Functional brain electrical activity mapping in boys with attention-deficit/hyperactivity disorder.

BACKGROUND: Symptoms of attention-deficit/hyperactivity disorder (ADHD) have been associated with frontal lobe deficits. We used a novel brain electrical imaging method to investigate rapid and continuous changes in brain activity during the continuous performance task (CPT) in normal boys and in boys with ADHD. The amplitude and latency topography of the steady-state visually evoked potential (SSVEP) were examined while subjects performed the "X" version of the CPT (CPT-X; the reference task) and the "A-X" version of the CPT (CPT-AX). METHODS: Seventeen boys meeting DSM-III-R criteria for ADHD and 17 age-matched controls participated in the study. Brain electrical activity was recorded from 64 scalp sites. During the reference task, subjects pressed a microswitch on the unpredictable appearance of the letter X. During the CPT-AX, subjects were required to press the microswitch on the appearance of the letter X only if an A had preceded it. RESULTS: In the interval between the appearances of the A and the X of the correct trials of the CPT-AX, control boys showed transient reductions in SSVEP latency at right prefrontal sites. By contrast, boys with ADHD showed no change or an increase in prefrontal SSVEP latency at right prefrontal sites. CONCLUSION: Our results suggest increased speed of prefrontal neural processing in children without ADHD following a priming stimulus, and a deficit in such processes in children with ADHD.

"Growing pains": clinical and behavioral correlates in a community sample.

Parents of 183 children identified them as having "pain in arms, legs, or joints during the previous 12 months." This group was compared with a group of children without pains selected randomly from the rest of a 1605-member community-based cohort in a study of chronic illness. The pains were most likely to be deep seated, to involve predominantly the lower limbs, and to be described in vague, nonspecific terms. These children were significantly more likely to have recurrent abdominal pain, a negative mood, and behavior problems, and to be aggressive, anxious, and hyperactive. There were no differences between the groups on any teacher ratings of behavior, temperament, social skills, or academic achievement. We conclude that children with "growing pains" are rated by their parents, but not their teachers, as having different temperamental and behavioral profiles than controls. These data suggest a psychosocial contribution to growing pains akin to that seen with other pain syndromes.

The detection of developmental problems in children.

General practitioners are ideally placed to assist in the identification of children whose development is slower than expected for age. In this article various methods of detecting developmental delay are discussed, and an algorithm is proposed for application in a busy office.

Informed consent. Communication problems: a patient's view.

In this paper, the author gives a personal account of how healthcare professionals' communication skills can contribute to confusion and fear in patients undergoing major treatment. She discusses why it is important for nursing staff to act as patient advocates and provide consistent information that is easily understood and that the patient can share with a relative or carer.

Are children with asthma affected by smog?

OBJECTIVE: To assess the relationship between atmospheric smog and emergency department attendances in children with asthma. DESIGN: The number of child attendances with acute asthma was calculated retrospectively for each day of the 1989 calendar year. Daily smog data for 1989 were then obtained from the Environment Protection Authority of Victoria, and were related statistically to asthma attendances. SETTING: The Emergency Department of the Royal Children's Hospital, Melbourne, which provides primary, secondary and tertiary level health care to the children of Victoria. PATIENTS: All children over two years of age with acute asthma. MAIN OUTCOME MEASURE: The number of attendances with asthma each day for the 1989 calendar year. RESULTS: Smog alerts (smog days predicted by the Environment Protection Authority) and smog episodes (actual smog days of all types) were not significantly related to asthma attendances. A significant relationship was noted, however, between asthma attendances and days when the airborne particulate index was above the acceptable threshold. No relationship was found between asthma attendances and ozone levels (a marker of photo-oxidant smog), or between any smog index and days of unusually high asthma attendance (asthma epidemic days). All smog variables combined explained only 2.3% of the variance in asthma attendance. CONCLUSIONS: Although the overall contribution of smog to asthma attendances in children is small, the correlation between asthma attacks and airborne particles is a hitherto unreported finding in Australia and is potentially of public health importance.

Side effects of methylphenidate and dexamphetamine in children with attention deficit hyperactivity disorder: a double-blind, crossover trial.

