Early intervention (EI): 0-3 years. Disclosure. HOT TOPICS Developmental and Behavioral Pediatrics

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1 Advances and Controversies in Clinical Pediatrics University of California San Francisco 2007 HOT TOPICS Developmental and Behavioral Pediatrics Disclosure I have no financial relationship with a manufacture of a commercial product discussed in this CME presentation Martin T. Stein, MD University of California San Diego Rady Children s Hospital San Diego Misconceptions lead to under-referral to early intervention programs Early intervention (EI): 0-3 years The law: evaluation of all children referred when Suspicion of a developmental delay (DD), Known DD Medical condition associated with a high probability of DD Random sample 1617 AAP fellows (RR=55%) Silverstein M et al. Ambulatory Pediatrics Mar-Apr 2006: Misconceptions lead to under-referral to early intervention programs Early intervention (EI): 0-3 years Referral was lower among pediatricians who considered a specific diagnosis important: Delayed speech (77% vs. 87%; P=.01) Global delay (91% vs. 97%) Loss of developmental milestones (80 vs. 88%) Parental concern for inappropriate development (45 vs. 60%; P=.002) When to consider an EI referral: Suspicion of a developmental delay (DD) Known DD Medical condition associated with a high probability of DD Silverstein M et al. Ambulatory Pediatrics Mar-Apr 2006:

2 Is autism in children associated with advanced of parents? Population-based cohort study: all births in Israel over a 6-year period followed by assessment at 17 years by the draft board Autistic spectrum disorder (ASD) were registered with a central agency Standard diagnostic criteria and psychometric tools were used. Reichenberg A. Arch Gen Psychiatry (2006) 63: Is autism in children associated with advanced age of parents? Prevalence of ASD: 8.3 per 10,000 persons (110 cases). ASD: 5.75 times more likely in offspring of men 40 years or older compared with fathers younger than 30 years (P<.001) Controlled socioeconomic status and maternal age Advancing maternal age was not associated with autism after adjusting for paternal age. Reichenberg A. Arch Gen Psychiatry (2006) 63: Is autism in children associated with advanced age of parents? Possible mechanisms for the association between advanced paternal age and ASD: Spontaneous mutations Imprinting whereby paternal genes are expressed and maternal genes are silenced by DNA methylation Limitations of the study: missing information Subgroup classification of ASD Normal cognitive function vs. MR Atypical social phenotypes and pragmatic language of parents Prenatal/environmental exposures Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Pediatrics July 2006; 118: Pediatricians Reporting Screening Young Children for Developmental Problems 96 % Any Screening 71 % Always Only Clinical Assessment 15 % Sometimes Only Clinical Assessment 23 % Standardized Instrument Developmental surveillance recommended as a part of all well-child care visits A flexible, longitudinal and continuous process Eliciting and attending to parent concerns Maintaining a developmental history Making accurate and informed observations Identifying the presence of risk and protective factors Documenting the process and findings AAP Periodic Survey #53, 20 2

3 Standardized developmental screening test should be administered regularly at the 9-, 18-and 30-month visits Rationale: to insure early recognition and referral of young children with a developmental delay Tests that meet psychometric criteria: Generalized development Language/cognitive development Motor development Autism screening 9-months: gross/fine motor skill and early social skills 18-months: early language and emerging social skills (when signs of autistic spectrum disorder may be detected) 30-months: expressive/receptive language especially among the 15-20% of late-talking toddlers at 24 months, many of whom will be normal at 30 months. Ref: Pediatrics July 2006; 118: A cautionary note: Standardized screening tests should not substitute for an awareness that pediatricians learn a great deal about a child and family from open-ended questions and careful listening to parents and children at each clinical encounter. Time with kids and parents and experienced clinical interviewing and observations matter! Time Matters The translation of (advances in medicine) to patient care rests on the psychosocial competence of clinicians. Technology isn t worth a damn unless doctor and patient become informed allies. Time with the patient will remain the currency of medical care. Leon Eisenberg, M.D. 2 nd opinion: iron deficiency may not be associated with ADHD 68 patients (5-16 yo): a referral clinic with a diagnosis of ADHD Range of serum ferritin: ng/mL (normal>20ng/ml) Mean serum ferritin: 39.1 (+/-40.6) ng/ml 44% were <30ng/mL and 18% were <20ng/mL When severity of ADHD, comorbid symptoms and response to stimulant medication was compared to patients with the lowest and highest serum ferritin levels, no associations were found. Millichap JG. Pediatric Neurology 2006; 34: nd opinion: early TV exposure may not be associated with ADHD Relationship between TV exposure and ADHD National sample: 22,000 families 5000 children randomly selected School readiness at kindergarten and cognitive performance and behavior in the first grade assessed with standardized measurements Early TV exposure was a weak predictor of subsequent ADHD symptoms Effect size: close to zero Stevens T, Muslow M. Pediatrics (2006) 117:

