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Mink R, Schwartz A, Carraccio C, High P, Dammann C, McGann KA, Kesselheim J, Herman B, Baffa G, Herman B, Turner DA, Fussell J, High P, Hsu D, Stafford D, Aye T, Sauer C, Kesselheim J, Myers A, McGann K, Dammann C, Chess P, Mahan J, Weiss P, Curran M, Schwartz A, Carraccio C, Herman B, Mink R, Havalad V, Pinheiro J, Alderman E, Fuloria M, McCabe ME, Mehta J, Rivas Y, Rosenberg M, Doughty C, Hergenroeder A, Kale A, Lee-Kim Y, Rama JA, Steuber P, Voigt B, Hardy K, Johnston S, Boyer D, Mauras C, Schonwald A, Sharma T, Barron C, Dennehy P, Jacobs ES, Welch J, Kumar D, Mason K, Roizen N, Rose JA, Bokor B, Chapman JI, Frank L, Sami I, Schuette J, Lutes RE, Savelli S, Amirnovin R, Harb R, Kato R, Marzan K, Monzavi R, Vanderbilt D, Doughty L, McAneney C, Rice W, Widdice L, Erenberg F, Gonzalez BE, Adkins D, Green D, Narayan A, Rehder K, Clingenpeel J, Starling S, Karpen HE, Rouster-Stevens K, Bhatia J, Fuqua J, Anders J, Trent M, Ramanathan R, Nicolau Y, Dozor AJ, Kinane TB, Stanley T, Rao AN, Bone M, Camarda L, Heffner V, Kim O, Nocton J, Rabbitt AL, Tower R, Amaya M, Jaroscak J, Kiger J, Macias M, Titus O, Awonuga M, Vogt K, Warwick A, Coury D, Hall M, Letson M, Rose M, Glickstein J, Lusman S, Roskind C, Soren K, Katz J, Siqueira L, Atlas M, Blaufox A, Gottleib B, Meryash D, Vuguin P, Weinstein T, Armsby L, Madison L, Scottoline B, Shereck E, Henry M, Teaford PA, Long S, Varlotta L, Zubrow A, Barlow C, Feldman H, Ganz H, Grimm P, Lee T, Weiner LB, Molle-Rios Z, Slamon N, Guillen U, Miller K, Federman M, Cron R, Hoover W, Simpson T, Winkler M, Harik N, Ross A, Al-Ibrahim O, Carnevale FP, Waz W, Bany-Mohammed F, Kim JH, Printz B, Brook M, Hermiston M, Lawson E, van Schaik S, McQueen A, Booth KVP, Tesher M, Barker J, Friedman S, Mohon R, Sirotnak A, Brancato J, Sayej WN, Maraqa N, Haller M, Stryjewski B, Brophy P, Rahhal R, Reinking B, Volk P, Bryant K, Currie M, Potter K, Falck A, Weiner J, Carney MM, Felt B, Barnes A, Bendel CM, Binstadt B, Carlson K, Garrison C, Moffatt M, Rosen J, Sharma J, Tieves KS, Hsu H, Kugler J, Simonsen K, Fastle RK, Dannaway D, Krishnan S, McGuinn L, Lowe M, Witchel SF, Matheo L, Abell R, Caserta M, Nazarian E, Yussman S, Thomas AD, Hains DS, Talati AJ, Adderson E, Kellogg N, Vasquez M, Allen C, Brion LP, Green M, Journeycake J, Yen K, Quigley R, Blaschke A, Bratton SL, Yost CC, Etheridge SP, Laskey T, Pohl J, Soprano J, Fairchild K, Norwood V, Johnston TA, Klein E, Kronman M, Nanda K, Smith L, Allen D, Frohna JG, Patel N, Estrada C, Fleming GM, Gillam-Krakauer M, Moore P, El Khoury JC, Helderman J, Barretto G, Levasseur K, Johnston L. Creating the Subspecialty Pediatrics Investigator Network. J Pediatr 2018; 192:3-4.e2. [PMID: 29246355 DOI: 10.1016/j.jpeds.2017.09.079] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 09/28/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Richard Mink
- Harbor-UCLA Medical Center and David Geffen School of Medicine at UCLA, Torrance, CA
| | | | | | - Pamela High
- W Alpert Medical School of Brown University, Providence, RI
| | | | | | | | - Bruce Herman
- University of Utah/Primary Children's Hospital, Salt Lake City, UT
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Abstract
Cultural beliefs may influence parents' willingness to raise concerns on a developmental screener. Our study evaluated the performance of the Parents' Evaluation of Developmental Status (PEDS) in an urban community health center where 75% of families are Spanish speaking. Our primary outcome was the presence of parent-reported concerns either in the medical record or on the PEDS before the PEDS was introduced compared with after it became routine care (post-PEDS). Covariates included family language and child age, gender, and risk status. The adjusted odds of a concern being identified was 1.5 times greater in the post-PEDS period for Developmental concerns and 2.1 times greater for Behavioral concerns. There was no association with family language indicating that the PEDS performs equally well for English- and Spanish-speaking families. The systematic inclusion of developmental screening as part of culturally competent primary care may aid in reducing current disparities in the identification of developmental concerns.
