RESUMEN
CASE: "Andrew" is a 6-year-old, right-handed, cisgender boy who presents for neuropsychological testing to determine whether he meets criteria for attention-deficit/hyperactivity disorder (ADHD). Andrew's parents report that he is easily distracted, has poor concentration, and is unable to sustain attention for discrete periods of time. Andrew is the product of an uncomplicated pregnancy and delivery, and there were no reported concerns in the postnatal period. Andrew met all of his language and motor milestones on time. He was described as having an "easy" temperament in his infancy and toddler years. Difficulties with attention started in preschool in that Andrew was described as frequently "getting lost" in his play or the task he was working on. He was easy to redirect and responded to cues and reminders. Socially, Andrew was described as friendly but not always "picking up on social cues." Andrew's kindergarten teachers first noted that sometimes Andrew would "blank out" and appear to stare off, which was attributed to inattention. His teachers brought their concerns to Andrew's parents, and his parents began to observe Andrew more carefully and noted that these episodes also occurred at home daily. When queried, his parents reported that these episodes would last 4 to 5 seconds and Andrew would not respond to his name being called or to being physically touched. Andrew's medical history, and that of his immediate and extended family, is unremarkable. Routine hearing and vision screenings are also unremarkable. There are no reports of head injuries or concussions. Andrew's gait is stable, and there are no signs of motor weakness. There are no reports of sensory seeking or avoiding behaviors. There are no reports of witnessing or experiencing trauma; motor or vocal tics; or compulsions, ritualized behaviors, or restricted interests.Testing revealed high average verbal comprehension skills, average perceptual and fluid reasoning, and lower end of average working memory and processing speed. During testing, the examiner noted a rapid eye flutter, which Andrew did not see to recognize himself but did ask the examiner to repeat the previous question. Parent and teacher rating scales of emotional and behavioral functioning showed elevations in the areas of inattention and adaptability and 1 scale of executive functioning noted elevations in task monitoring but no other difficulties. Socially, Andrew is well liked by his peers, although he can present as "silly." He has many same-aged friends and enjoys group activities. His parents have been hesitant to get him involved in sports because he has been known to have these staring episodes right after competing in sporting events. He also tends to have them more often during the school week when he has less sleep, which his parents attribute to having a difficult time falling asleep at night. What would you do next?
Asunto(s)
Trastorno por Déficit de Atención con Hiperactividad , Humanos , Masculino , Trastorno por Déficit de Atención con Hiperactividad/diagnóstico , Niño , Epilepsia/diagnóstico , ComorbilidadRESUMEN
CASE: DL is an 8-year-old Mexican boy with a posterior atrial septal defect and partial anomalous pulmonary venous return of the right lower pulmonary vein with resultant right heart dilation with normal right ventricular systolic and diastolic function and no arrhythmias. Surgical repair was deferred, and DL's condition was being medically managed with furosemide 0.5 mg/kg BID and spironolactone 0.5 mg/kg BID.DL presents for developmental assessment due to poor performance in school following a lifting of COVID-19 pandemic restrictions and return to in-person classes. He has been attending full-time classes for 3 months without improvements in math, reading, and writing skills. Current attentional concerns at school include an inability to complete tasks without getting distracted by minimal stimuli and highly impulsive behavior.At the first assessment, DL was performing below grade expectations (e.g., reading by syllable without text comprehension, demonstrating preoperational addition and subtraction skills, inability to take dictation)-all of which was viewed as negatively impacted by attentional deficits. DL met DSM-5 criteria for ADHD, predominantly inattentive type. He was started on 10-mg immediate-release methylphenidate PO at 8 am with breakfast and a second dose of 10-mg immediate-release methylphenidate PO 4 hours after the first dose.After a month, at the first follow-up consultation, improvement in attention span, impulsivity, and school performance were observed, including reading skills and math proficiency. However, DL's mother raised concerns about circumoral cyanosis and acrocyanosis in the fingers of both hands after playing outside. These signs were not previously observed. During physical examination at the same visit, heart rate, blood pressure, and oximetry were within baseline ranges and his cardiac examination was unchanged. DL's dosage of methylphenidate was lowered to 10-mg immediate-release methylphenidate PO QD in the mornings with breakfast (8 am).DL did not return to clinic for another 2 months, having discontinued the medication after 2 months of treatment given financial limitations. His mother reported that DL's exertional circumoral cyanosis and acrocyanosis resolved while he was off medication. However, she observed an increase in inattentive symptoms and impulsivity and decline in his academic skills. She asked if our team was able continue the treatment despite the drug side effects, since she believed the benefits outweighed the disadvantages.Given these concerns, the team requested an updated cardiology assessment. The Cardiologist recommended discontinuation of methylphenidate and recommended follow-up with cardiothoracic surgery for reassessment of the surgical timeline.Given the limited treatment options in Mexico, what would you do next as the treating developmental-behavioral clinician ?
