Adjuvant effects of vitamin A and vitamin D supplementation on treatment of children with attention-deficit/hyperactivity disorder: a study protocol for a randomised, double-blinded, placebo-controlled, multicentric trial in China

INTRODUCTION

Approximately 7.2% of children in the world suffer from attention-deficit/hyperactivity disorder (ADHD). Due to the availability of the osmotic-release oral-system methylphenidate, ADHD currently has a remission rate of up to 30.72%. Nevertheless, it has been reported that patients with ADHD tend to exhibit vitamin A and vitamin D deficiency, which may aggravate the symptoms of ADHD. This study aims to determine the effect of vitamin A and vitamin D supplementation as adjunctive therapy to methylphenidate on the symptoms of ADHD.

METHODS AND ANALYSIS

This is a parallel, prospective, interventional multicentric study. Patients will be enrolled from the southern, central and northern parts of China. A target of 504 patients will be followed for 8 weeks. They will be allocated into three groups (vitamin AD, vitamin D and placebo) and administered the interventions accordingly. Data on changes in the symptoms of ADHD as well as changes in the serum concentrations of vitamin A and vitamin D will be recorded. Both responders and nonresponders based on the sociodemographic and clinical data will also be described to mitigate selection bias.

ETHICS AND DISSEMINATION

This study is performed in accordance with the Declaration of Helsinki and was approved by the Institutional Review Board of Children's Hospital of Chongqing Medical University, China (approval number: (2019) IRB (STUDY) number 262). The results of the trial will be reported in peer-reviewed scientific journals and academic conferences regardless of the outcomes.

TRIAL REGISTRATION NUMBER

NCT04284059.

A phenomenologic investigation of pediatric residents' experiences being parented and giving parenting advice

Factors surrounding pediatricians' parenting advice and training on parenting during residency have not been well studied. The primary purpose of this study was to examine pediatric residents' self-reported experiences giving parenting advice and explore the relationship between parenting advice given and types of parenting residents received as children. Thirteen OUHSC pediatric residents were individually interviewed to examine experiences being parented and giving parenting advice. Phenomenological methods were used to explicate themes and secondary analyses explored relationships of findings based upon Baumrind's parenting styles (authoritative, authoritarian, permissive). While childhood experiences were not specifically correlated to the parenting advice style of pediatric residents interviewed, virtually all reported relying upon childhood experiences to generate their advice. Those describing authoritative parents reported giving more authoritative advice while others reported more variable advice. Core interview themes related to residents' parenting advice included anxiety about not being a parent, varying advice based on families' needs, and emphasis of positive interactions and consistency. Themes related to how residents were parented included discipline being a learning process for their parents and recalling that their parents always had expectations, yet always loved them. Pediatric residents interviewed reported giving family centered parenting advice with elements of positive interactions and consistency, but interviews highlighted many areas of apprehension residents have around giving parenting advice. Our study suggests that pediatric residents may benefit from more general educational opportunities to develop the content of their parenting advice, including reflecting on any impact from their own upbringing.

Randomized, controlled trial of oros methylphenidate once a day in children with attention-deficit/hyperactivity disorder

OBJECTIVE

A new once-a-day methylphenidate (MPH) formulation, Concerta (methylphenidate HCl) extended-release tablets (OROS MPH), has been developed. This study was conducted to determine the safety and efficacy of OROS MPH in a multicenter, randomized, clinical trial.

METHODS

Children with attention-deficit/hyperactivity disorder (ADHD; n = 282), all subtypes, ages 6 to 12 years, were randomized to placebo (n = 90), immediate-release methylphenidate (IR MPH) 3 times a day (tid; dosed every 4 hours; n = 97), or OROS MPH once a day (qd; n = 95) in a double-blind, 28-day trial. Outcomes in multiple domains were assessed, and data were analyzed using analysis of variance and Kaplan Meier product limit estimates for time to study cessation. The primary time point for analysis was the last available patient visit using last observation carried forward.

RESULTS

Children in the OROS and IR MPH groups showed significantly greater reductions in core ADHD symptoms than did children on placebo. This was true both at the end of week 1 and at the end of treatment on the basis of mean teacher and parent IOWA Conners ratings. IR MPH tid and OROS MPH qd did not differ significantly on any direct comparisons. Forty-eight percent of the placebo group discontinued early compared with 14% and 16% in the IR MPH and OROS MPH groups, respectively.

CONCLUSIONS

For the treatment of core ADHD symptoms, OROS MPH dosed qd and IR MPH dosed tid were superior to placebo and were not significantly different from each other.attention-deficit/hyperactivity disorder, methylphenidate, OROS, Concerta.