OBJECTIVE: To compare the side effect profiles of methylphenidate (MPH) and dexamphetamine (DEX) in children with attention deficit hyperactivity disorder (ADHD), as well as to determine which symptoms are genuine adverse effects of stimulant medication, as opposed to aspects of the child's underlying behavioral phenotype. DESIGN: Double-blind, crossover study. SETTING: Pediatric teaching hospital ambulatory behavior clinic. SUBJECTS: A total of 125 children with ADHD with a mean age of 104.8 months. INTERVENTIONS: Subjects received DEX (0.15 mg/kg/dose) and MPH (0.3 mg/kg/dose) twice a day for 2 weeks each in a randomized order. OUTCOME MEASURES: The Barkley Side Effects Rating Scale (17 symptoms; 0 = absent, severity rated from 1 to 9) was completed by parents at baseline and at the completion of each trial fortnight. RESULTS: Subjects' parents reported a significantly greater mean number (8.19) and mean severity (4.08) of "side effects" before commencing the trial than during the MPH period (number 7.19; severity 3.24), but not the DEX period (number 7.64, severity 3.73). The mean severity (but not mean number) was greater on DEX than on MPH. DEX caused more severe insomnia and appetite suppression compared with the baseline rating. Appetite suppression was the only item rated more severe on MPH than at baseline. Six side effects were significantly more severe on DEX than MPH: insomnia, irritability, proneness to crying, anxiousness, sadness/unhappiness, and nightmares. None were more severe on MPH than DEX. Overall, both MPH and DEX were well tolerated by most subjects, with only four subjects discontinuing the trial period because of severe adverse effects (2 -1.6%- on each stimulant). CONCLUSIONS: Many symptoms commonly attributed to stimulant medication are actually preexisting characteristics of children with ADHD and improve with stimulant treatment. At the doses investigated, both DEX and MPH caused appetite suppression, and DEX caused insomnia. Negative emotional symptoms were more severe on DEX than MPH.

Methylphenidate versus dexamphetamine in children with attention deficit hyperactivity disorder: A double-blind, crossover trial.

OBJECTIVE: To compare methylphenidate (MPH) and dexamphetamine (DEX) in a sample of children with attention deficit hyperactivity disorder (ADHD). METHOD: A total of 125 children with ADHD received both MPH (0.3 mg/kg twice daily) and DEX (0.15 mg/kg twice daily) for 2 weeks a double-blind, crossover study. Outcome measures were Conners' Parent Rating Scale-Revised, Conners' Teacher Rating Scale-Revised, a Parent Global Perceptions questionnaire, the Continuous Performance Test, and the Barkley Side Effects Rating Scale. RESULTS: There were significant group mean improvements from baseline score on all measures for both stimulants. On the Conners' Teacher Rating Scale-Revised, response was greater on MPH than DEX on the conduct problems and hyperactivity factors, as well as on the hyperactivity index. On the Conners' Parent Rating Scale-Revised, anxiety was the only factor to differ significantly, in favor of MPH. Parents rated 73% of subjects as globally improved on MPH and 69% improved on DEX, compared with baseline. Overall, 46% of parents chose MPH as the preferred drug, compared with 37% who chose DEX. On the Continuous Performance Test, there was no difference in the number of correct responses or errors between the two drugs. CONCLUSIONS: Most children with ADHD improve significantly on both MPH and DEX. There was a slight advantage to MPH on most measures.

Antipsychotic medication and marked hyperprolactinaemia: iatros or true prolactinoma?

AIM: To demonstrate that hyperprolactinaemia and/or prolactinoma occur in association with antipsychotic medication use. METHODS: Three case studies of patients with markedly elevated serum prolactin level (>132 microg/l); either antipsychotic medication induced or as a consequence of a prolactinoma. CONCLUSION: The management and investigation of children with markedly elevated serum prolactin levels remains poorly defined. In our case series, two patients were found to have prolactinomas. We suggest that paediatric patients with serum prolactin level above 50 microg/l in males and 70 microg/l in females, regardless of any antipsychotic medication use, receive magnetic resonance imaging to exclude prolactinoma.

Late adolescent outcome of early onset anorexia nervosa.