Asunto(s)
Trastorno por Déficit de Atención con Hiperactividad , Cardiopatías Congénitas , Humanos , Masculino , Trastorno por Déficit de Atención con Hiperactividad/tratamiento farmacológico , Niño , Cardiopatías Congénitas/tratamiento farmacológico , México , COVID-19 , Estimulantes del Sistema Nervioso Central/farmacología , Estimulantes del Sistema Nervioso Central/administración & dosificación , Metilfenidato/farmacología , Metilfenidato/administración & dosificaciónRESUMEN
CASE: Layla is a 6.7-year-old girl diagnosed with attention-deficit/hyperactivity disorder (ADHD)-predominantly hyperactive/impulsive type-delayed adaptive skills, enuresis, unspecified malnutrition, and feeding difficulties. She presented to developmental-behavioral pediatrics (DBP) in January 2022 due to caregiver concerns for autism spectrum disorder (ASD).Layla lives in a polyamorous family with her biological mother and father, mother's partner whom Layla refers to as her uncle, and her 2 half-siblings. There is a maternal history of special education services, schizoaffective disorder, bipolar disorder, multiple sclerosis, Wolff-Parkinson-White syndrome, and ADHD. Layla's father is a veteran diagnosed with post-traumatic stress disorder. Layla's siblings, aged 5 and 9 years, have established diagnoses of ADHD, ASD, global developmental delays, behavioral concerns, and poor sleep. There is a history of adverse childhood experiences, including parental mental health, poverty, and involvement with child protective services. Acknowledgement and inclusion of all members of this diverse family structure, as well as consistent validation from the DBP and social worker, allowed a strong treatment alliance to form and the mother continued to contact the DBP clinic, even for those questions related to other specialties. A social worker received weekly calls from the mother sharing grievances related to feeling misunderstood and spoke about the assumptions she felt external providers made about her family, culture, and parenting styles. For example, she recalls the pediatrician commenting about their family structure being "confusing for the children" and describing their home as "chaotic," assumptions that may not have been made of nuclear family structures. Behavioral therapies were a repeated recommendation, but the mother verbalized not being interested in these options as she had participated in parent management training several years earlier and felt that the strategies taught were not applicable to her unique family structure, to which the clinician replied, "this is the standard recommendation for all children this age with disruptive behaviors." Although the mother was initially hesitant to trial medications, she eventually agreed that Layla's symptoms were negatively affecting her school performance, and the DBP initiated a stimulant medication.Layla's initial evaluation included a developmental history, behavioral observations, and standardized testing. The results from developmental testing demonstrated age equivalents between 4 and 6 years across gross motor, adaptive, visual motor, and speech-language domains.On observation, Layla was extremely active. During the visit, she walked over to her mother, made eye contact, and showed her the picture that she had drawn. She engaged in imaginary play, reciprocal conversation, and responded to social bids. The mother felt strongly that Layla had ASD and reported symptoms such as motor stereotypies (hand flapping), covering ears with certain noises/sounds, and rigidity when it came to things being a certain way or a certain color. These behaviors did not occur in the initial or subsequent clinic visits with DBP, her general pediatrician, or during other outside evaluations the mother pursued. The DBP felt strongly that Layla was mimicking her siblings' symptoms and provided ongoing education regarding ADHD symptomology.In terms of behavior management, the mother did not attempt to redirect Layla's behaviors during the initial clinic visit and in subsequent visits, and both adult men yelled loudly, clapped, and hit their hands on the table as a form of redirection. The mother continued to voice her diagnostic disagreement with the DBP and the pediatrician and insisted that Layla met the criteria for ASD. When the mother reviewed the report, a statement insinuating that Layla's behaviors were "understandable given parental inconsistency and complicated family structure" upset her.What factors would you consider when thinking about caregiver disagreement with the diagnosis and treatment plan? Does diagnostic overshadowing apply here?