4 When preschool children have ADHD NIMH-funded: 6 center, randomized controlled trial of the efficacy and safety of methylphenidate (MPH) in preschool children 303 children (3-5.5 years old; DSM-IV criteria for combined type ADHD) enrolled with parents Intensive 10-week behavioral therapy program Children whose behaviors did not improve after the behavioral therapy and whose parents agreed to a medication trial were entered in the medication phase of the study 165 children were randomized When preschool children have ADHD 5-week, placebo-controlled, double blind trial with immediate release MPH prescribed TID at 3 different doses Outcomes: standardized ADHD questionnaires completed by parents and teachers ADHD symptoms decreased significantly compared to controls on TID doses of MPH: 2.5 mg (p<.01), 5 mg (p<.001), and 7.5 mg (p<.001) Mean effective MPH dose for the entire group was 14.2 (+/-8.1) mg/day Jour Amer Acad Child Adolesc Psychiatry (2006) 45: (4 articles) When preschool children have ADHD Safety Study 140 preschool children Open-labeled trial: 10-months 30% of parents reported moderate to severe adverse effects including emotional outbursts, difficulty falling asleep, repetitive behaviors and thoughts, appetite suppression and irritability Discontinuation of medication: 11% Growth rates: 20% less than expected for height (-1.38 cm/year) and 55% for weight (-1.32 kg/yr) Challenge of ADHD diagnosis in preschool children Hyperactivity, impulsivity and inattentiveness: consistent with many developmental variations of typically developing preschool children Frequent and unremitting disruptive behaviors in the classroom/home not responsive to behavioral management suggests ADHD BUT CONSIDER: Significant family dysharmony Psychosocial deprivation Sexual abuse Autistic spectrum disorder Early bipolar disease ADHD in children with borderline-tomild intellectual disability Children w/adhd typically have average or above average intellectual ability. Most studies of ADHD exclude children with below average IQ. All children born in Rochester, Minn. from (n=5718); available medical and educational records Frequency of ADHD in children with borderlineto-mild intellectual disability (IQ=51-79 measured by a standardized intelligence test between 6-18 years of age) Voight RG. Developmental Medicine & Child Neurology 2006; 48: ADHD in children with borderline-tomild intellectual disability 70 children (1.2%) were classified with borderline-tomild intellectual disability 21 (30%) of these children (14 males; 7 females) had ADHD documented by standard criteria Prevalence of ADHD among the 5629 children without intellectual disability was 6.4% Odds ratio for ADHD among children with borderline-to-mild intellectual disability was 6.3 (p<.001) Recent studies: behavioral and cognitive benefits of stimulant medication in intellectually disabled children with ADHD 4

5 ADHD in syndromes associated with significant developmental disabilities Fetal alcohol syndrome Fragile X syndrome Angelman syndrome Prader-Willi syndrome Tourette syndrome Turner syndrome Williams syndrome Hagerman RJ. Neurodevelopmental Disorders: Diagnosis and Treatment (1999) New York: Oxford University Press. Major depression in women of parenting age (5-10%) Potential effects on children Quality of parent-child interactions Risk for childhood depression Increased use of office visits most pediatricians use an unstructured interview Only 8% of pediatricians routinely ask about specific symptoms related to maternal depression. Two questions about mood and anhedonia, previously shown to be as effective as standardized screening measures to detect maternal depression: Over the past 2 weeks, have you felt down, depressed or hopeless? Over the past 2 weeks, have you felt little interest or pleasure in doing things? 4 New England rural pediatric practices recruited to screen mothers during well child visits on randomly selected days over a 1-month period Interview format (IF) or by a paper-based format (PF) using the 2 screening questions WCC visits (kids 2 wks-16 yo; 50%<24 months) Olson AL J Devel Behav Pediar 2005; 26: Positive screen (affirmative response to either question) 22.9% of mothers using the PF 5.7% of mothers using the IF Subsequently, 7.6% of all women with PF screening and 1.6% with IF received a mental health referral. Preventing childhood depression by Studies in adults with mood disorders have shown a beneficial effect of omega-3 fatty acids found in biologically active forms in fish. Primary long-chain polyunsaturated fatty acid in the omega-3 group: Eicosapentaenoic acid (EPA) Docosahexaenoic acid (DHA) Hypothesis for the rise in depression in western populations: change in diet from omega-3 fatty acids (fish, wild game and plants) to omega-6 fatty acids (vegetable oils) over the past 150 years. 5

6 Preventing childhood depression by 20 children w/ first major depression Mean age: 10 years (range yrs) Duration of depression: mean 3.5 months Randomized: omega-3 or a placebo capsule over a 16-week study period 10 children w/ depression in each group Nemets, H Am J Psychiatry June 2006, 163: Preventing childhood depression by 3 standardized rating scales that included depression symptoms and global impression >50% reduction in depression symptoms in 7 of 10 children in the omega-3 group compared with none in the placebo group 4/10 children in the omega-3 group had a complete remission. Beneficial effect in the omega-3 group was found at 2, 4, 8, 12 and 16 weeks No significant side effects Preventing childhood depression by Two hypotheses proposed to explain the relationship between omega-3 and depression: Reduction of inflammatory mediators from arachidonic acid has been linked to depression The maintenance of CNS membrane integrity from increased levels of DHA Strong negative correlation between fish consumption and major depression documented in a large international study (Am J Psychiatry 2006, 163: ) More research before establishing clinical recommendation for children and adolescents 6