Attention deficit-hyperactivity disorder and its deceivers.

There is a myriad of disorders that can mimic ADHD. Often parents or teachers, through their own investigation, will determine the diagnosis for their child's school problems as ADHD, when in fact, the difficulties are unrelated to ADHD. A carefully taken history, observation, and interaction with the child are needed. An evaluation of the school situation will help to indicate if the child's primary problem is behavioral, academic, medical, psychiatric, social, or attentional. Psychologic and educational testing is necessary to completely delineate the child's problems and needs. The greatest service that a physician can give children with academic problems is to approach each child in a systematic, scientific, and professional manner to determine the best treatment for the child and to demonstrate the most favorable outcome.

Encopresis in the child with a behavioral disorder: when the initial treatment does not work.

Behavioral disorders occur more commonly in children who fail the initial standard treatment protocol of cathartics and designated toileting time. Whether such disorders are causally related or the result of encopresis, these children require a much more intensive, multimodal therapy. Treatment failures should have an in-depth history that reviews the potential developmental, emotional, behavioral, and psychosocial issues that may be causative. Use of the treatment protocols that have been outlined in this article can be time-consuming and will often require the help of a behavioral therapist. However, if they are successfully implemented, research shows that positive behavioral changes frequently occur in the child. The pediatrician can be instrumental in preventing long-term family, emotional, and social consequences by aggressively treating these difficult cases.

Early identification and management of hearing impairment.

Early detection and treatment of hearing loss can prevent a lifetime of difficulties. Severe sensorineural hearing loss is present in approximately one in 1,000 newborns. Many newborns have mild to moderate hearing loss, either conductive or sensorineural, that interferes with normal functioning. The family physician is in an excellent position to identify hearing impairment at an early stage. During well-child visits, simple checklists and screening tests can be completed to aid in detection of a hearing loss. The Joint Committee on Infant Hearing and the National Institutes of Health Consensus Statement recommend screening all infants for hearing loss, preferably during the newborn period. Children at high risk for hearing loss should be referred for auditory function tests, such as behavioral observation audiometry, auditory brain stem response, otoacoustic emissions testing, visual reinforcement audiometry and conditioned play audiometry. The advantages and limitations of each test should be understood by the family physician. An infant is never too young to be treated for hearing loss. The earlier intervention begins, the greater the chance a child will develop to maximum potential.

Survey of treatment practices for neonatal seizures.

A nationwide survey of neonatologists was conducted to determine the common management of neonatal seizures. The questionnaire addressed practice setting, causes, length of treatment, and criteria used in discontinuation of treatment. A response rate of 68% was achieved. Results indicate continued disagreement among practitioners. The prevailing literature recommends treatment of neonatal seizures in the acute phase. Recent studies indicate that 8% to 15% of infants with neonatal seizures will have recurrent seizures after the newborn period. Animal models have shown that brain growth retardation and behavioral and learning impairment may occur from the use of phenobarbital in early infancy. The question of continued treatment of neonatal seizures beyond the acute phase is raised.

Disorders of attention and vigilance.

Attention deficit hyperactivity disorder has gone through multiple name and criterion changes over the last 10 years. It is still viewed as the most common neurobehavioral disorder in the pediatric age group. Diagnostic criteria, as outlined by the DSM III-R, have, as primary diagnostic features of ADHD, inattention, impulsivity, and hyperactivity. There are no diagnostic tests that will absolutely confirm this disorder. Many questionnaires have been devised to help organize and systematize the evaluation. Vision and hearing screening, physical examination, and the neurologic examination are important to exclude other causes for hyperactivity and impulsivity. There are no routine laboratory or specialized tests that are useful in the diagnosis of ADHD. When psychologic testing is deemed necessary, specific areas to study would include discrepancies in the performance and verbal IQ (possibly indicating further testing needed to rule out learning disabilities) and difficulties in the coding portion of the examination, which might point to attentional difficulties. Educational testing can further complete an evaluation when needed. Management of children with ADHD involves multimodal treatment, including educational, behavioral, and possibly pharmacologic intervention. Pharmacotherapy can be a useful adjunct in treating these children. The psycho-stimulants continue to be the first-line medication in treatment, although investigators have studied other drugs. Once the diagnosis has been made and a child has been placed on the multimodal treatment, he should be carefully followed. This disorder does not disappear at the time of puberty, as once was thought, but instead continues to cause problems through adolescence.