Asunto(s)
Trastorno por Déficit de Atención con Hiperactividad , Trastorno del Espectro Autista , Adulto , Niño , Femenino , Masculino , Humanos , Trastorno por Déficit de Atención con Hiperactividad/diagnóstico , Trastorno por Déficit de Atención con Hiperactividad/terapia , Madres , Padres , Responsabilidad ParentalRESUMEN
There is growing consensus that diagnostic labels are insufficient to describe the individual child's psychiatric profile, much less inform the precise combination of interventions that will minimize the impact of risk and/or bolster protective factors over the course of a particular child's development. Moreover, investigations of neurobiological and genetic mechanisms associated with psychopathology have revealed considerable cross-diagnostic overlap, undermining the validity of models that propose a 1:1 relationship between risk and psychiatric disorder. Accordingly, recent publications have advocated for neurodevelopmental models that utilize trait-based measurement, as well as increased emphasis on integration of biological and experiential mechanisms. Despite an expanding body of literature supporting this conceptual shift, the practical implications remain unclear. In this special issue, we compile a collection of novel empirical research papers and reviews that build on the trans-diagnostic principles of the RDoC framework.
Asunto(s)
Trastornos Mentales , Psicología Clínica , Niño , Humanos , Trastornos Mentales/diagnóstico , Psicopatología , NeurobiologíaRESUMEN
OBJECTIVE: Autism spectrum disorder (ASD) diagnosis relies on clinical observation and documentation, but the presence of comorbidities can affect diagnostic validity across clinicians and exacerbate access to timely care. This study used latent class analysis to optimize subgroup identification based on functional level and associated comorbidities using the Behavior Assessment System for Children, Third Edition (BASC-3), and Vineland Adaptive Behavior Scales, Third Edition (Vineland-3), in a pediatric population referred for autism evaluation. METHODS: This retrospective study reviewed clinical data extracted over a 3-year period (2018-2021). A latent class analysis was used to explore the presence of latent groups guided by the likelihood ratio test and fit indices. Additional analyses contrasted ASD and non-ASD groups on the BASC-3 and Vineland-3 variables. RESULTS: There were 191 included participants (mean age 65.9 months, 76.4% male), of whom over half (60.7%) had an ASD diagnosis. Using 185 cases, the exploratory latent class analysis showed the emergence of 4 distinct subgroups. Composition of classes varied on ASD diagnosis, neurodevelopmental difficulties, behavioral health concerns, and intellectual disability. When contrasting ASD and non-ASD groups, significant between-group differences were observed across Vineland-3 variables and BASC-3 adaptive skills subscales indicating poorer social and adaptive functioning. CONCLUSION: Latent class analysis of commonly used behavioral and adaptive measures can help distinguish between subgroups of pediatric patients referred for ASD evaluations and assist in triage of cases based on severity.
Asunto(s)
Trastorno del Espectro Autista , Trastorno Autístico , Discapacidad Intelectual , Humanos , Niño , Masculino , Adolescente , Preescolar , Femenino , Trastorno del Espectro Autista/diagnóstico , Trastorno del Espectro Autista/epidemiología , Estudios Retrospectivos , Análisis de Clases Latentes , Discapacidad Intelectual/diagnóstico , Discapacidad Intelectual/epidemiologíaRESUMEN
Trait irritability in toddlerhood is a powerful risk factor for later internalizing and externalizing challenges in non-autistic children, but the predictive clinical utility of irritability is unknown in autism. Irritability is a trait-level emotional response (i.e., frustration) to a blocked goal and is one source of disruptive behavior. Irritability has two facets: Frustration is the degree to which emotion is elevated after a blocked goal, while soothability is the rate of recovery from peak distress. We aimed to: (1) compare and describe the two facets of irritability in non-autistic and young autistic children, and (2) assess whether children's reward sensitivity and executive function moderate the relation between irritability and clinical symptoms. Participants were 90 autistic (n=43) and non-autistic (n = 47) 2- and 4-year-olds. Autistic children did not have different levels of frustration but were more difficult to soothe compared to non-autistic children, according to parents. Further, frustration and soothability were less strongly correlated for autistic compared to non-autistic children. For all children, executive function (specifically, inhibition) moderated, or ameliorated the strength of, the relation between irritability (both soothability and frustration) and externalizing challenges. This study provides evidence for irritability as a transdiagnostic risk factor for clinically significant emotion regulation challenges. Further, the effect of trait irritability may be ameliorated by children's executive function in a transdiagnostic manner. Future work should examine the unique aspects of soothability to how irritability presents within autism, as well as evaluate and modify emotion regulation interventions for autistic toddlers and preschoolers.
