- Email: [email protected]
Can Guidelines Help Reduce the Medicalization of Early Childhood?
THE JOURNAL OF PEDIATRICS
www.jpeds.com
19. Sampson MR, Bloom BT, Lenfestey RW, Harper B, Kashuba AD, Anand R, et al. Population pharmacokinetics of intravenous acyclovir in preterm and term infants. Pediatr Infect Dis J 2014;33:42-9.
Vol. 166, No. 6 20. Menon S, Kirkendall ES, Nguyen H, Goldstein SL. Acute kidney injury associated with high nephrotoxic medication exposure leads to chronic kidney disease after 6 months. J Pediatr 2014;165:522-7.e2.
Can Guidelines Help Reduce the Medicalization of Early Childhood?
T
he 2011 publication of the American Academy of Pediservices, even when combined treatment approaches have atrics’ (AAP) clinical practice guidelines for the diagbeen recommended as the most effective intervention stratenosis, evaluation, and treatment of attention-deficit gies.4 Likewise, almost no ADHD care follows AAP ADHD hyperactivity disorder (ADHD) in children and adolescents consensus guideline recommendations for the collection of emphasized special circumstances and concerns in specific ratings for monitoring treatment outcomes and potential age groups.1 In particular, the guidelines stimulant medication side effects.3 The study See related article, p 1423 provided new recommendations to include by Visser et al provides valuable benchmark preschool-aged children—expanding the lower age range data prior to the 2011 AAP guidelines for monitoring future from 6 years of age to 4 years of age. In the diagnosis and national ADHD diagnostic and treatment patterns. These treatment of ADHD, the guidelines considered confounding findings also provide an opportunity to reflect, in general, factors such as value judgments, parental preferences, and on the scope and nature of behavioral problems in prebenefit-harm assessments while acknowledging that specific schoolers in modern society. cultural differences were beyond the scope of the guidelines. Many persons with severe attention deficits, impulsivity, In young children with concerning ADHD behaviors, clear and other ADHD symptoms leading to social and educaemphasis was placed on the importance of parent training tional difficulties will be helped by pharmacologic treatprograms that “must include helping parents develop agements. ADHD can be a controversial diagnosis when its appropriate developmental expectations and specific signs and symptoms are mild, or even moderate. Recent stamanagement skills for problem behaviors.” For preschool tistics indicate that most US children diagnosed with ADHD children ages 4 and 5, the action statement stressed “the prihave mild (46.7%) or moderate (39.5%) problems, similar to mary care clinician should prescribe parent and/or teacherthe parent-reports in the current study from Visser and administered behavior therapy as the first line of treatment collagues.2,5 Hence, only about 1-in-5 or 1-in-6 children (quality of evidence A/strong recommendation).” diagnosed with ADHD are considered to have severe ADHD. Leading up to these 2011 clinical practice guidelines, the These dimensions (mild, moderate, and severe) of ADHD AAP Subcommittee on ADHD must have recognized many are widely recognized as representing the underlying strucgrowing concerns about the diagnosis of ADHD in preschool ture of the disorder; but DSM (5th edition) relies on categorchildren. In this issue of The Journal, evidence for such concern ical diagnosis to motivate any type of intervention.6,7 has become apparent. Visser et al examine the 2009-2010 ChilOrthogonal to the concept of dimensionality is the concept dren with Special Health Care Needs national parentalof impairment—the extent to which symptoms are impairing reported survey data estimating the geographic prevalence of a child’s quality and progress of life. Both International ClasADHD and the general pattern of its behavioral and pharmasification of Disease and DSM diagnoses now take impaircologic treatments (alone or in combination) by state, age, dement into account, and there is evidence that evaluations mographics, and severity level.2 Their most striking finding is of impairment decrease ADHD prevalence rates.8 However, that only about one-half of the 4- to 5-year-old preschoolers impairment is a poorly operationalized concept, left largely received the recommended first-line behavioral therapy. Other to subjective clinical opinion.9 Thus, neither the acknowlrecent studies also show that the utilization of ADHD guideedgement of ADHD dimensionality nor the application of lines in US community-based pediatric practices remains the impairment criterion seem likely in the near-term to poor.3 Pediatricians use parent and teacher rating scales during address the problem of appropriate recognition and management of ADHD-type behaviors in early childhood. The ADHD assessments in only approximately one-half of their current level of use of stimulant drug treatments in the 4patients, and document Diagnostic and Statistical Manual to 5-year-old preschool population makes this an especially (DSM) criteria in only approximately two-thirds of patients. important problem to address quickly. In community-based practices, the vast majority of children with ADHD receive medication, yet few receive psychosocial
AAP ADHD DSM
American Academy of Pediatrics Attention-deficit hyperactivity disorder Diagnostic and Statistical Manual
The authors declare no conflicts of interest. 0022-3476//$ - see front matter. Copyright ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2015.03.049
1344
EDITORIALS
