Evaluation of the ability of neurobiological, neurodevelopmental and socio-economic variables to predict cognitive outcome in premature infants.

BACKGROUND: When developed in the 1990s, the Neurobiologic Risk Score (NBRS) and Neurodevelopmental Risk Exam (NRE) correlated well with developmental outcomes in premature infants. Given recent advances in neonatology, we assessed their present ability to predict cognitive outcome, alone and combined with socio-economic factors. METHODS: One hundred and twenty-nine neonates <32 weeks gestational age were assessed at 6, 12 and/or 24 months corrected age with the Cognitive Adaptive Test/Clinical Linguistic and Auditory Milestone Scale (CAT/CLAMS). Indices of socio-economic status included maternal education and marital status. RESULTS: At 24 months corrected age (n= 67), the NBRS (r=-0.5), maternal education (r= 0.46) and marital status (r= 0.37) correlated with the CAT/CLAMS. These correlations increased when NBRS and maternal education were combined (r= 0.63) and when specific NBRS components (intraventricular haemorrhage, periventricular leukomalacia, seizures) and maternal education were combined (r= 0.66). CONCLUSIONS: In the contemporary neonatal intensive care unit, measures used to predict cognitive outcome should incorporate both neurobiological risk factors and socio-economic variables.

Incidence of reading disability in a population-based birth cohort, 1976-1982, Rochester, Minn.

OBJECTIVE: To report the incidence of reading disability among school-aged children. SUBJECTS AND METHODS: In this population-based, retrospective birth cohort study, subjects included all 5718 children born between 1976 and 1982 who remained in Rochester, Minn, after the age of 5 years. Based on records from all public and nonpublic schools, medical facilities, and private tutorial services and on results of all individually administered IQ and achievement tests, extensive medical, educational, and socioeconomic information were abstracted. Reading disability was established with use of research criteria based on 4 formulas (2 regression-based discrepancy, 1 non-regression-based discrepancy, and 1 low achievement). RESULTS: Cumulative incidence rates of reading disability varied from 5.3% to 11.8% depending on the formula used. Boys were 2 to 3 times more likely to be affected than girls, regardless of the identification methods applied. CONCLUSIONS: In this population-based birth cohort, reading disability was common among school-aged children and significantly more frequent among boys than girls, regardless of definition.

Boy/girl differences in risk for reading disability: potential clues?

The authors conducted a case-control study to determine whether risk factors for reading disability (RD) differentially affect boys and girls. The study population included all children born between 1976 and 1982 in Olmsted County, Minnesota (n = 5,701). A total of 303 RD cases were identified by using intelligence quotient and achievement test scores collected from school and medical records. After excluding those who met exclusion criteria (n = 869), controls consisted of all children not identified with RD (n = 4,529). The authors examined the association between RD and potential risk factors in boys and girls and confirmed their results in multivariable logistic regression models. Multivariable models indicated that girls of low birth weight were more than twice as likely to be identified as RD (odds ratio (OR) = 2.94, 95% confidence interval (CI): 1.09, 6.25). Girls whose mothers had 12 or fewer years of education were twice as likely to be identified as RD (OR = 2.14, 95% CI: 1.24, 3.72). However, girls whose fathers were aged 35 years or older at the time of birth were less likely to be identified as RD (OR = 0.24, 95% CI: 0.06, 0.92). Only 12 or fewer years of paternal education was associated with increased RD in boys (OR = 2.28, 95% CI: 1.59, 3.27). Boys and girls appear to be differentially susceptible to RD risk factors, suggesting that the biologic processes leading to RD may differ between boys and girls.

An opportunity for office-based research.

Robert, a nearly 12-year-old boy, traveled an hour to see a new pediatrician. Robert's mom told the pediatrician that Robert had not been seen by a doctor for several years because "no one seems to be able to help him with his problem." Robert had been wetting the bed "ever since he was toilet-trained" at age 2 years. Robert wets the bed about 5 out of 7 nights. He never has daytime accidents. He did not have a history of urinary tract infection, dysuria, urgency, or increased frequency of urination. He has daily bowel movements and denied soiling or accidents. Robert's mom said he had "toilet-trained himself" at age 2 years. Both Robert's mom and maternal grandfather had nocturnal enuresis "into their teenage years." The pediatrician was surprised to learn that another physician had treated Robert with imipramine at age 5 years. The medication worked intermittently and Robert continued to take it for about a year. At age 6 years, Robert's parents saw an advertisement for a bed-wetting alarm. They purchased the alarm but found that Robert never woke up when the alarm sounded. At age 7 years, Robert saw a urologist who told him he would "outgrow the problem." A year later, the urologist prescribed desmopressin acetate (DDAVP) nasal spray, which Robert took on occasion during the next 2 years. Every time he stopped the DDAVP, he resumed wetting the bed. His parents never punished him for his accidents, but they did try restricting fluids after dinner and also woke Robert in the middle of the night and encouraged him to go to the bathroom. Neither of these strategies was successful. Robert said he was "frustrated" and wondered if "I would still be wetting the bed as a grown-up." The pediatrician explained the nature of enuresis to Robert and his mom, provided them with instructions and an order form for a bed-wetting alarm, and arranged a follow-up visit. The next day, during nursery rounds, he asked several of his colleagues about their approaches to the treatment of enuresis. A few used DDAVP, one found imipramine beneficial, and one preferred behavioral treatment with a bed-wetting alarm. The pediatrician became concerned that he had misread the literature on enuresis. He brought the question up at the next pediatric staff meeting at the local hospital. A lively discussion ensued as the physicians realized that they employed a variety of treatments for enuresis. Robert's pediatrician wondered why his colleagues were not using the alarm because the literature seemed to indicate it to be the preferred treatment for enuresis. He asked the group if they would be interested in talking about the issue further and perhaps trying to understand the reasons for their varied approaches to this problem.