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Affiliation(s)
- Noelle Huntington
- Boston Children's Hospital & Harvard Medical School, Boston, MA, USA
| | - Kelly Horan
- Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | | | - Alison Schonwald
- Boston Children's Hospital & Harvard Medical School, Boston, MA, USA
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Olson H, Shen Y, Avallone J, Sheidley BR, Pinsky R, Bergin AM, Berry GT, Duffy FH, Eksioglu Y, Harris DJ, Hisama FM, Ho E, Irons M, Jacobsen CM, James P, Kothare S, Khwaja O, Lipton J, Loddenkemper T, Markowitz J, Maski K, Megerian JT, Neilan E, Raffalli PC, Robbins M, Roberts A, Roe E, Rollins C, Sahin M, Sarco D, Schonwald A, Smith SE, Soul J, Stoler JM, Takeoka M, Tan WH, Torres AR, Tsai P, Urion DK, Weissman L, Wolff R, Wu BL, Miller DT, Poduri A. Copy number variation plays an important role in clinical epilepsy. Ann Neurol 2014; 75:943-58. [PMID: 24811917 DOI: 10.1002/ana.24178] [Citation(s) in RCA: 120] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 05/07/2014] [Accepted: 05/07/2014] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To evaluate the role of copy number abnormalities detectable using chromosomal microarray (CMA) testing in patients with epilepsy at a tertiary care center. METHODS We identified patients with International Classification of Diseases, ninth revision (ICD-9) codes for epilepsy or seizures and clinical CMA testing performed between October 2006 and February 2011 at Boston Children's Hospital. We reviewed medical records and included patients who met criteria for epilepsy. We phenotypically characterized patients with epilepsy-associated abnormalities on CMA. RESULTS Of 973 patients who had CMA and ICD-9 codes for epilepsy or seizures, 805 patients satisfied criteria for epilepsy. We observed 437 copy number variants (CNVs) in 323 patients (1-4 per patient), including 185 (42%) deletions and 252 (58%) duplications. Forty (9%) were confirmed de novo, 186 (43%) were inherited, and parental data were unavailable for 211 (48%). Excluding full chromosome trisomies, CNV size ranged from 18kb to 142Mb, and 34% were >500kb. In at least 40 cases (5%), the epilepsy phenotype was explained by a CNV, including 29 patients with epilepsy-associated syndromes and 11 with likely disease-associated CNVs involving epilepsy genes or "hotspots." We observed numerous recurrent CNVs including 10 involving loss or gain of Xp22.31, a region described in patients with and without epilepsy. INTERPRETATION Copy number abnormalities play an important role in patients with epilepsy. Because the diagnostic yield of CMA for epilepsy patients is similar to the yield in autism spectrum disorders and in prenatal diagnosis, for which published guidelines recommend testing with CMA, we recommend the implementation of CMA in the evaluation of unexplained epilepsy.