Prevalence and assessment of attention-deficit/hyperactivity disorder in primary care settings

Research literature relating to the prevalence of attention-deficit/hyperactivity disorder (ADHD) and co-occurring conditions in children from primary care settings and the general population is reviewed as the basis of the American Academy of Pediatrics clinical practice guideline for the assessment and diagnosis of ADHD. Epidemiologic studies revealed prevalence rates generally ranging from 4% to 12% in the general population of 6 to 12 year olds. Similar or slightly lower rates of ADHD were revealed in pediatric primary care settings. Other behavioral, emotional, and learning problems significantly co-occurred with ADHD. Also reviewed were rating scales and medical tests that could be employed in evaluating ADHD. The utility of using both parent- and teacher-completed rating scales that specifically assess symptoms of ADHD in the diagnostic process was supported. Recommendations were made regarding the assessment of children with suspected ADHD in the pediatric primary care setting.

American Academy of Pediatrics. Committee on Psychosocial Aspects of Child and Family Health. The child in court: a subject review

When children come to court as witnesses, or when their needs are decided in a courtroom, they face unique stressors from the legal proceeding and from the social predicament that resulted in court action. Effective pediatric support and intervention requires an understanding of the situations that bring children to court and the issues that will confront children and child advocates in different court settings.

How pediatricians can respond to the psychosocial implications of disasters. American Academy of Pediatrics. Committee on Psychosocial Aspects of Child and Family Health, 1998-1999

Natural and human-caused disasters, violence with weapons, and terrorist acts have touched directly the lives of thousands of families with children in the United States.1 Media coverage of disasters has brought images of floods, hurricanes, and airplane crashes into the living rooms of most American families, with limited censorship for vulnerable young children. Therefore, children may be exposed to disastrous events in ways that previous generations never or rarely experienced. Pediatricians should serve as important resources to the community in preparing for disasters, as well as acting in its behalf during and after such events.

Examination of DSM-IV criteria for attention deficit/hyperactivity disorder in a county-wide sample

This study replicated, in the subsequent academic year, teacher-reported prevalence rates for attention deficit/hyperactivity disorder (ADHD) based on DSM-IV. Teachers in grades K-5 in a Tennessee county (10 schools, 214 teachers, and 4323 children) completed questionnaires on all their students consisting of the DSM-IV symptoms for disruptive behavior disorders, except for eight conduct disorders symptoms, seven symptoms screening for anxiety or depression, ratings of performance, and questions about the presence of ADHD, stimulant medication treatment, and behavioral or academic problems. The prevalence rates were 16.1% for ADHD-all types, 8.8% for ADHD-inattentive type (AD), 2.6% for ADHD-hyperactive/impulsive type (HI), and 4.7% for ADHD-combined type and 6.8, 3.2, 0.6, and 2.9%, respectively, when impairment was taken into consideration. The rates of problems differed mostly between ADHD-AD AND ADHD-HI (30% vs. 68%) for behavior and (56% vs. 16%) for academics. Few (11-33%) had an ADHD diagnosis or were treated with stimulant treatment (8-26%). DSM-IV criteria are likely to increase the prevalence but may better characterize the heterogeneity of this disorder.

Obtaining systematic teacher reports of disruptive behavior disorders utilizing DSM-IV

This study examines the psychometric properties of the Vanderbilt AD/HD Diagnostic Teacher Rating Scale (VADTRS) and provides preliminary normative data from a large, geographically defined population. The VADTRS consists of the complete list of DSM-IV AD/HD symptoms, a screen for other disruptive behavior disorders, anxiety and depression, and ratings of academic and classroom behavior performance. Teachers in one suburban county completed the scale for their students during 2 consecutive years. Statistical methods included (a) exploratory and confirmatory latent variable analyses of item data, (b) evaluation of the internal consistency of the latent dimensions, (c) evaluation of latent structure concordance between school year samples, and (d) preliminary evaluation of criterion-related validity. The instrument comprises four behavioral dimensions and two performance dimensions. The behavioral dimensions were concordant between school years and were consistent with a priori DSM-IV diagnostic criteria. Correlations between latent dimensions and relevant, known disorders or problems varied from .25 to .66.

The practical aspects of diagnosing and managing children with attention deficit hyperactivity disorder

AD/HD is a behaviorally defined disorder with specific behavioral criteria. The most recent definitions decrease heterogeneity by defining subtypes although the current treatments tend to be more generic. The main well-established treatments are stimulant medication and behavior modification, which are most effective when used together.