Use and costs of medical care for children and adolescents with and without attention-deficit/hyperactivity disorder.

CONTEXT: A shortage of data exists on medical care use by persons with attention-deficit/hyperactivity disorder (ADHD). OBJECTIVE: To compare medical care use and costs among persons with and without ADHD. DESIGN AND SETTING: Population-based cohort study conducted in Rochester, Minn. SUBJECTS: All children born in 1976-1982 were followed up through 1995, using school and medical records to identify those with ADHD. The 4880 birth cohort members (mean age, 7. 3 years) still residing in Rochester in 1987 were followed up in medical facility-linked billing databases until death, emigration, or December 31, 1995. MAIN OUTCOME MEASURES: Clinical diagnoses, likelihood and frequency of inpatient and outpatient hospitalizations, emergency department (ED) visits, and total medical costs (including ambulatory care), compared among individuals with and without ADHD. RESULTS: Among the 4119 birth cohort members who remained in the area through 1995 (mean age, 15.3 years), 7.5% (n = 309) had met criteria for ADHD. Compared with persons without ADHD, those with ADHD were more likely to have diagnoses in multiple categories, including major injuries (59% vs 49%; P<.001) and asthma (22% vs 13%; P<.001). The proportion with any hospital inpatient, hospital outpatient, or ED admission was higher for persons with ADHD vs those without ADHD (26% vs 18% [P<. 001], 41% vs 33% [P =.006], and 81% vs 74% [P =.005], respectively). The 9-year median costs for persons with ADHD compared with those without ADHD were more than double ($4306 vs $1944; P<.001), even for the subset with no hospital or ED admissions (eg, median 1987 costs, $128 vs $65; P<.001). The differences between individuals with and without ADHD were similar for males and females and across all age groups. CONCLUSION: In our cohort, compared with persons without ADHD, those with ADHD exhibited substantially greater use of medical care in multiple care delivery settings.

Potential influence of migration bias in birth cohort studies.

OBJECTIVE: To assess the potential bias, due to migration from the community, in a birth cohort study of learning disability in Olmsted County, Minnesota. MATERIAL AND METHODS: The 1976 through 1982 birth cohort consisted of 8,548 children born to mothers who were residents of Rochester, Minnesota, at the time of delivery. The current status of all children was determined for the 1995 to 1996 school year with the resources of Independent School District #535, the Rochester Epidemiology Project, and the Rochester Reading Center. Information from birth certificates was compared between migrants and nonmigrants with use of standard statistical tests. RESULTS: The cumulative probability of migration by age 5 years was 32.2% (95% confidence interval, 31.2 to 33.2%). When migrants were compared with nonmigrants, the distributions of Apgar scores, father's age, gestational age at birth, and number of children in the family were virtually identical. In contrast, migrants were more likely to be nonwhite (6% versus 2%), be born to a single parent (11% versus 7%), and have a congenital defect noted at birth (1.5% versus 0.7%). When considered simultaneously in a logistic regression model, the parents of migrants were more highly educated, migrant mothers were younger and had fewer prenatal visits, and migrant children were more likely to be black. CONCLUSION: This report demonstrates the extreme effort that must be made to assemble a birth cohort in our mobile society. Furthermore, the results suggest that only slight differences exist between migrants and nonmigrants; these are unlikely to compromise the future results of the ongoing learning disability study.

An ADHD educational intervention for elementary schoolteachers: a pilot study.

We assessed the effect of pediatrician-led inservice training on the knowledge and stress of elementary schoolteachers related to attention-deficit/hyperactivity disorder (ADHD). The subjects were 44 schoolteachers staffing a 750-student school. Preintervention and postintervention questionnaires assessed teachers' training and knowledge concerning ADHD, teacher stress, and teacher-rated student behavior. The intervention was an ADHD curriculum developed by the national organization, Children and Adults with Attention-Deficit Disorder (CHADD). At preintervention, 41% of the teachers thought that ADHD could be caused by poor parenting and 41%, by sugar or food additives; 64% thought that methylphenidate should be used only as a last resort. Postintervention percentages of teachers holding these beliefs were 7%, 5%, and 34%, respectively. Sixty-one percent had no contact with physicians prescribing stimulants. Teacher stress correlated with ADHD behavior in male students and decreased postintervention. Use of the CHADD curriculum and discussion with a pediatrician were associated with improved teacher knowledge and decreased teacher stress related to ADHD.

Primary-care approach to the diagnosis and management of attention-deficit hyperactivity disorder.

Attention-deficit hyperactivity disorder (ADHD), a relatively common problem, affects 3 to 5% of school-age children. Physicians are often reluctant to treat children with ADHD, possibly because of the lack of a practical approach to the assessment. The medical model, with some modifications, is well suited for this purpose. Comprehensive treatment, including both medication and nonmedical intervention, should be coordinated by the primary-care provider. Logistic considerations are another barrier to effective treatment of ADHD. The physician must have a practical plan to provide high-quality care to children with ADHD. Primary-care physicians, who have detailed information about children and their families, are in an ideal position to treat patients with ADHD.