Asunto(s)
Trastorno Autístico , Humanos , Preescolar , Trastorno Autístico/psicología , Genio Irritable/fisiología , Frustación , Padres , Factores de RiesgoRESUMEN
CASE: Jay is a 6-year-old boy who was referred to a multidisciplinary developmental clinic for evaluation because of speech/language delays and challenging behaviors. He attends kindergarten with an Individualized Education Program (IEP) supporting developmental challenges with speech/language, motor, and academic skills.Jay was reportedly born full-term after an uneventful pregnancy and lived with his biological family for several months before transitioning to institutional care. Shortly before his first birthday, he transitioned to the first of 3 foster homes. It is suspected that Jay experienced malnourishment, neglect, lack of appropriate supervision, and inappropriate levels of responsibility (e.g., providing care to an infant when he was a toddler) as well as limited language input while in foster care. Ages at which he attained developmental milestones are unknown, but he has displayed delays across all developmental domains, including speech/language development in his primary language, which is not English.Jay's adoptive parents report that he is learning English vocabulary well but has been noted to have occasional word-finding difficulties and errors in verb conjugation, pronoun use, and syntax in English. Behavioral concerns include impulsivity, hyperactivity, and aggression exacerbated by new or loud environments and transitions. Socially, he seems to be typically engaged with peers but lacks understanding of personal space/boundaries. His adoptive parents have also noted that he is very sensitive to the emotions of others around him, more irritable in the morning, fascinated by "scary" things, and seems to fear abandonment. During the initial months in his adoptive home, he had frequent night awakenings, fear of the dark, and aggression at bedtime, but all these concerns have improved with time.Neuropsychological testing was completed as part of the multidisciplinary developmental evaluation, and Jay demonstrated low-average cognitive abilities, delayed preacademic skills in all language-based areas, and receptive and expressive language delays. He was socially engaged during the evaluation. Ultimately, he was diagnosed with mixed receptive-expressive language disorder, attention-deficit/hyperactivity disorder, combined presentation, and unspecified trauma/stress-related disorder.Given what is known about Jay's early history, what factors would you consider in addressing his parents' concerns regarding his speech/language development and behavior challenges?
Asunto(s)
Trastorno por Déficit de Atención con Hiperactividad , Niño Adoptado , Trastornos del Desarrollo del Lenguaje , Masculino , Humanos , Niño , Conducta Social , Agresión , Trastorno por Déficit de Atención con Hiperactividad/diagnóstico , Trastornos del Desarrollo del Lenguaje/diagnósticoRESUMEN
CASE: Maria is an 8-year-old girl with Down syndrome, described by her mother as an affectionate and social child, who was referred to developmental-behavioral pediatrics by her pediatrician because of increasing aggressive behaviors and inattention.Maria was 5 pounds at birth, delivered full-term by cesarean section, and hospitalized for 1 month after delivery because of feeding issues that required a nasogastric (NG) tube. Maternal age was 24 years, pregnancy was uncomplicated, and there were no reported prenatal exposures to substances. Additional medical history includes corrective cardiac surgery at age 11 months, mild-to-moderate hearing loss in 1 ear, and myopia.At the time of Maria's presentation to developmental-behavioral pediatrics, she was in third grade and had an IEP with placement in a substantially separate multigrade classroom and inclusion for special classes such as music and art. She had multiple academic goals and accommodations for behaviors such as eloping from class, shoving, and growling at adults; communication Picture Exchange Communication System (PECS); and extended time to complete assignments. Previously, she had attended an inclusion setting with a 1:1 aide. Maria is followed annually at a specialty clinic that focuses on the health needs of children with Down syndrome. At home, Maria's parents speak primarily Spanish, while her 2 older brothers speak primarily English. Maria has been using 3-word phrases since she was 6 years old and understands some American Sign Language. She also uses a PECS book for communication.During the visit, Maria was notably fidgety, frequently interrupted the parent interview despite having toys to play with, and became aggressive-hitting, kicking, pushing, and shoving-when she did not want to comply with directives. She used mostly single words and a variety of gestures to communicate. Both the parent-completed and teacher-completed Conners-3 (Long Version) produced elevated T-scores (>70) in the domains of inattention, hyperactivity/impulsivity, defiance/aggression, peer relations, Global Index scale, DSM-5 Hyperactive/Impulsive symptom scale, and DSM-5 Conduct Disorder symptom scale. The teacher endorsed full criteria for attention-deficit/hyperactivity disorder, consistent with combined presentation, and the parent endorsed symptoms in a similar pattern. Methylphenidate (2.5 mg) was trialed but tolerated poorly when it was titrated to 5 mg. Maria's mother reported that Maria's focus was somewhat better, but she was easily brought to tears and "not herself."What would be the next steps in Maria's evaluation/treatment? Could there be reasons for her worsening behavior other than a primary attention disorder?