Addressing behavior problems among school-aged children: traditional and controversial approaches

Managing children's behaviors is primarily the responsibility of parents, but pediatricians can help parents be more effective managers, especially when the child involved is presenting a particular challenge. Such help can range from providing reading material and brief counseling to referring the family to mental health clinicians. First, the pediatrician must be able to identify and judge the severity of the problems to refer appropriately. Behavioral interventions, commonly based on the principles of behavior modification with an emphasis on improving the positive and reinforcing aspects of parent-child relationships, can be effective. In addition, pediatricians need to be aware of unconventional therapies in the categories of dietary and exercise interventions. They need to know what motivates parents to seek such therapies, how to judge the efficacy of these approaches, and how to help parents become better-informed consumers.

An economic analysis of developmental detection methods

OBJECTIVE

To assess the costs and benefits of various approaches to early detection of developmental disabilities.

DESIGN

Cost-benefit analyses based on data from previously published studies of developmental screening tests.

SETTING

General pediatric practices and day care centers.

PATIENTS AND OTHER PARTICIPANTS

A total of 247 parents and their 0- to 6-year-old children-103 from day care centers and 144 from pediatric practices.

MAIN OUTCOME MEASURES

Licensed psychological examiners administered a screening test of parents' concerns about children's development and one or two direct screening tests: the Denver-II and/or the Battelle Developmental Inventory Screening Test. For the day care sample, examiners also administered to each child measures of intelligence, adaptive behavior, and language. In the pediatric sample, children were administered additional assessments. At the same time, diagnostic measures were administered to a randomly selected subsample to make determinations about developmental status. Each screening method was evaluated for its short-term costs (administration, interpretation, diagnosis, and treatment) and long-term benefits (impact of early intervention on adult functioning as inferred from longitudinal studies by other researchers).

RESULTS

When the long-term costs and benefits were considered, none of the approaches emerged as markedly superior to another. When viewing the short-term costs, the various screening approaches differed markedly. The use of parents' concerns was by far the least costly for physicians to administer and interpret.

CONCLUSION

Physicians can incur tremendous expenses when attempting to detect children with developmental problems. Although the benefits of early detection and intervention are substantial, physicians are not well-compensated for providing a critical service to society. Health policymakers and third-party payers must reconsider their minimal investment in early detection by health care providers. Nevertheless, our findings have encouraging implications for practice, because the use of parents' concerns as a screening technique offers substantial savings over and above other methods.

Comparison of diagnostic criteria for attention-deficit hyperactivity disorder in a county-wide sample

OBJECTIVE

To examine teacher-reported prevalence rates for attention-deficit hyperactivity disorder (ADHD) based on DSM-III-R and DSM-IV in the same population.

METHOD

Teachers completed questionnaires in which they rated all their students on all DSM-III-R and DSM-IV symptoms for disruptive behavior disorders except for seven conduct disorder symptoms but including seven symptoms screening for anxiety or depression. This constituted all children in kindergarten through fifth grade in a middle Tennessee county during the 1993-1994 academic year (16 schools, 398 teachers, and 8,258 children). Also included were questions about the children's diagnosis of ADHD, treatment with stimulants, and the presence of behavior or academic problems.

RESULTS

The prevalence rates were 7.3% for ADHD (DSM-III-R); 11.4% for ADHD, total (TOT); 5.4% for ADHD, inattentive type (AD); 2.4% for ADHD, hyperactive-impulsive type (HI); and 3.6% for ADHD, combined type (CT). Factor analysis identified five factors: opposition/defiance-conduct, inattention, hyperactivity/impulsivity, anxiety/depression, and stealing-truancy. The rates of problems differed mostly between ADHD-AD and ADHD-HI (40% versus 80%) for behavior and (75% versus 23%) for academics. Few (15% to 40%) had an ADHD diagnosis or stimulant treatment (21% to 32%).

CONCLUSION

DSM-IV criteria are likely to increase the prevalence of this disorder in comparison with DSM-III-R rates, but they may better characterize its heterogeneity.

Erythrocyte L-aspartyl-L-phenylalanine hydrolase activity and plasma phenylalanine and aspartate concentrations in children consuming diets high in aspartame

A deficit of alpha-aspartyl-phenylalanine (alpha-Asp-Phe) hydrolase activity has been suggested as a cause of possible adverse effects of aspartame ingestion. Twenty-five normal preschool children and 23 school-age children described by their parents as sensitive to sugar were fed diets high in sucrose, aspartame, or saccharin for three successive 3-wk periods. Blood samples were obtained at baseline (fasting) and within the last 3 d of each dietary period (postprandial). alpha-Asp-Phe concentrations were below detection limits (0.5 mumol/L) in all plasma samples and Phe and Asp concentrations remained within normal limits, alpha-Asp-Phe hydrolase activities in baseline hemolysate samples did not differ between groups. One subject had a plasma alpha-Asp-Phe hydrolase activity > 2 SD below the mean. Despite this low activity, this subject did not show consistent cognitive or behavioral anomalies that could be linked to low hydrolase activity.