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Affiliation(s)
- Heather Olson
- Epilepsy Genetics Program, Division of Epilepsy and Clinical Neurophysiology and Neurogenetics Program, Department of Neurology, Boston Children's Hospital, and Harvard Medical School, Boston, MA
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Shen Y, Dies KA, Holm IA, Bridgemohan C, Sobeih MM, Caronna EB, Miller KJ, Frazier JA, Silverstein I, Picker J, Weissman L, Raffalli P, Jeste S, Demmer LA, Peters HK, Brewster SJ, Kowalczyk SJ, Rosen-Sheidley B, McGowan C, Duda AW, Lincoln SA, Lowe KR, Schonwald A, Robbins M, Hisama F, Wolff R, Becker R, Nasir R, Urion DK, Milunsky JM, Rappaport L, Gusella JF, Walsh CA, Wu BL, Miller DT. Clinical genetic testing for patients with autism spectrum disorders. Pediatrics 2010; 125:e727-35. [PMID: 20231187 PMCID: PMC4247857 DOI: 10.1542/peds.2009-1684] [Citation(s) in RCA: 264] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Multiple lines of evidence indicate a strong genetic contribution to autism spectrum disorders (ASDs). Current guidelines for clinical genetic testing recommend a G-banded karyotype to detect chromosomal abnormalities and fragile X DNA testing, but guidelines for chromosomal microarray analysis have not been established. PATIENTS AND METHODS A cohort of 933 patients received clinical genetic testing for a diagnosis of ASD between January 2006 and December 2008. Clinical genetic testing included G-banded karyotype, fragile X testing, and chromosomal microarray (CMA) to test for submicroscopic genomic deletions and duplications. Diagnostic yield of clinically significant genetic changes was compared. RESULTS Karyotype yielded abnormal results in 19 of 852 patients (2.23% [95% confidence interval (CI): 1.73%-2.73%]), fragile X testing was abnormal in 4 of 861 (0.46% [95% CI: 0.36%-0.56%]), and CMA identified deletions or duplications in 154 of 848 patients (18.2% [95% CI: 14.76%-21.64%]). CMA results for 59 of 848 patients (7.0% [95% CI: 5.5%-8.5%]) were considered abnormal, which includes variants associated with known genomic disorders or variants of possible significance. CMA results were normal in 10 of 852 patients (1.2%) with abnormal karyotype due to balanced rearrangements or unidentified marker chromosome. CMA with whole-genome coverage and CMA with targeted genomic regions detected clinically relevant copy-number changes in 7.3% (51 of 697) and 5.3% (8 of 151) of patients, respectively, both higher than karyotype. With the exception of recurrent deletion and duplication of chromosome 16p11.2 and 15q13.2q13.3, most copy-number changes were unique or identified in only a small subset of patients. CONCLUSIONS CMA had the highest detection rate among clinically available genetic tests for patients with ASD. Interpretation of microarray data is complicated by the presence of both novel and recurrent copy-number variants of unknown significance. Despite these limitations, CMA should be considered as part of the initial diagnostic evaluation of patients with ASD.
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Affiliation(s)
- Yiping Shen
- Autism Consortium, Boston, Massachusetts,Department of Laboratory Medicine, Children’s Hospital Boston, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts,Center for Human Genetic Research, Massachusetts General Hospital, Boston, Massachusetts
| | - Kira A. Dies
- Autism Consortium, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | - Ingrid A. Holm
- Autism Consortium, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts,Program in Genomics, Children’s Hospital Boston, Boston, Massachusetts,Manton Center for Orphan Disease Research, Children’s Hospital Boston, Boston, Massachusetts
| | - Carolyn Bridgemohan
- Autism Consortium, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts,Developmental Medicine Center, Children’s Hospital Boston, Boston, Massachusetts
| | - Magdi M. Sobeih
- Autism Consortium, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts,Department of Neurology, Children’s Hospital Boston, Boston, Massachusetts
| | - Elizabeth B. Caronna
- Autism Consortium, Boston, Massachusetts,Department of Pediatrics, Boston University School of Medicine, Massachusetts
| | - Karen J. Miller
- Autism Consortium, Boston, Massachusetts,Floating Hospital for Children, Tufts Medical Center, Boston, Massachusetts
| | - Jean A. Frazier
- Autism Consortium, Boston, Massachusetts,University of Massachusetts Medical School, Worcester, Massachusetts,UMass Memorial Medical Center, Worcester, Massachusetts
| | - Iris Silverstein
- Autism Consortium, Boston, Massachusetts,Massachusetts General Hospital for Children LADDERS Clinic, Boston, Massachusetts
| | - Jonathan Picker
- Autism Consortium, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts,Division of Genetics, Children’s Hospital Boston, Boston, Massachusetts
| | - Laura Weissman
- Autism Consortium, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts,Developmental Medicine Center, Children’s Hospital Boston, Boston, Massachusetts
| | - Peter Raffalli
- Autism Consortium, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts,Department of Neurology, Children’s Hospital Boston, Boston, Massachusetts