Asunto(s)
Trastorno por Déficit de Atención con Hiperactividad , Síndrome de Down , Discapacidad Intelectual , Metilfenidato , Femenino , Embarazo , Adulto , Recién Nacido , Masculino , Niño , Humanos , Lactante , Adulto Joven , Síndrome de Down/complicaciones , Trastorno por Déficit de Atención con Hiperactividad/diagnóstico , CesáreaRESUMEN
PURPOSE: While positive contributions of religion and spirituality (R/S) to quality of life (QOL) are confirmed by a growing body of evidence, only limited research has involved people with intellectual disabilities and so far, no studies included prelingually deaf individuals with intellectual disabilities. This study explores the role of R/S in people with intellectual disabilities and deafness living in three therapeutic living communities specifically adapted to their needs. METHODS: Forty-one individuals (mean age: 46.93 years, 43.9% female) with prelingual deafness and mild to moderate intellectual disability participated in structured sign language interviews adapted to their cognitive-developmental level, regarding their QOL, individual spirituality and participation in spiritual practices in the community. Participants' QOL was assessed with an established short measure for QOL (EUROHIS-QOL) adapted to easy-to-understand sign language. With 21 participants, qualitative interviews were conducted. In addition, proxy ratings from caregivers were obtained. RESULTS: The participants' ratings of their individual spirituality (r = 0.334; p = 0.03) and spiritual practices-in-community (r = 0.514; p = 0.00) correlated positively with their self-reported QOL. Qualitative findings illustrate the importance of R/S and give insights into R/S concepts and practices. CONCLUSIONS: Personal spirituality and participating in spiritual practices are positively related to self-reported quality of life in deaf individuals with intellectual disability (ID). As a consequence, access to spiritual and religious services should be included in comprehensive programs and society at large.
Asunto(s)
Discapacidad Intelectual , Espiritualidad , Humanos , Femenino , Persona de Mediana Edad , Masculino , Religión , Calidad de Vida , CuidadoresRESUMEN
Individuals who are prelingually deaf and have intellectual disabilities experience great challenges in their language, cognitive and social development, leading to heterogeneous profiles of intellectual and adaptive functioning. The present study describes these profiles, paying particular attention to domain discrepancies, and explores their associations with quality of life and maladaptive behavior. Twenty-nine adults with prelingual deafness (31% female) and mild intellectual functioning deficits (mean IQ = 67.3, SD = 6.5) were administered the Vineland Adaptive Behavior Scales-II (VABS-II) and an adapted sign language version of a quality of life scale (EUROHIS-QOL 8). Intellectual disability domain discrepancies were characterized as at least one standard deviation difference between the social domain and IQ and the practical domain and IQ, and a significant difference, according to the VABS-II manual, between the social and practical domains. Domain discrepancies were found between intellectual functioning and both the practical (58.6%) and social domain (65.5%). A discrepancy between intellectual and social functioning was significantly associated with a higher level of internalizing maladaptive behavior (T = 1.89, p < 0.05). The heterogeneous profiles highlight the importance of comprehensive assessments for adequate service provision.