The effect of sugar on behavior or cognition in children. A meta-analysis

OBJECTIVE

To examine the effects of sugar on the behavior or cognition of children by using meta-analytic techniques on reported studies.

DATA SOURCES

Studies were identified through a literature search of the MEDLINE and PsychINFO databases and the authors' files using sugar, sucrose, and attention deficit disorder as the search terms.

STUDY SELECTION

Studies were required to (1) intervene by having the subjects consume a known quantity of sugar, (2) use a placebo (artificial sweetener) condition (3) blind the subjects, parents, and research staff to the conditions; and (4) report statistics that could be used to compute the dependent measures effect sizes.

DATA EXTRACTION

Variables included publication year, study setting, subject type and number, gender, age, sugar and placebo type and dose, prior dietary condition, measurement construct, means and SDs for the sugar and placebo conditions, and direction of effect.

DATA SYNTHESIS

Sixteen reports met the inclusion criteria for a total of 23 within-subject design studies. The weighted mean effect size and related statistics for each of the 14 measurement constructs revealed that although the range for these means was from -0.14 for direct observations and up to +0.30 for academic tests, the 95% confidence interval for all 14 mean effect sizes included 0.

CONCLUSION

The meta-analytic synthesis of the studies to date found that sugar does not affect the behavior or cognitive performance of children. The strong belief of parents may be due to expectancy and common association. However, a small effect of sugar or effects on subsets of children cannot be ruled out.

Comparison of diagnostic criteria for attention deficit disorders in a German elementary school sample

OBJECTIVE

This study compares teacher-reported prevalence rates for disruptive behavior disorders using DSM-IV, DSM-III-R, and DSM-III criteria within the same population of elementary school students and examines the relationships between DSM "subtypes" and academic performance, perceived behavior problems, and demographic variables.

METHOD

Teacher rating scales were obtained on 1,077 students in five rural and five urban public schools in Regensburg, Germany. Rating scales included DSM-III-R items (attention-deficit hyperactivity disorder, oppositional defiant disorder, conduct disorder), DSM-IV items (attention-deficit/hyperactivity disorders [AD/HDs], oppositional defiant disorder), and DSM-III items (attention deficit disorder, with and without hyperactivity). Factor analyses of significance were performed.

RESULTS

Overall prevalence for attention deficit disorders increased from 9.6% (DSM-III) to 17.8% (DSM-IV) primarily because of new cases identified as AD/HD-AD (inattentive type) and to a lesser degree, AD/HD-HI (hyperactive-impulsive type). Inattention in any subtype was associated with academic problems, and perceived behavior problems were associated with more than 80% of the cases that included hyperactivity-impulsivity. DSM-IV AD/HD subtypes showed significant behavioral, academic, and demographic differences.

CONCLUSION

Application of DSM-IV criteria increased total AD/HD prevalence rates by 64% and identified the majority of children with academic and/or behavioral dysfunction. The data show significant heterogeneity between the subtypes and imply that many children screened into these subtypes require further evaluation to ensure appropriate management.

Effects of diets high in sucrose or aspartame on the behavior and cognitive performance of children

BACKGROUND

Both dietary sucrose and the sweetener aspartame have been reported to produce hyperactivity and other behavioral problems in children.

METHODS

We conducted a double-blind controlled trial with two groups of children: 25 normal preschool children (3 to 5 years of age), and 23 school-age children (6 to 10 years) described by their parents as sensitive to sugar. The children and their families followed a different diet for each of three consecutive three-week periods. One diet was high in sucrose with no artificial sweeteners, another was low in sucrose and contained aspartame as a sweetener, and the third was low in sucrose and contained saccharin (placebo) as a sweetener. All the diets were essentially free of additives, artificial food coloring, and preservatives. The children's behavior and cognitive performance were evaluated weekly.

RESULTS

The preschool children ingested a mean (+/- SD) of 5600 +/- 2100 mg of sucrose per kilogram of body weight per day while on the sucrose diet, 38 +/- 13 mg of aspartame per kilogram per day while on the aspartame diet, and 12 +/- 4.5 mg of saccharin per kilogram per day while on the saccharin diet. The school-age children considered to be sensitive to sugar ingested 4500 +/- 1200 mg of sucrose per kilogram, 32 +/- 8.9 mg of aspartame per kilogram, and 9.9 +/- 3.9 mg of saccharin per kilogram, respectively. For the children described as sugar-sensitive, there were no significant differences among the three diets in any of 39 behavioral and cognitive variables. For the preschool children, only 4 of the 31 measures differed significantly among the three diets, and there was no consistent pattern in the differences that were observed.

CONCLUSIONS

Even when intake exceeds typical dietary levels, neither dietary sucrose nor aspartame affects children's behavior or cognitive function.