| | - Shafali Jeste
- Autism Consortium, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts,Department of Neurology, Children’s Hospital Boston, Boston, Massachusetts
| | - Laurie A. Demmer
- Autism Consortium, Boston, Massachusetts,Floating Hospital for Children, Tufts Medical Center, Boston, Massachusetts
| | - Heather K. Peters
- Autism Consortium, Boston, Massachusetts,Program in Genomics, Children’s Hospital Boston, Boston, Massachusetts
| | - Stephanie J. Brewster
- Autism Consortium, Boston, Massachusetts,Program in Genomics, Children’s Hospital Boston, Boston, Massachusetts
| | - Sara J. Kowalczyk
- Autism Consortium, Boston, Massachusetts,Department of Pediatrics, Boston University School of Medicine, Massachusetts
| | - Beth Rosen-Sheidley
- Autism Consortium, Boston, Massachusetts,Floating Hospital for Children, Tufts Medical Center, Boston, Massachusetts
| | - Caroline McGowan
- Autism Consortium, Boston, Massachusetts,Division of Genetics, Children’s Hospital Boston, Boston, Massachusetts
| | - Andrew W. Duda
- Autism Consortium, Boston, Massachusetts,Massachusetts General Hospital for Children LADDERS Clinic, Boston, Massachusetts
| | - Sharyn A. Lincoln
- Autism Consortium, Boston, Massachusetts,Division of Genetics, Children’s Hospital Boston, Boston, Massachusetts
| | - Kathryn R. Lowe
- Autism Consortium, Boston, Massachusetts,Program in Genomics, Children’s Hospital Boston, Boston, Massachusetts
| | - Alison Schonwald
- Autism Consortium, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts,Developmental Medicine Center, Children’s Hospital Boston, Boston, Massachusetts
| | - Michael Robbins
- Autism Consortium, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts,Department of Neurology, Children’s Hospital Boston, Boston, Massachusetts
| | - Fuki Hisama
- Autism Consortium, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts,Division of Genetics, Children’s Hospital Boston, Boston, Massachusetts
| | - Robert Wolff
- Autism Consortium, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts,Department of Neurology, Children’s Hospital Boston, Boston, Massachusetts
| | - Ronald Becker
- Autism Consortium, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts,Developmental Medicine Center, Children’s Hospital Boston, Boston, Massachusetts
| | - Ramzi Nasir
- Autism Consortium, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts,Developmental Medicine Center, Children’s Hospital Boston, Boston, Massachusetts
| | - David K. Urion
- Autism Consortium, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts,Department of Neurology, Children’s Hospital Boston, Boston, Massachusetts
| | - Jeff M. Milunsky
- Autism Consortium, Boston, Massachusetts,Department of Pediatrics, Boston University School of Medicine, Massachusetts,Clinical Genetics, Boston University School of Medicine, Massachusetts
| | - Leonard Rappaport
- Autism Consortium, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts,Developmental Medicine Center, Children’s Hospital Boston, Boston, Massachusetts
| | - James F. Gusella
- Autism Consortium, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts,Center for Human Genetic Research, Massachusetts General Hospital, Boston, Massachusetts
| | - Christopher A. Walsh
- Autism Consortium, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts,Division of Genetics, Children’s Hospital Boston, Boston, Massachusetts
| | - Bai-Lin Wu
- Autism Consortium, Boston, Massachusetts,Department of Laboratory Medicine, Children’s Hospital Boston, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts,Departments of Pediatrics and Pathology, Children’s Hospital, Shanghai Medical College and Institutes of Biomedical Science, Fudan University, Shanghai, China
| | - David T. Miller
- Autism Consortium, Boston, Massachusetts,Department of Laboratory Medicine, Children’s Hospital Boston, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts,Division of Genetics, Children’s Hospital Boston, Boston, Massachusetts
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Abstract
OBJECTIVES The American Academy of Pediatrics recommends routine developmental screening in well-child care. Providers cite time restraints as a limitation preventing its widespread adoption. The objectives were to determine whether routine screening lengthened well-visits and was associated with changes in parent satisfaction and report of anticipatory guidance. METHODS Visits before and after implementation of routine screening were timed. Parents whose children were seen before or after screening began were contacted to query their perceptions of the visit. RESULTS There was no change in visit lengths after the screener was included. With screening, more parents reported their provider talked about their concerns, and that their questions were answered. There were no changes in parent satisfaction ratings or reports of anticipatory guidance discussions. CONCLUSIONS The perceived obstacle that routine screening requires more time than pediatricians have should not prevent its adoption. Screening tools may empower some parents otherwise reluctant to raise concerns unsolicited.