Asunto(s)
Discapacidad Intelectual , Adaptación Psicológica , Adulto , Cognición , Femenino , Humanos , Discapacidad Intelectual/psicología , Masculino , Calidad de Vida , Ajuste SocialAsunto(s)
Adaptación Psicológica , Racismo Sistemático , Emociones , Humanos , Racismo Sistemático/psicologíaRESUMEN
Following predictions of a dramatic drop in the developmental-behavioral healthcare workforce by 2023 due to retirement and/or burnout, much has been written about ways to replenish or sustain needed personnel. To date, we continue to have a crisis of not enough new clinicians being attracted to the field to replenish the third of the workforce that is expected to retire. Recent concerns about increased clinician mental health problems and burnout in the wake of COVID-19 and other societal stressors add further complexity and urgency. This crisis will not be solved solely by a top-down focus on intensive graduate training or marketing to newly licensed professionals. Through the lived experience of three fellows from the Leadership Education in Neurodevelopmental and related Disabilities (LEND) program, this paper offers a "grassroots" approach to supporting people with disabilities (PWD) to weather this rebuilding period by increasing (a) their material wealth through entrepreneurship and (b) capacities for self-determination through thoughtful mentorship and considered changes in institutional culture.
RESUMEN
BACKGROUND/OBJECTIVES: The psychosocial impact of pediatric skin conditions can be difficult to assess accurately. There is currently no way to formally screen and provide stepped care specifically for psychosocial dysfunction or mental illness during dermatology clinics. The Psychosocial Screening Tool for Pediatric Dermatology (PDPS) was designed to identify patients in need of psychosocial support and to promote multidisciplinary care. METHODS: The PDPS was studied at Boston Children's Hospital outpatient dermatology clinics. A pilot study was conducted with 16 participants to assess language and applicability. The validation study included 105 participants aged 8-19 years. Participants completed the PDPS, the Children's Depression Index 2 Short (CDI-2 Short), and three subscales of the Behavior Assessment System for Children 2 (BASC-2) to assess content validity. Model fit from confirmatory factor analysis was evaluated using the root-mean-square error of approximation (RMSEA), Comparative Fit Index (CFI), and Tucker-Lewis Index (TLI). RESULTS: Proper model fit and criterion validity were demonstrated through positively correlating the PDPS and the CDI-2 Short (CFI = 0.972, TLI = 0.969, RMSEA 5.3%) and BASC-2 subscales (RMSEA = 7.2%, CFI = 0.975, TLI = 0.969). Patient resilience was positively correlated with higher scores in each psychosocial domain. CONCLUSIONS: The PDPS is an effective screening tool for resilience versus need for early behavioral/mental health intervention in dermatology patients aged 8-19. The PDPS identifies psychosocial dysfunction and problems patients may not disclose otherwise (bullying, self-harm, social supports, neurodermatitis, and body dysmorphic disorder). Additionally, patients can directly indicate interest in various psychosocial health resources on the PDPS, guiding practitioners in providing comprehensive care.
Asunto(s)
Dermatología , Trastornos Mentales , Adaptación Psicológica , Niño , Humanos , Trastornos Mentales/diagnóstico , Proyectos Piloto , Psicometría , Reproducibilidad de los Resultados , Encuestas y CuestionariosRESUMEN
The relative difference of resting EEG frontal alpha activation between left and right hemispheres (FAA; i.e., asymmetry) correlates with global approach and avoidance tendencies. FAA may relate to problems with executive and affective functioning in children with neurodevelopmental differences, including autism and ADHD. We (1) characterize relative left vs. right FAA in autistic, ADHD, and neurotypical children (NT) and (2) investigate whether FAA predicts "hot" executive function or emotion dysregulation. Participants were 97 7- to 11-year-old autistic, ADHD, and NT Children. Children with ADHD displayed greater left (relative to right) FAA compared to autistic and neurotypical children. Children with ADHD displayed greater challenges with "hot" EF on a gambling task than autistic children, whereas children with co-occurring autism and ADHD had greater parent-reported emotion dysregulation than NT and autism-only groups. Greater left FAA predicted worse hot EF for all children but was not significantly related to emotion dysregulation. Regardless of clinical diagnosis, relatively greater left FAA relates to hot EF. While hot EF deficits may be specific to ADHD rather than autism, both together confer additive risk for emotion dysregulation. Future research should explore the functional relation between FAA, reward processing, and affect for children with different EF-related neurodevelopmental differences.