Professionals' prognoses for individuals with mental retardation: search for consensus within interdisciplinary settings

Previous studies have shown a lack of consensus in professionals' prognoses for individuals with mental retardation. The present study was designed to continue the investigation of professionals' prognoses for the achieved capabilities and residential and vocational placement of individuals with mild, moderate, or severe mental retardation. Four professional groups (N = 567 subjects) from 50 of the 52 University Affiliated Programs throughout the country were surveyed. The Prognostic Beliefs Scale was used. Results showed that physicians had significantly lower expectations and more pessimistic prognoses for children with moderate or severe mental retardation than did the other professionals. The only consensus on prognosis was for children with mild mental retardation. Results call into question one of the assumed benefits of interdisciplinary teams--communication--and its impact on professionals' expectations and prognoses for individuals with mental retardation.

Follow-up of clean intermittent catheterization for children with neurogenic bladders

Intermittent catheterization remains the primary method of treatment in the management of patients with neurogenic bladders such as those with meningomyelocele. In a follow-up of a previous study, we re-examined the urologic status of patients with neurogenic bladders continuing on a regimen of clean intermittent catheterization five years after the completion of the first study. Thirty-seven of the original 49 patients were available for follow-up, and no significant differences were found between those lost to follow-up and those included in this study. Among the patients re-evaluated, reflux remained unchanged or improved in most patients, renal function was maintained, and the urinary tract infection rate remained low. Additionally, continuation of an intermittent catheterization program does provide independence and social continence in most young adults with meningomyelocele. We conclude that a long-term intermittent catheterization program is associated with stable reflux status, renal function, and infection rate, and that compliance with a catheterization program can result in improved social continence and independence.

Physicians' prognoses about the quality of life for infants with intraventricular hemorrhage

There is an absence of definitive information concerning the long-term outcome of children born with intraventricular hemorrhage (IVH). Physicians, however, are called on to prognosticate about the future quality of life of these children. Our study examined pediatricians' and neonatologists' prognoses for infants with grade I- and grade-IV IVH and the impact of those prognoses on recommendations for treatment. A national random survey of 289 pediatricians and 283 neonatologists found that both groups expected infants with grade-I IVH to have slight impairments to future development, whereas infants with grade-IV IVH were expected to have severe impairments. Physicians prognosticated that infants with grade-IV IVH would function at a moderate to severe level of mental retardation, incapable of any employment, and residing in an institution. Furthermore, physicians would encourage parents to seek medical treatment of respiratory distress for the infant with grade-I IVH but were neutral or would discourage parents from seeking treatment for the infant with grade-IV IVH. Lastly, physicians' prognoses were significantly related to their recommendations for treatment. Several differences in physicians' prognoses and recommendations were found to be related to their discipline and training.

Doctors' decisions and prognostications for infants with Down syndrome

Random samples of pediatricians, family practitioners and pediatric surgeons were surveyed with a questionnaire, which included three questions regarding their decisions about treatment of duodenal atresia in two hypothetical infants with Down syndrome, one with complete trisomy 21 and one with mosaicism. Results showed that doctors are more likely now to advocate surgery than in the past. Pediatricians and family practitioners had similar views, but pediatricians were more assertive about treatment if parents refused. Pediatric surgeons had the most pessimistic outlook and a greater number would not encourage surgery. There was a relationship between the doctors' prognostications and their decisions about treatment. These results emphasize the importance of ensuring that doctors have accurate perceptions about the capabilities of individuals born with Down syndrome.

Stimulant medication use by primary care physicians in the treatment of attention deficit hyperactivity disorder

Treatment of attention deficit hyperactivity disorder (ADHD), one of the most common behavioral disorders in children in the United States, remains controversial because of concern about stimulant medication use. Extending a previous study of pediatricians, the present study surveyed a random national sample of family practitioners and then directly screened 457 patients of 10 pediatricians and family practitioners in two small midwestern cities. Responses to the national survey indicated that stimulant medication remains the main treatment prescribed by primary care physicians for children with ADHD. In the direct patient screening, the prevalence of ADHD diagnoses was 5.3% (pediatricians) and 4.2% (family practitioners) of all elementary-school-aged children screened. Eighty-eight percent of these children were treated with methylphenidate. Although medication was considered an effective treatment by the parents of 85% of the children given the medication, efficacy was unrelated to the accuracy of diagnosis. When explicit DSM-III-R criteria were used, only 72% of those assigned a diagnosis of ADHD by the physicians would have received that diagnosis based on a structured psychiatric interview with the parents and only 53% received that diagnosis based on teacher report of symptoms, even when the child was not receiving medication. Although the majority of physicians (in both the surveys and the direct screenings) reported using at least some behavioral treatments with their patients, parents reported infrequent use of nonpharmacologic forms of therapy, such as behavior modification. These data thus indicate a relatively modest rate of stimulant medication use for ADHD, but a serious underuse of systematic behavioral treatments in primary care.(ABSTRACT TRUNCATED AT 250 WORDS)