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Affiliation(s)
- Alison Schonwald
- Division of General Pediatrics, Children's Hospital, Boston, Massachusetts, Division of Developmental Medicine, Children's Hospital, Boston, Massachusetts, USA.
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Schonwald A, Huntington N, Chan E, Risko W, Bridgemohan C. Routine developmental screening implemented in urban primary care settings: more evidence of feasibility and effectiveness. Pediatrics 2009; 123:660-8. [PMID: 19171635 DOI: 10.1542/peds.2007-2798] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The purpose of this study was to examine the feasibility and effectiveness of implementation of validated developmental screening by using the Parents' Evaluation of Developmental Status in 2 urban pediatric practices. DESIGN AND METHODS We implemented the Parents' Evaluation of Developmental Status at Boston Children's Hospital Primary Care Center and at Joseph Smith Community Health Center as quality improvement initiatives. Each practice offered screening to all of the patients attending well-child care visits between 6 months and 8 years of age. The implementation process was investigated by using preimplementation and postimplementation surveys and a focus group of pediatric primary care providers. To assess outcomes, such as changes in identification rates and referrals for developmental and behavioral concerns, we reviewed medical charts of all of the 2- and 3-year-olds present at Children's Hospital Primary Care Center well-child care visits in the periods before and after screening implementation. RESULTS Providers found routine screening easier than expected and feasible to conduct in a busy primary care setting. The practice change resulted in screening of 61.6% of eligible children. Compared with same-aged children before screening, after screening was implemented more behavioral concerns were detected in the 2-year-old group, and more children with developmental concerns were identified in the 3-year-old group. Referral rates for additional evaluation increased only for 3-year-olds, although the types of referrals (ie, audiology and early intervention) were consistent as those found before screening started. CONCLUSIONS Implementation of validated screening by using the Parents' Evaluation of Developmental Status was feasible in large, urban settings. Effectiveness was demonstrated via chart review documenting an increased rate of identification of developmental and behavioral concerns. Perceived obstacles, such as the time requirement, should not prevent widespread adoption of screening.
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Affiliation(s)
- Alison Schonwald
- Divisions of Developmental Medicine, Children's Hospital Boston, 300 Longwood Ave, Boston, MA 02115, USA.
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8
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Abstract
PURPOSE OF REVIEW Attention deficit/hyperactivity disorder continues to be a prevalent childhood behavioral disorder, with significant clinical and media interest. Providers must be current with research findings that impact the evolving understanding of this complex entity. This article summarizes recent progress in our view of attention deficit/hyperactivity disorder, with emphasis on controversies around diagnosis and treatment, and future management directions. RECENT FINDINGS Literature about attention deficit/hyperactivity disorder in 2005 further enhanced our understanding of the genetic contribution to the expression of attention deficit/hyperactivity disorder, with exploration of sophisticated genetic models and their dynamic interaction with exposures and experiences. Previous literature focuses on conventional treatment; new developments in pharmacological/alternative options add to treatment choices, but have brought well publicized controversies. Furthermore, optimal management continues to gain evidence-based support. SUMMARY Attention deficit/hyperactivity disorder is a subject of great interest to families, providers, researchers, and public forums. Scientific investigation supports a primary genetic contribution, but the relationship of molecular bases and environmental exposures appears intricate and complex. With increased awareness of this disorder, diagnostic dilemmas and medication side effects are more widely understood, topics particularly important to clinicians. Stimulant treatment remains the mainstay of intervention, but new delivery forms and nonstimulant options are potential therapies as well.