RESUMEN
OBJECTIVE: To describe bullying experiences throughout childhood of people with and without childhood ADHD and co-occurring learning and psychiatric disorders from a population-based birth cohort. METHODS: In a secondary data analysis of 199 childhood ADHD cases and 287 non-ADHD referents (N = 486), reported experiences of peer interactions during elementary, middle, or high school were classified as "bully," "victim," "neither," or "both." Associations were assessed with multinomial logistic regression. RESULTS: Adjusted for male sex, the odds of classification as victim-only, victim/bully, or bully- only (vs. neither) were 3.70 (2.36-5.81), 17.71, and 8.17 times higher for childhood ADHD cases compared to non-ADHD referents. Victim-bullies (62.5%) and bullies (64.3%) had both childhood ADHD and other psychiatric disorders versus 38.4% of victims-only and 17.3% of those classified as "neither." CONCLUSION: The list of serious lifetime consequences of having ADHD also includes bullying. We offer future research directions for determining potential causal pathways.
Asunto(s)
Trastorno por Déficit de Atención con Hiperactividad , Acoso Escolar , Víctimas de Crimen , Trastorno por Déficit de Atención con Hiperactividad/epidemiología , Acoso Escolar/psicología , Niño , Víctimas de Crimen/psicología , Humanos , Masculino , Grupo Paritario , Instituciones AcadémicasRESUMEN
OBJECTIVES: The 21st Century Cures Act included an "OpenNotes" mandate to foster transparent communication among patients, families, and clinicians by offering rapid electronic access to clinical notes. This article seeks to address concerns about increased documentation burden, vulnerability to patient complaints, and other unforeseen consequences of patients having near-real-time access to their records. METHODS: This topical review explores both extant literature, and case examples from the authors' direct experience, about potential responses/reactions to OpenNotes. RESULTS: The ethics of disclosing medical information calls for nuanced approaches: Although too little access can undermine a patient's autonomy and the capacity for truly egalitarian shared decision-making, unfettered access to all medical information has significant potential to harm them. Suggested strategies for mitigating risks in premature disclosure include patient and provider education and "modularizing" sensitive information in notes. CONCLUSION: The OpenNotes era has ushered in the possibilities of greater patient and family collaboration in shared decision-making and reduced barriers to documentation sharing. However, it has raised new ethical and clinician documentation considerations. In addition to clinician education, patients and families could benefit from education around the purpose of clinical documentation, how to utilize OpenNotes, and the benefits of engaging in dialogue regarding the content and tone of documentation.
Asunto(s)
Revelación , Registros Electrónicos de Salud , Niño , Comunicación , Humanos , Encuestas y CuestionariosRESUMEN
CASE: Phillip is a young man born with hypoplastic left heart syndrome referred to your practice for a range of mental health concerns. He underwent palliation to an extracardiac Fontan in infancy and experienced multiple complications over the next decade including valvular regurgitation and arrhythmias necessitating a pacemaker. Phillip continued to have systolic heart failure with New York Heart Association class II symptoms, managed with 4 medications and anticoagulation.Despite this complex history, Phillip had intact cognitive abilities, achieved typical milestones, and performed well academically in secondary school. His first year of college proved to be more challenging, and Phillip presented to the outpatient psychiatry service with an acute depressive episode. His family history included depression, without known attention-deficit/hyperactivity disorder (ADHD). Treatment, including a selective serotonin reuptake inhibitor, cognitive behavioral therapy, and family support, led to near resolution of his symptoms of depression.In subsequent appointments, Phillip described a long history of inattention and disorganization with onset in childhood. This contributed to the decision to leave college, despite remission of symptoms of depression. Phillip was unable to study for any extended period without "perfect conditions," described as the absence of potential distractions except for background music. Despite attempts to maintain "perfect conditions," Phillip was often off task and "hyperfocusing" on irrelevant topics. Phillip struggled with planning and time management and would misplace items daily. Moreover, although the importance of self-care was well understood, Phillip often forgot to take his cardiac medication or to exercise, and he admitted to inconsistent sleep habits because of losing track of time.Based on a comprehensive psychiatric evaluation including retrospective report from a parent, Phillip was diagnosed with ADHD, coexisting with major depressive disorder, in remission. Significant ADHD symptoms were documented by interview, self-report, and administration of an abbreviated neuropsychological battery.Considering concerns regarding use of stimulants in a patient with congenital heart disease, including death, stroke, and myocardial infarction,1,2 how would you assess the risks-benefits of use of stimulants with Phillip? REFERENCES: 1. Wilens TE, Prince JB, Spencer TJ, et al. Stimulants and sudden death: what is a physician to do? Pediatrics. 2006;118:1215-1219.2. Zito JM, Burcu M. Stimulants and pediatric cardiovascular risk. J Child Adolesc Psychopharmacol. 2017;27:538-545.