Stimulant medication therapy in the treatment of children with attention deficit hyperactivity disorder

Despite the tremendous research advances that have increased our knowledge regarding the pharmacodynamics, clinical pharmacology, pharmacokinetics, and adverse effects of stimulant medications in the treatment of children with ADHD, our knowledge is yet incomplete. Perhaps the most central unresolved issue concerns our understanding of the pathogenesis, pathophysiology, and diagnosis of ADHD. This review has touched briefly on the controversy and confusion surrounding this issue. Although our understanding of the use of stimulant medications in this disorder is similarly incomplete, a review of the literature does allow certain conclusions to be made that are helpful to the practitioner. 1. Stimulant medications are an effective treatment modality for most children with ADHD. Short-term efficacy is well documented, and long-term outcome may be improved when stimulants are used with other therapeutic strategies. Stimulants in and of themselves are not a panacea. 2. It is impossible to predict which children will have a favorable response to stimulant medications and which children may have a placebo response. The use of individual single-blind medication trials is a practical solution to this problem and should be considered for all children who are candidates for stimulant therapy as a means for preventing overuse or inappropriate use of these medications. 3. The precise mechanism of action of stimulants is not yet completely understood, but stimulants appear to exert their therapeutic effects through their influence on multiple neurotransmitters in the catecholamine, dopamine, norepinephrine axis in the central nervous system. 4. The three major stimulants--methylphenidate, dextroamphetamine, and pemoline--appear to be equally efficacious, although methylphenidate has emerged as the most commonly used and most studied drug. Because of its potential for causing liver toxicity, pemoline has remained a second-line medication. 5. The three major stimulants appear to have somewhat different mechanisms of action so that failure of a patient to respond to one medication does not mean that he or she will not respond to another. 6. The recommended starting doses for the stimulants are 0.3 mg per kg of methylphenidate, 0.15 mg per kg of dextroamphetamine, and 37.5 mg of pemoline. There is a great deal of individual variability in dose response, so doses must be titrated for optimal effects in each child. Sustained release preparations are much more expensive than regular preparations and may be less effective. 7. There is no evidence that stimulants have any effect on ultimate adult height. 8. Although relatively uncommon, motor tics have been observed in children on stimulants, and all children on stimulants need to be carefully monitored for the development of tics. (ABSTRACT TRUNCATED AT 250 WORDS)

Medical decisions and prognostications of pediatricians for infants with meningomyelocele

To determine how pediatricians' prognostications and decisions about the treatment of infants with meningomyelocele are affected by varying degrees of hydrocephalus, we randomly selected a sample of pediatricians to receive written surveys. This questionnaire assessed the relationship between the decisions and the prognostications, and compared their accuracy with that of outcome studies. Each pediatrician completed a questionnaire for two of three possible cases, which were identically described as infants with meningomyelocele and complete paraplegia varying only in the degree of hydrocephalus at birth from none to moderate to severe. Recommendations for treatment and prognostications (the Prognostics Belief Scale of Impressions of adult functional capabilities and likely residential and vocational placements) were compared. Significantly fewer pediatricians would present information to parents in an encouraging light, and significantly fewer would treat their own child, if the case involved severe hydrocephalus in comparison with no hydrocephalus. Pediatricians' prognostications were the least optimistic for the infant with severe hydrocephalus and most optimistic for the infant without hydrocephalus, and they were considerably less optimistic than seems justified on the basis of follow-up studies. Last, physicians' less-than-optimistic prognoses were significantly related to their decisions concerning surgery for the infants with moderate and severe hydrocephalus. The major import of the findings is that pediatricians' prognoses reflect, in part, a misconception of the impact of hydrocephalus on children born with meningomyelocele and that these prognoses then have and impact on the pediatricians' decisions concerning treatment.

Pediatricians' perceptions of mentally retarded individuals

Three hundred randomly selected members of the American Academy of Pediatrics were surveyed to determine their perceptions of mildly, moderately, and severely mentally retarded individuals. For each of the three categories of mental retardation, pediatricians completed the Prognostic Beliefs Scale which consisted of 27 functional capabilities and choices of residential and vocational placement. Of the 169 (56%) questionnaires returned, 142 (47%) were available for analysis. The pediatricians' perceptions were different for mildly, moderately, and severely retarded individuals. Most pediatricians believed mildly retarded individuals could do all but tasks requiring judgment, could function in unskilled competitive employment, and were likely to live in their own apartments. They believed that those with moderate retardation were limited in their capacity to simple and supervised tasks, could function in sheltered workshops, and were likely to live in group-home settings. They believed that severely retarded individuals were restricted to simple feeding tasks and following one-stage commands, were not capable of any productive employment, and would most likely live in institutions. Pediatric expectations and prognostications for placements were significantly lower than those of other professionals caring for mentally retarded individuals.

