Beyond infant colic.

Some of the most interesting cases in pediatric practice evolve through time. What may begin as a clear, well defined problem with a predictable natural history and an accepted intervention strategy may develop into a more complex, multi-faceted set of problems. It is these children who potentially provide clinicians with new insights into behaviors. This case of a colicky infant illustrates the wide spectrum of behavioral and physiological symptoms that emerge from a specific underlying behavioral phenomenon. It also emphasizes the significant benefit derived from a longitudinal perspective of developmental events.

Effects of methylphenidate and behavioral contingencies on sustained attention in attention-deficit hyperactivity disorder: a test of the reward dysfunction hypothesis.

Psychostimulants and behavior therapy have been postulated to be effective in treating attention-deficit hyperactivity disorder (ADHD) by compensating for a pathologically elevated reward threshold, but no studies have compared reinforcement to psychostimulants in maintaining task performance. The separate and combined effects of methylphenidate (MPH, 0.6 mg/kg) and a behavioral intervention (reward plus response cost) were assessed on a continuous performance test (CPT, a measure of sustained attention) modified to deliver auditory feedback contingent upon the subject's responses. Each of 22 children (6-10 years old) with ADHD were tested under four treatment conditions: placebo + feedback, placebo + behavioral contingencies, MPH + feedback, and MPH + contingencies. CPT performance, indexed by d' (ability to discriminate between target and false targets), was significantly better with MPH than with placebo, showing reduced deterioration over time. Contingency treatment improved mean d' compared to placebo + feedback but, in contrast, had no effect on the slope of performance deterioration. Addition of contingencies to MPH did not yield further improvement. The results indicate that MPH improved sustained attention on a laboratory task (and reduced task-irrelevant and other disinhibited behaviors), whereas behavioral contingencies did not. These findings suggest that, although both interventions improved stimulus discrimination processes, only MPH enhanced processes that mediate the regulation of effort over time. In addition, the disjunction between the effects of reward and of MPH provides evidence that psychostimulant effects on attention are only partially explained by the stimulation of brain centers associated with reward.

Pediatric residency training: ten years after the Task Force report.

A sample of 3000 pediatricians who had completed their residency training in 1978 or later were surveyed regarding the perception of the adequacy of their residency training in specific aspects of pediatric practice and in a number of subspecialty areas. The survey was almost identical with the one that formed the basis for the American Academy of Pediatrics Task Force on Pediatric Education report in 1978. The results revealed relatively little change in the high rates of perceived "insufficient training" in all the areas of pediatrics described as "underemphasized" in the Task Force report. However, those residents who received their training during the second half of the 10 years since the Task Force survey reported significant improvement in the previously underemphasized areas of developmental and behavioral pediatrics and adolescent medicine. Results also revealed a significant increase in the number of pediatricians who identify either a subspecialty interest or subspecialty practice in developmental or behavioral pediatrics. The increase in pediatric subspecialists and the improved training experience since 1984 indicate that the Task Force report may have had a positive impact on residency training in developmental and behavioral pediatrics.

Effects of sugar on aggressive and inattentive behavior in children with attention deficit disorder with hyperactivity and normal children.

Foods high in refined sugar are claimed to exacerbate hyperactivity and increase aggressive behavior. Controlled studies have failed to confirm any effect on hyperactivity and effects on inattention have been equivocal. Possible effect on aggressive behavior has received little study. This study assessed cognitive attention and aggressive behavior immediately following an acute ingestion of sugar compared with saccharin and aspartame-sweetened placebos in 17 subjects with attention deficit disorder with hyperactivity compared with 9 age-matched control subjects. The sugar and placebo challenges were given with a breakfast high in carbohydrate. Although the children with attention deficit disorder with hyperactivity were significantly more aggressive than the control subjects, there were no significant effects of sugar or either placebo on the aggressive behavior of either group. However, inattention, as measured by a continuous performance task, increased only in the attention deficit disorder with hyperactivity group following sugar, but not saccharin or aspartame. This result is of questionable clinical significance inasmuch as aggressive behavior was unchanged. The finding may be due to the combination of the sugar challenge with a high-carbohydrate breakfast. These findings should be replicated and any possible clinical significance should be documented before any dietary recommendations can be made.

Does methylphenidate constrict cognitive functioning?

It has been suggested that stimulants enhance attention in children with (attention deficit disorder with hyperactivity) (ADDH) by producing a generalized constriction or "over-focusing." Such a phenomenon might be expected to adversely affect performance on tasks, such as those in the Wallach-Kogan (W-K) battery, which explicitly call for cognitive flexibility or "divergent thinking." Nineteen ADDH children, 6 to 10 years of age, were tested on two modified subtests of the W-K battery at baseline, following placebo, and following three different dosages (.3, .6 and 1.0 mg/kg) of methylphenidate. Contrary to the hypothesis, methylphenidate did not decrease but rather sustained output on the tests, which contrasted with a decline in productivity seen across nondrug days. Some ADDH subjects displayed particularly large increases in output following methylphenidate and may represent an atypical subgroup of children who became overaroused on medication.

Prevalence of hyperactivity among newly immigrated Chinese-American children.

There has been little research on the prevalence of hyperactivity among Chinese or Chinese-American children. We administered the 28-item Conners Teacher Rating Scale (TRS) to the teachers of recently immigrated Chinese-American children in grades one through six and obtained data on 282 children. The percentages of children scoring above the criterion score for hyperactivity were 8.76% (boys) and 1.72% (girls). These percentages are less than those reported for comparable samples from all other countries, except South Africa. A factor analysis of the TRS data revealed a factor structure that was largely similar to that reported by Conners, but with notable differences between boys and girls. The relative contributions of genetic and cultural factors to the etiology of hyperactivity are considered in a discussion of the prevalence data.

The food additive-free diet in the treatment of behavior disorders: a review.

A food additive-free diet has been recommended as a component of the treatment of developmental/behavioral disorders in children. This diet was initially developed by Dr. Benjamin Feingold for the treatment of aspirin sensitivity in adults, and then extended by him to the management, particularly, of hyperactivity and learning disability in children. The rationale for this diet and the methods employed in investigating its use are described. The claimed therapeutic effects of this diet have been investigated in a number of well-designed studies reviewed here. These studies generally refute a causal association between food additives and behavioral disturbance in children. Suggestions are made regarding the approach towards food additive-free diet therapy in the management of developmental/behavioral disorders.

Hyperactivity in adolescence.

The behavioral syndrome called hyperactivity is not outgrown in adolescence. Though excess activity becomes less prominent, emotional immaturity and academic underachievement develop into primary complaints. Antisocial behavior emerges as a serious problem in young adolescents. In late adolescence and early adulthood, many of these individuals apparently improve as they adjust to employment. There is some evidence that older adolescents display no more psychiatric disease or serious delinquency than matched controls. Those adolescents with persistent problems continue to respond favorably to stimulant medication, though often they resist pharmacologic treatment. The clinician is urged to advise patience and supportive tolerance in response to the persisting problems of the adolescent.

Chronic nonspecific diarrhea. Behavioral aspects.

In an attempt to demonstrate an association between chronic nonspecific diarrhea and behavioral problems in young children, structured interviews were conducted to elicit from parents a detailed history of behavior from birth. Problems relating to sleep, crying and irritability, digestion (excluding diarrhea), activity, and discipline were significantly more frequent or severe in the group of 16 youngsters with chronic nonspecific diarrhea than in the control group of children with no symptoms of this disorder. Also more common in the index group were a definite family history of gastrointestinal problems and the presence of certain specific emotional responses.