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Abstract
PURPOSE OF REVIEW Attention-deficit/hyperactivity disorder (AD/HD) affects 7.5% of children, making it among the more common behavioral disorders of childhood. Pediatricians increasingly are expected to recognize AD/HD, as well as diagnose and manage it in the primary care setting. This article reviews recent developments in the care of the pediatric AD/HD patient, with emphasis on information enhancing primary care management. RECENT FINDINGS Studies published in 2004 provide evidence to guide the treatment of AD/HD. The AD/HD literature continues to support the important role of genetics in its etiology. The absence of universal genetic or neuroimaging findings indicates that history from multiple sources and physical exam remain the standard diagnostic method. Comorbid medical problems, such as sleep disruption and growth suppression, continue to be better understood in the setting of AD/HD, as do the substantial impacts of comorbid learning and psychiatric disorders. Despite great interest in alternative, nonstimulant and behavioral treatments, methylphenidate and amphetamine-based medications remain the mainstay of AD/HD intervention. SUMMARY AD/HD is a common medical condition with implications for long-term safety and life function, such as academic success, accident occurrence, and drug use. Identification and treatment is increasingly based in the primary care office, where children must be monitored for co-occurring disorders and referred for additional supports when necessary. Tools and guidelines provided by the American Academy of Pediatrics (AAP) provide a framework for consistent and competent AD/HD care supported by current evidence.
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Affiliation(s)
- Alison Schonwald
- Children's Hospital, Boston, Harvard Medical School, Boston, Massachusetts 02115, USA.
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Bass JL, Corwin M, Gozal D, Moore C, Nishida H, Parker S, Schonwald A, Wilker RE, Stehle S, Kinane TB. The effect of chronic or intermittent hypoxia on cognition in childhood: a review of the evidence. Pediatrics 2004; 114:805-16. [PMID: 15342857 DOI: 10.1542/peds.2004-0227] [Citation(s) in RCA: 307] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE A review of the evidence concerning the effect of chronic or intermittent hypoxia on cognition in childhood was performed by using both a systematic review of the literature and critical appraisal criteria of causality. Because of the significant impact of behavioral disorders such as attention-deficit/hyperactivity disorder on certain cognitive functions as well as academic achievement, the review also included articles that addressed behavioral outcomes. METHODS Both direct and indirect evidence were collected. A structured Medline search was conducted from the years 1966-2000 by using the OVID interface. Both English- and non-English-language citations were included. Significant articles identified by the reviewers up to 2003 were also included. To be included as direct evidence, an article needed to be an original report in a peer-reviewed journal with data on cognitive, behavioral, or academic outcomes in children up to 14 years old, with clinical conditions likely to be associated with exposure to chronic or intermittent hypoxia. Indirect evidence from other reviews and publications in closely related fields, including experimental studies in adults, was used to help formulate conclusions. Two reviewers screened abstracts and titles. Each article included as direct evidence received a structured evaluation by 2 reviewers. Adjudication of differences was performed by a group of 2 reviewers and a research consultant. After this review, tables of evidence were constructed that were used as the basis for group discussion and consensus development. Indirect evidence assigned by topic to specific reviewers was also presented as part of this process. A formal procedure was used to rank the studies by design strength. The critical appraisal criteria for causation described in Evidence Based Pediatrics and Child Health (Moyer V, Elliott E, Davis R, et al, eds. London, United Kingdom: BMJ Books; 2000:46-55) were used to develop consensus on causality. RESULTS A total of 788 literature citations were screened. For the final analysis, 55 articles met the criteria for inclusion in the direct evidence. Of these, 43 (78.2%) reported an adverse effect. Of the 37 controlled studies, 31 (83.8%) reported an adverse effect. Adverse effects were noted at every level of arterial oxygen saturation and for exposure at every age level except for premature newborns. The studies were classified into 5 clinical categories: congenital heart disease (CHD), sleep-disordered breathing (SDB), asthma, chronic ventilatory impairment, and respiratory instability in infants. Two of these categories, CHD and SDB, which accounted for 42 (76.4%) of the included articles, fulfilled the Evidence Based Pediatrics and Child Health criteria for causation. The indirect evidence included 8 reviews, 1 meta-analysis, and 10 original reports covering the fields of adult anoxia, animal research, SDB in adults, natural and experimental high-altitude studies, perinatal hypoxic-ischemic encephalopathy, anemia, and carbon-monoxide poisoning. The studies of high-altitude and carbon-monoxide poisoning provided evidence for causality. CONCLUSIONS Adverse impacts of chronic or intermittent hypoxia on development, behavior, and academic achievement have been reported in many well-designed and controlled studies in children with CHD and SDB as well as in a variety of experimental studies in adults. This should be taken into account in any situation that may expose children to hypoxia. Because adverse effects have been noted at even mild levels of oxygen desaturation, future research should include precisely defined data on exposure to all levels of desaturation.