Physicians' and other professionals' expectations and prognoses for mentally retarded individuals

A questionnaire was sent to 600 randomly selected professional members of the American Association on Mental Deficiency (an equal number of educators, physicians, psychologists, and social workers). It consisted of an assessment of expectations and prognostications about residential and vocational placement for persons in the three levels of retardation. Results showed that physicians had significantly lower expectations than did educators and social workers. Professionals' expectations factored into four skill groups: Independent Living, Decision Making, Self-Help, and Social Activity Skills. Physician expectations on cluster scores of Independent Living and Self-Help Skills were significantly lower for moderately retarded persons for Independent Living and severely retarded individuals for Self-Help. Physicians were also significantly more restrictive about residential and vocational placements for mildly retarded individuals. Results suggest that there are differences in expectations and prognostications even among professionals in the area of mental retardation.

Medical Communication Behavior System. An interactional analysis system for medical interactions

The study assessed the psychometric properties of the Medical Communication Behavior System. This observation system records time spent by the physicians and patients on specific behaviors in the categories of informational, relational, and negative situation behaviors by using hand-held electronic devices. The study included observations of 101 genetic counseling sessions and also assessed the outcome measures of patient knowledge and satisfaction. In addition, 41 of the sessions were rated using the Roter Interactional Analysis System, and 20 additional control subjects completed the post-counseling information without being observed to examine the effects of recording the session. Results showed good interobserver reliability, and evidence of concurrent, construct, and predictive validity. No differences were found between the observed and unobserved groups of any of the outcome measures.

Dietary characteristics of hyperactive and control boys

The purpose of this study was to examine the relationship between dietary habits and behavioral problems in hyperactive boys and to determine how successful parents are in maintaining their children on sugar-free diets. The mothers of 32 hyperactive boys aged 7 to 12 years and 26 matched controls completed 3-day diet records and food frequency interviews. The hyperactive boys were also evaluated in a playroom for impulsivity, compliance, attention, motor activity, memory, and learning. No differences were found in any of the measures of dietary content between the hyperactive and control groups. The only significant differences between those two groups were a lower socioeconomic status and a greater number of parents attempting sugar-restricted diets in the hyperactive group. Boys on sugar-restricted diets had only one significant dietary difference from those not restricted. Correlations between the information obtained in food frequency interviews and in 3-day diet histories were not significant (r = .06 to .33) for the hyperactive group, but the food frequency interviews were significant for the control group (r = .41 to .47). Four behavioral variables showed significant partial correlations with reported sugar intake. Overall, the results demonstrated that the diets of a group of hyperactive boys were similar to those of a control group. There appeared to be little difference between the diets of the families that attempted to restrict sugar and those that did not.

Situational effects on the communication behaviors of pediatric residents

The variation in communication behaviors of pediatric residents in different interview circumstances was examined. Twenty-three residents were videotaped in three simulated counseling sessions. Two of the sessions entailed counseling a mother of a toddler with multiple handicaps during a well-child visit. The third, which took place between the other two sessions, entailed informing a new mother that her child has Down's syndrome. The residents' performances were evaluated using a subjective rating scale and an objective frequency count of behaviors. Analysis of variance demonstrated significant effects for both observation scales. Spearman correlations were not significant between any of the situations. The results suggest that residents' communication behaviors vary with the type of counseling situation.

Results of clean intermittent catheterization for children with neurogenic bladders

Forty-nine patients were placed on a regimen of clean intermittent catheterization one to four years prior to this review. The children were intermittently catheterized, and a silver nitrate solution 1:1000 was instilled after each catheterization. Nurse practitioners, and community and school personnel contributed to the management. Twenty-one patients were continent with anticholinergics, and 18 also required alpha-adrenergic agents. Eighty-eight per cent were essentially bacteriuria-free, 65 per cent were essentially infection-free, and forty-nine per cent were totally continent. The remaining 25 had mild incontinence. Eleven had clearances below 85 mm/min with 8 reverting to normal on therapy. Nine had reflux prior to the study and one improved. In 8 patients reflux developed during therapy; 4 had severe reflux which required ureteral reimplantation. The results demonstrated that a clean intermittent catheterization program is feasible in a rural setting and that a genitourinary irrigant does decrease bacteriuria.