Forty-three young female patients admitted consecutively to hospital with anorexia nervosa (AN) were re-evaluated in late adolescence an average of 4.3 years following initial presentation. Follow-up interviews were conducted individually by a paediatrician and a psychiatrist on 32 of the original 43 patients (mean age 18.3 years) with outcome assessed by multidimensional physical, menstrual, eating behaviour, psychosocial and global outcome criteria. Physical outcome, as assessed by validated indices of body adiposity, was within the normal range (3-97th percentiles) in 94% of the 32 patients seen at follow-up, although only 56% reported regular cyclical menstrual function. Good physical outcome, however, was not necessarily predictive of successful adjustment in other areas. Eating behaviour was unequivocally normal in only 25% of patients, with a majority still dieting, binging or vomiting with meals, Psychosocial adjustment was satisfactory in the majority of cases but varied widely. Univariate and multivariate statistical analysis identified higher premorbid and admission body mass index (BMI) percentiles, a family history of obesity and shorter duration of illness on admission as significant prognostic indicators of favourable physical outcome. Although girls who develop AN in early adolescence are generally thought to have a favourable long-term prognosis, health professionals need to be aware that these patients form a heterogeneous group and may have considerable ongoing physiologic and psychologic disturbance despite normalization of body mass.

Medium-term outcomes are comparable with short-term outcomes in children with attention deficit hyperactivity disorder treated with stimulant medication.

OBJECTIVE: To compare the short- and medium-term effects of psychostimulant medication in children with attention deficit hyperactivity disorder (ADHD). METHODS: Seventy-three children with ADHD participated in a double-blind crossover study of dextroamphetamine (DEX) and methylphenidate (MPH; results previously reported). At the completion of this study, subjects continued to take the preferred stimulant. Subjects were restudied 6-9 months later. The principal outcome measures were the Revised Conners' Parent and Teacher Rating Scales. RESULTS: Fifty-three families (73%) returned the follow-up surveys. At 6-9 months, mean T scores were still significantly lower than the mean at baseline for all factors of both the CPRS-R and CTRS-R (P < 0.01). There were no statistically significant differences between scores at 6-9 months and scores at the completion of the corresponding medication period in the crossover trial. CONCLUSIONS: After 6-9 months treatment with stimulant medication, ratings remained significantly better than at baseline. This suggests that the early benefits of stimulants are sustained for at least 6 months.

Child and parent perceptions of stimulant medication treatment in attention deficit hyperactivity disorder.

OBJECTIVE: To evaluate child and parent perceptions of treatment with stimulant medication in a sample of children with attention deficit hyperactivity disorder (ADHD). METHODOLOGY: Child and parent perceptions questionnaires were completed for 102 subjects participating in a double-blind, crossover trial of methylphenidate (MPH) and dexamphetamine (DEX). RESULTS: Most children viewed medication effects favourably, although 12.7% and 18.8% of children reported feeling worse than usual when taking MPH and DEX, respectively. There was disagreement between the child's and parents' perceptions of response in over one quarter of cases. Most disagreements involved parents viewing the child's response favourably, but the child rating reporting an unfavourable outcome. Side-effects were the main determinant of children's perceptions of adverse response. CONCLUSIONS: A substantial proportion of children with ADHD experience treatment with stimulant medication adversely. Side-effects are the principal determinant of negative child perceptions. Parental report is usually in agreement with child report; however, parental report alone is not infallible in providing reliable information regarding effects as experienced by the child.

Clinical markers of serious illness in young infants: a multicentre follow-up study.

OBJECTIVE: To perform a multicentre follow-up study to determine if previously identified markers of serious illness in early infancy were robust and statistically reliable. METHODS: Infants aged 1 week to 26 weeks presenting to the Emergency Departments of the Royal Children's Hospital and two Melbourne metropolitan hospitals were seen over a 12-month period. Eleven clinical markers as well as their temperature were documented by nursing staff and resident medical officers. Serious illness was defined if infants had a positive body fluid bacterial culture, a positive chest X-ray or if significant treatment was required in hospital. The predictive values, sensitivity and specificity for the individual and the best combination of clinical markers were determined. RESULTS: Assessments (3806) were performed with 312 infants being assessed as seriously ill (8.2%). The combination of either drowsiness on history or examination, pallor on history or examination, breathing difficulty (chest wall recession), temperature above 38 degrees C and a lump being present, identified 82.5% of all babies deemed subsequently to be seriously ill. The positive predictive value of an infant who was febrile, drowsy and pale on examination was 70.7% (previous study 74%). CONCLUSIONS: This study confirmed the high individual predictive value of arousal variables, pallor, and chest wall recession, especially when associated with fever, reaffirming their utility in the recognition of serious illness in infants under 6 months of age.

