at 09:00 AM
Steven L. Pastyrnak, PhD, Division Chief, Pediatric Psychology
Helen DeVos Children's Hospital
A recent study from researchers at Notre Dame University suggests that children who are "young" for their grade, i.e., the child who turned 5 just before the cutoff for kindergarten, are more likely to be diagnosed with attention deficit hyperactivity disorder (ADHD) than children who are "older" for their grade, i.e., the child who turned 5 the March before kindergarten began.
The press release on this research from the university tries to link this study to high rates of ADHD, suggesting that such misdiagnosis may "at least in part" be driving the "epidemic" of ADHD.
I have to at least partially disagree with the notion of an epidemic of ADHD. I would agree that younger children may exhibit more immature behavior in comparison to their older peers. They may be more inattentive and restless and this may impact their classroom behavior. Whether they have ADHD, however, depends on far more than just classroom behavior.
Recall that an ADHD diagnosis requires evidence of certain behaviors in the home, the community, and the classroom. Therefore, when evaluating ADHD, it is important to gather information from multiple sources. Parents are the most important individuals to interview followed closely by teachers. Day care providers and extended family can also offer helpful information. It is the consistency of symptoms across time and within multiple settings that should be considered when making an ADHD diagnosis. In addition, these symptoms must also cause some type of problem before a diagnosis is considered.
So if a child is more active than typical, but has no trouble making friends, is doing well at school, is behaving reasonably well at home, then that child probably doesn't qualify for an ADHD diagnosis. It is important that when pediatricians and other specialists evaluate children for ADHD, they do not rely only on teacher reports, nor do they rely on observations that may simply compare one child to another in the classroom.
Bottom line: There must be evidence of certain behaviors linked to ADHD across multiple locations. If the child is having problems in the classroom only, other options may be available other than medication, such as placing the child closer to the teacher, allowing the child to move around more, or providing additional accommodations to keep the child on task.
While I'm sure that some children are misdiagnosed with ADHD, my concern-and the concern of my peers-is that far more children are underdiagnosed. Kids may have a different problem such as a learning disability or anxiety that better explains the problems they are experiencing at home and/or school. This is particularly troubling given research demonstrating that children with ADHD who do not receive appropriate treatment are more likely to have functional problems later, including a higher risk of substance abuse and addiction.1,2,3,4
Today, there are several validated checklists available to aid the community physician in diagnosing ADHD and very clear guidelines from the American Academy of Pediatrics on diagnosis and treatment. If you feel uncomfortable diagnosing and/or treating the condition, however, I suggest you refer, whether to a behavioral or developmental pediatrician, a child psychiatrist, or to a licensed psychologist who specializes in pediatric mental health.
How do you assess patients for ADHD in your practice? Click "Add Comment" below.)
Steven L. Pastyrnak, PhD, is the division chief of Pediatric Psychology at Helen DeVos Children's Hospital in Grand Rapids, Michigan.
1. Biederman J, Petty CR, Monuteaux MC, et al. Adult psychiatric outcomes of girls with attention deficit hyperactivity disorder: 11-year follow-up in a longitudinal case-control study. Am J Psychiatry. 2010;167(4):409-417.
2. Mannuzza S, Klein RG, Bessler A, et al. Adult psychiatric status of hyperactive boys grown up. Am J Psychiatry. 1998;155(4):493-498.
3. Wilens TE, Biederman J, Mick E. Does ADHD affect the course of substance abuse? Findings from a sample of adults with and without ADHD. Am J Addict. 1998;7(2):156-163.
4. Wilens TE, Adamson J, Monuteaux MC, et al. Effect of prior stimulant treatment for attention-deficit/hyperactivity disorder on subsequent risk for cigarette smoking and alcohol and drug use disorders in adolescents. Arch Pediatr Adolesc Med. 2008;162(10):916-921.
|Friday, October 22, 2010
|Kids – Sleep = Obesity
|by Pediatric Perspectives at 09:56 AM
James Chamness, MD, Sleep Medicine
Helen DeVos Children's Hospital
The recent study in the Archives of Pediatrics & Adolescent Medicine regarding the impact of reduced nighttime sleep in children ages 0 to 4 on body mass index (BMI) is just the latest to show a strong association between lack of sleep and obesity.
The study found that short duration of sleep in the early childhood years was associated with an 80% increased risk of being overweight or obese later in life, while no increased risk was found in children between the ages of 5 and 13. And no, napping didn't make up for the lack of nighttime snoozing. These findings parallel those of an earlier study that found that children 2 years and younger who got less than 12 hours of sleep in a 24-hour period had a two-fold increased risk of being overweight at age 3.1
So what's going on?
We know that sleep deprivation leads to increased fatigue and altered thermoregulation (slower metabolic rate), both of which can result in reduced energy expenditure and weight gain. In addition, sleep deprivation increases appetite, leading to increased energy consumption. Adolescents who sleep less than 8 hours at night are more likely to consume a larger portion of their daily calories in the early morning, and more than twice as likely to consume high-calorie snacks.2
One reason for the link between sleep and appetite may be metabolic changes, with increased ghrelin (the appetite hormone) and decreased leptin (the "stop eating" hormone) release occurring with less sleep. This probably results from hypothalamic mechanisms, although we're still exploring the exact links.
Another interesting thing about the sleep/weight association is that boys are more susceptible than girls. We think that's because testosterone further amplifies the ghrelin/leptin effect.
This study is very timely as we are seeing insufficient sleep occurring very early in life. There are several reasons for the low amounts of sleep in young children. They include restrictions of parents' schedules (i.e., keeping children up later to compensate for working parents not being home during the day); unrealistic expectations of parents in terms of the amount of sleep their children need; and actual sleep disorders. The biggest reason, however, is probably that these children are simply not going to bed early enough.
While adolescents are a particularly high-risk group for short sleep, this study shows that the early sleep patterns in children under 5 may be setting kids up for weight problems for the rest of their lives. Given that reduced sleep patterns parallels the growth in overweight and obese children over the past 20 years, it is likely a major contributor to our current "obesity epidemic." And, in many cases, the parent may be responsible for this lack of sleep.
Thus, I think it's important that community pediatricians address sleep duration with parents during well-baby visits. They should also screen for snoring in toddlers and preschoolers. Remember, one of the peak ages for needing tonsil and adenoid removal is 3 to 4, and snoring could be a sign of sleep apnea, which further interferes with sleep quality and duration.
What are you seeing in your practice in terms of sleep patterns in very young children? Click "Add Comment" to join the conversation.
Jim Chamness, MD, is a pediatric sleep medicine specialist at Helen DeVos Children's Hospital in Grand Rapids, Michigan
1Taveras EM, Rifas-Shiman SL, Oken E, Gunderson EP, Gillman MW. Short sleep duration in infancy and risk of childhood overweight. Arch Pediatr Adolesc Med. 2008;162(4):305-11.
2Weiss A, Xu F, Storfer-Isser A, et al. The association of sleep duration with adolescents' fat and carbohydrate consumption. Sleep. 2010;1;33(9):1201-9.