Symptomatic neurogenic bladder in a cerebral-palsied population

This study reports the incidence of symptomatic neurogenic bladders in a cerebral-palsied population. Of the 50 patients screened, 13 underwent routine urological assessment, including cystometrograms. Four were found to have a neurogenic bladder. 18 of the total population had one or more symptoms indicative of a neurogenic bladder: enuresis, stress incontinence and dribbling. The authors speculate that a continuum of the disorder exists. Preliminary follow-up revealed a significant response to medication in symptomatic patients, both with and without demonstrable neurogenic bladders.

Methylphenidate treatment of hyperactive children: effects on the hypothalamic-pituitary-somatomedin axis

To further define the influence of methylphenidate on the growth hormone-somatomedin axis and prolactin secretion, serum growth hormone and prolactin concentrations were assessed over 24 hours and in response to provocative stimuli. The nine hyperactive subjects were all studied during methylphenidate therapy and after drug discontinuation, Diurnal patterns of growth hormone and prolactin concentrations were assessed using an ambulatory, continuous blood withdrawal procedure to ensure that activity, caloric intake, and sleep patterns mimicked normal schedules. No significant difference in integrated concentration of growth hormone, fasting somatomedin concentration, or prolactin integrated concentration was detected between subjects receiving or not receiving methylphenidate. There was a significant increase in peak growth hormone response to arginine stimulation among subjects receiving methylphenidate therapy; however, this appeared to correlate with acute methylphenidate administration. These data do not support the hypothesis that growth defects in hyperactive children treated with methylphenidate are caused by alteration in the hypothalamic-pituitary-somatomedin axis.

Factors affecting physician communication and parent-physician dialogues

The purpose of the study reported here was to determine whether improvement in medical knowledge affects medical students' interviewing skills in each, or any, of the four years of medical school. Nineteen first-year students, 21 second-year students, 18 third-year students, and 20 fourth-year students at the University of Iowa College of Medicine were randomly assigned to an experimental or a control group. The experimental group observed a 45-minute videotape lecture that discussed the practical issues of the diagnosis and management of children with meningomyelocele. All subjects in both groups then completed a multiple-choice examination on meningomyelocele. The interviews were videotaped and then blindly rated. The results of the ratings show that there was no group effect but there was a significant class difference in that the first-year class was less sophisticated than the three other classes. The results suggest that interview skills are not affected by increasing knowledge about medical conditions but do improve with training in interview skills.

Communication between physicians and parents of handicapped children

The physician has an important and sometimes difficult role in communicating with parents of children with developmental handicaps. Some of the major factors which affect physician-parent communication are (a) the physician's knowledge of developmental problems, (b) the physician's attitude toward handicapped children, and (c) the physician's skill in communicating with parents. All three of these factors are crucial and interrelated; deficiencies in one of the areas may affect the physician's abilities in other areas. Details about each of the factors and training programs addressing each factor are discussed.

Pediatric practitioners' knowledge of developmental disabilities

The purpose of this study was to assess the level of knowledge and attitudes of pediatric practitioners about developmental disabilities and compare their level to the performance of pediatric residents before and after a 1-month rotation about developmental disabilities. The level of knowledge was measured using a 50-question multiple choice examination and the attitudes were measured utilizing a hypothetical question about allocation of funds, a scale which measured prognostic abilities about mental function and the Attitude Towards Disabled Persons Scale. The results showed that the practitioners' mean scores were near the resident pretest mean scores with the exception of knowledge of developmental landmarks and school behavior and learning problems. Only slight changes in the residents were seen on the attitudinal measures, and the practitioners tended to have less optimistic attitudes than other professionals. The results help document that residency training in developmental disabilities improves knowledge about the area and that practitioners without that training have not acquired it on their own.

Training physicians in communication skills

Communication skills are a vital part of physicians' activities, so it is important that they receive appropriate training and experience in these skills, particularly as they relate to emotionally difficult situations such as dealing with death or severe disability. Experience in the Department of Pediatrics, University of Iowa, has demonstrated that videotaped simulated interviews, with immediate play-back, may be an effective method. The videotapes showed that there were frequent errors in communication.

Behavior modification therapy in hyperactive children. Research and clinical implications

One hundred fifty-seven studies employing behavior modification in the management of hyperactive and disruptive children were reviewed. The studies were analyzed against standards of scientific validity. The review found: (1) behavior modification was effective in alleviating problem behaviors; (2) token programs were the most commonly used; (3) both positive reinforcement and punishment were effective; positive reinforcement, however, had the advantage of improving self-esteem; (4) behavioral problems occurring in the home most likely require a home-based program; (5) behavior modification and stimulant medication can be used simultaneously, often with additive effects; and (6) long-term benefits beyond one year have not been assessed.