Late diagnosis of congenital sensorineural hearing impairment: why are detection methods failing?

This study was designed to look in detail at the paths to diagnosis for a group of 197 children with congenital sensorineural hearing impairment (SNHI), who were diagnosed between 1989 and 1991 in the state of Victoria, Australia. Despite the existence of universal infant screening at 7-9 months by distraction test or questionnaire, the median age at diagnosis for the study group was 18.0 months, with median age at aid fitting of 20.8 months, and median age at commencement of specialised intervention programmes of 22.3 months. Parent questionnaires completed for 143 (73%) of these children showed that 49% had known risk factors for hearing loss yet only 20% of them had been referred for audiological assessment before the 7-9 month screen. Only 63% of those eligible for the 7-9 month screen had received it. Of those children who were screened by distraction test 46% passed as did 57% of those screened by questionnaire. Twenty four parents (17%) described how they had initially 'denied' their own observations of their infants' abnormal hearing behaviour. When concerns were raised with professionals, 10% of parents were falsely reassured without audiological assessment. Detection methods are failing through a combination of poor screen test efficacy, incomplete population coverage, and parental and professional denial.

Randomised trial of histoacryl blue tissue adhesive glue versus suturing in the repair of paediatric lacerations.

OBJECTIVE: To compare histoacryl blue tissue adhesive glue with suturing in the repair of simple paediatric lacerations. METHODOLOGY: Prospective, randomised controlled trial in tertiary paediatric emergency department. Children 4 years old or older with non-ragged lacerations <5 cm in length, <12-h-old and not involving eyelid or mucous membrane. A total of 163 patients were randomly allocated to either glue (83 cases) or sutures (80 controls) to repair their laceration. Primary outcome measures were cosmetic outcome at 3 and 12 months with secondary outcomes-length of time to perform procedure, and pain assessment of procedure by doctor, nurse, parent and child. RESULTS: Cases and controls were similar in age, wound length and width and body part involved, but more females received glue (P = 0.013). Time taken to repair the wound was faster in the glue group (median 0-2 mins vs. 6-10 min suture, P<0.001). Doctors (P = 0.02), nurses (P<0.01) and parents (P = 0.02) but not the children themselves (P = 0.24) rated glue repair as less distressing. Complications at 1 week (wound dehiscence, redness and discharge) were the same for both groups (P>0.2). Cosmetic outcome was the same for both groups at 3 (n = 65) and 12 (n = 65) months (P>0.7). CONCLUSION: Tissue adhesive glue is faster and probably less painful than suturing. Tissue adhesive glue has the same cosmetic result as suturing when used for the repair of simple lacerations in children.

Qualitative analysis of parents' experience with early detection of hearing loss.

AIMS: To determine key themes from parents' comments on paths to diagnosis and intervention for their children with hearing loss, following introduction of at-risk neonatal hearing screening and modification of distraction test screening for infants not at-risk. METHODS: Parents of children born in 1993 in Victoria, Australia, who were eligible for screening via the Victorian Infant Hearing Screening Program and who were subsequently diagnosed with a permanent congenital hearing loss and fitted with hearing aids prior to the year 2000 were asked to complete a semi-structured questionnaire shortly after aid fitting. Two researchers independently analysed parent comments using the constant comparative method. RESULTS: Parents of 82 children (61%) replied to the questionnaire. Themes analysis revealed a generally positive response to neonatal ABR screening, with a mixed response to the distraction test; powerful emotions experienced by parents at diagnosis including denial and shock; frustration arising from delays in diagnosis, and communication difficulties with providers. Special difficulties testing children with other medical and developmental problems, confusion about tympanostomy tube insertion, and difficulty with wearing hearing aids were also reported. Some children had experienced problems in the school setting. Experience of post-diagnostic services was generally positive. CONCLUSIONS: Parents need greater support both during the testing of screen failures and at the time of diagnosis. Providers need more training in how to communicate findings to parents, particularly at times when parents are experiencing strong emotions. Parents need more strategies to enable hearing aid wearing in very young children. Some children with additional medical, developmental, and behavioural problems need specialised approaches to testing.