Retinal hemorrhage predicts neurologic injury in the shaken baby syndrome.

Shaken baby syndrome consists of intracranial and intraocular hemorrhage in the absence of signs of direct trauma in infants who have sustained whiplash/shaking injuries. We evaluated 14 consecutive cases of presumed shaken baby syndrome seen at the University of Michigan Hospitals, Ann Arbor, between August 1983 and March 1988, to determine if the severity of retinal hemorrhage was predictive of the severity of acute neurologic injury. The severity of retinal hemorrhage was based on the type and size of hemorrhage and the extent of fundus involvement. We found a significant correlation between retinal hemorrhage severity and acute neurologic findings. Diffuse fundus involvement, vitreous hemorrhage, or large subhyaloid hemorrhages were associated with more severe acute neurologic injury.

The use of methylphenidate in Michigan.

OBJECTIVE: To describe the epidemiologic findings associated with the use of methylphenidate hydrochloride among children aged 0 to 19 years in Michigan. DESIGN: A population-based data set of all prescriptions filed with the Michigan Triplicate Prescription Program during February and March 1992 was analyzed, maintaining complete anonymity. SETTING: State of Michigan. PARTICIPANTS: All patients receiving a prescription for methylphenidate who are residents of Michigan, and all physicians prescribing methylphenidate. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Descriptive data. RESULTS: Eleven of 1000 Michigan residents between the ages of 0 and 19 years received a prescription for methylphenidate during the study period. Eighty-four percent were boys. Boys aged 10 or 11 years received more prescriptions for methylphenidate than any other age group--43 per 1000. The number of children receiving prescriptions for methylphenidate ranged from 2.5 to 28 per 1000. The range for boys aged 10 or 11 years was from 9.6 to 117 per 1000. Primary care physicians wrote 84% of all prescriptions; pediatricians wrote 59% of the prescriptions for patients younger than 20 years old. Half of the prescriptions written by pediatricians were written by 5% of the pediatricians in the state. CONCLUSIONS: Michigan has been among the states with the highest per capita consumption of methylphenidate for the past 10 years. The major use of methylphenidate is for treatment of attention deficit hyperactivity disorder. The number of boys in Michigan aged 10 or 11 years who were treated with methylphenidate was similar to the national prevalence of the disorder, 3% to 5%. A tenfold variation was noted in the percentage of children medicated when the data were analyzed by county. Relatively few pediatricians account for the largest proportion of prescriptions. Future studies are needed to link the use of methylphenidate with diagnostic and treatment considerations in attention deficit hyperactivity disorder.

Diagnosis of attention-deficit/hyperactivity disorder and use of psychotropic medication in very young children.

CONTEXT: Increases in diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD) have elicited public and professional concern. Research suggests that this trend warrants the inclusion of previously underdiagnosed children and adults. It is not clear whether this trend includes young children. OBJECTIVE: To identify patterns of diagnosis and treatment of ADHD in very young children over time. DESIGN: Descriptive study of Michigan Medicaid claims data. PATIENTS: Inclusion criteria included recorded ADHD diagnosis, continuous Medicaid eligibility during a 15-month period, and age 3 years or younger at the first date of service. MAIN OUTCOME MEASURES: Diagnoses of ADHD, conditions commonly comorbid with ADHD, other chronic health conditions, and injuries; treatments such as psychological services and psychotropic medication; and the number of ambulatory visits. RESULTS: We identified 223 children aged 3 years or younger diagnosed with ADHD. Many had conditions commonly comorbid with ADHD (44%), other chronic health conditions (41%), and injuries (40%). More than half received psychotropic medication (57%); fewer received psychological services (27%). Twenty-two different psychotropic medications were used. Patterns included more than 1 psychotropic medication (46%) in 30 combinations of simultaneous use and 44 combinations of sequential use. The mean number of ambulatory visits was 18. CONCLUSIONS: Children aged 3 years or younger had ADHD diagnosed and received markedly variable psychotropic medication regimens. Little information is available to guide these practices. The presence of comorbid conditions and injuries attests to these children's vulnerability. Resources must be identified that will enable physicians to better respond to the compelling needs of these children and their families.

Safety issues in the use of methylphenidate. An American perspective.

Methylphenidate is the most widely use psychotropic medication in children in the US. It is both well tolerated and efficacious in the treatment of attention deficit hyperactivity disorder, and is associated with few serious adverse effects. However, the abuse of methylphenidate for the purpose of experiencing a 'high' is hazardous. The use of methylphenidate in combination with other medications increases the risk of adverse effects and drug interactions. Good communication between the physician, patient and family, together with monitoring, increases the likelihood that methylphenidate therapy will be effective and have no adverse consequences.

Initial evaluation and interview techniques for child sexual abuse.

Because physicians are often the first professionals to have contact with a sexually abused child, they must be alert to the symptoms and prepared to respond knowledgeably. Early and effective intervention affects the overall prognosis for the child and family positively. As physicians become aware of child sexual abuse, protocols can be used routinely as part of a child's medical care. Regular checks on potentially abusive situations can prevent the tragic and traumatic occurrence of child sexual abuse.

Treatment of child abuse.

Standards of care have recently been established for the diagnosis and treatment of child abuse. This article addresses the key areas of treatment with which each primary care physician should be acquainted. As part of a community-based approach to this problem, the physician can positively impact the prognosis for the victimized child and his or her family.

Association and linkage of alpha-2A adrenergic receptor gene polymorphisms with childhood ADHD.

Attention-deficit hyperactivity disorder (ADHD) is a heritable disorder, prevalent from childhood through adulthood. Although the noradrenergic (NA) system is thought to mediate a portion of the pathophysiology of ADHD, genes in this pathway have not been investigated as frequently as those in the dopaminergic system. Previous association studies of one candidate gene in the NA system, ADRA2A, showed inconsistent results with regard to an MspI polymorphism. In the current study, two nearby single-nucleotide polymorphisms, which define HhaI and DraI restriction fragment length polymorphisms, were also genotyped and were in significant linkage disequilibrium with the MspI RFLP. Transmission disequilibrium tests (TDTs) in a sample of 177 nuclear families showed significant association and linkage of the DraI polymorphism with the ADHD combined subtype (P=0.03), and the quantitative TDT showed association of this polymorphism with the inattentive (P=0.003) and hyperactive-impulsive (P=0.015) symptom dimensions. The haplotype that contained the less common allele of the DraI polymorphism likewise showed a strong relationship with the inattentive (P=0.001) and hyperactive-impulsive (P=0.004) symptom dimensions. This study supports the hypothesis that an allele of the ADRA2A gene is associated and linked with the ADHD combined subtype and suggests that the DraI polymorphism of ADRA2A is linked to a causative polymorphism.