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Affiliation(s)
- Joel L Bass
- Department of Pediatrics, Newton-Wellesley Hospital, MassGeneral Hospital for Children, Harvard Medical School, Newton, Massachusetts 02462, USA.
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11
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Affiliation(s)
- Alison Schonwald
- Developmental Medicine Center, Boston Children's Hospital, MA, USA
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12
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Abstract
OBJECTIVE To identify temperament and behavioral patterns in children with difficult toilet training and to compare those children with same-aged toilet-trained children. METHODS We compared 46 referred clinic patients who were difficult toilet trainers (DTT) with 62 comparison children (CC) using the Carey-McDevitt Behavioral Style Questionnaire, the Parenting Scale, and a questionnaire of toilet-training history. RESULTS CC were more likely to have easy temperaments (odds ratio [OR]: 33.51). DTT were more likely to be less adaptable (OR: 3.12), more negative in mood (OR: 2.79), less persistent (OR: 2.97), and lower in approach (OR: 1.85). DTT were more likely than CC to be constipated (OR: 3.52), although 55% of CC were constipated. DTT were likely to hide to stool (74%) and to ask for pull-ups in which to leave stool (37%). Parenting styles did not differ between the groups. CONCLUSIONS Although the referral population may be inherently biased, these data suggest that difficult toilet training is associated with difficult temperamental traits and constipation in affected children.
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Affiliation(s)
- Alison Schonwald
- Children's Hospital, Division of General Pediatrics, and Harvard Medical School, Boston, Massachusetts 02115, USA.
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13
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Abstract
OBJECTIVE To compare the characteristics of children with encopresis referred to a single encopresis clinic over the course of 20 years, including symptoms, previous diagnostic and therapeutic interventions, and parental attitudes. METHODS A retrospective study was conducted of an encopresis clinic at a tertiary care pediatric hospital. Questionnaires at initial evaluation elicited information about bowel habits, soiling, previous evaluations, previous treatments, and parental attitudes. RESULTS In 503 children with encopresis, the average age of referral dropped from 115 months during the earliest 5 years to 77 months during the most recent 5 years. Children who had soiling for >3 years before referral decreased from 63% to 12%. The use of barium enema before referral decreased from 14% to 5%, as did psychological evaluation, from 25% to 14%. Previous therapy with enemas decreased from 45% to 27%. Mineral oil use remained at approximately 50%, and 20% of children had no previous treatment. Symptoms at referral and parental attitudes did not change across the years. CONCLUSIONS Children are now referred at an earlier age to our tertiary encopresis clinic. The number of invasive and psychological evaluations has decreased before referral. However, treatment by many primary care providers before the referral has not changed. These data may suggest that pediatricians have increased awareness of encopresis and greater appreciation of its primarily physical rather than psychological nature. Additional studies will be needed to determine how these factors affect outcome.
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Affiliation(s)
- Laurie Fishman
- Combined Program in Gastroenterology and Nutrition, Children's Hospital, Boston, Massachusetts 02115, USA.
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