June 2015 An obvious route to decreasing the use of stimulants in very young children is to increase effectiveness, accessibility, and awareness of the first-line recommended treatments— behavioral interventions. Both the AAP and the United Kingdom National Institute for Clinical Care and Excellence recognize the effectiveness of parent behavior training in preschool children with behavioral problems.10,11 The United Kingdom National Institute for Clinical Care and Excellence guidelines specifically do not mention the need for diagnosis in management of child behaviors at this age. The programs of intervention are the same as those recommended for conduct disorder, and the guidelines state that only when “more help is needed” should a child be “referred to a tertiary (psychiatric) service.”11 If it is the case that ADHD diagnosis tends to trigger stimulant drug treatment, then providing families access to non-drug interventions without the requirement of a diagnosis at an early stage may reduce the use of stimulant drugs. Such a process might also ensure that only children with more severe cases go forward to diagnosis and drug treatment. Although this may be a common sense approach, behavioral interventions in ADHD are also beset by problems that need to be systematically investigated and resolved. A foundational question is to ask why health professionals are not following guidelines or evidence that opposes use of ADHD drugs among preschoolers. A related question is to ask why parents are accepting drugs to treat behaviors in very young children. Other contextual concerns must also be addressed (and may well intersect with responses to the previous 2 questions). Access to behavioral interventions is unequally distributed across geographic regions.12 Poor access intersects with other barriers to mental health services, which includes parental beliefs, ethnicity, and other factors.13,14 Part of the problem of poor access is limited access; that is, access to a very limited set of evidence-based interventions. Nevertheless, “behavioral interventions” is a broad spectrum, including parent, home, school, and camp-based programs, often focused on specific impairments and outcomes.12 Although there is some good evidence for these programs, health professionals require training in ensuring a good fit between a family and a particular behavioral intervention. One key to making behavioral and psychological interventions more accessible is the development of internet and mobile technologies-based tools. Telemedicine is reshaping the landscape of mental health service provision, but much more needs to be done both to develop innovative technologies in this area, and to ensure that interventions are safe and effective.15 Adherence to behavioral intervention programs also presents an ongoing challenge, particularly where parents themselves present with stress and psychopathology.16 In resolving the problem of adherence, the requirement for “evidence-based” interventions may itself result in a paradoxical problem: the “evidence” for a particular intervention is derived from controlled research studies, in which compliance with an intervention is usually highly valued by parents and researchers alike.17 More studies of natural-
istic intervention settings are required to understand the reasons for and value of adherence to behavioral interventions. Recent studies suggest that more precise operationalization of “adherence” will also be valuable: in citing “poor adherence” to behavioral intervention programs, many studies give statistics on the drop-out rate among parents. However, it may be that parental engagement is more predictive of good outcomes in children, at least on some dimensions, than the number of program sessions attended.18 A related, longstanding problem in studies of parenting and ADHD, is that most studies have focused on mothers rather than parents.19 Much work needs to be done to develop parent training programs that acknowledge the realities of modern families, in which fathers, same sex partners, and grandparents have taken on an increasing parenting role.20 One-size parent behavior training is unlikely to fit or appeal to all. Because of the ambiguity surrounding ADHD diagnosis, it is difficult to predict the risks of medicalization and misdiagnosis. This same ambiguity contributes to the problem of over diagnosis and overuse of ADHD medications. However, the increased emphasis on early intervention in child health and well-being presents important opportunities for ecologically oriented research with preschoolers.21 Early intervention programs for toddlers at high risk of developing ADHD are underway.22-24 Such studies enable prospective investigation of the clinical and contextual factors that mediate and moderate good outcomes in very young children with behavioral problems. These can include factors as those discussed in this editorial such as early labeling with or without diagnosis, dimensional assessment, and intervention, adherence to and acceptability of treatments.25 The opportunity to add knowledge about the risks and benefits of early intervention programs for preschoolers at risk of ADHD should not be missed. n William D. Graf, MD Departments of Pediatrics and Neurology Yale University School of Medicine New Haven, Connecticut Ilina Singh, PhD Department of Psychiatry Uehiro Center for Practical Ethics University of Oxford Oxford, England Reprint requests: William D. Graf, MD, Departments of Pediatrics and Neurology, Yale University School of Medicine, P.O. Box 208064, 333 Cedar St, New Haven, CT 06510. E-mail: [email protected]
References 1. Management Steering Committee on Quality Improvement and Subcommittee on Attention-Deficit/Hyperactivity Disorder. ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics 2011;128:1007-22. Epub October 16, 2011. 1345
THE JOURNAL OF PEDIATRICS
www.jpeds.com
2. Visser SN, Bitsko RH, Danielson ML, Gandhour R, Blumberg SJ, Schieve L, et al. Treatment of attention-deficit/hyperactivity disorder among children with special health care needs. J Pediatr 2015;166:1423-9. 3. Epstein JN, Kelleher KJ, Baum R, Brinkman WB, Peugh J, Gardner W, et al. Variability in ADHD care in community-based pediatrics. Pediatrics 2014;134:1136-43. 4. The MTA Cooperative Group, Multimodal Treatment Study of Children with ADHD. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Arch Gen Psychiatry 1999;56:1073-86. 5. Centers for Disease Control and Prevention (CDC). Increasing prevalence of parent-reported attention-deficit/hyperactivity disorder among children—United States, 2003 and 2007. MMWR Morb Mortal Wkly Rep 2010;59:1439-43. 6. Marcus DK, Barry TD. Does Attention-deficit/hyperactivity disorder have a dimensional latent structure? A taxometric analysis. J Abnorm Psychol 2011;120:427-42. 7. American Psychiatric Association. Diagnostic and statistical manual of mental health disorders: DSM-5. 5th ed. Washington, DC: American Psychiatric Publishing; 2013. 8. D€ opfner M, Breuer D, Wille N, Erhart M, Ravens-Sieberer U. How often do children meet ICD-10/DSM-IV criteria of attention deficit/hyperactivity disorder and hyperkinetic disorder? Parent-based prevalence rates in a national sample–Results of the BELLA study. Eur Child Adolesc Psychiatry 2008;17(S1):59-70. 9. Batstra L, Nieweg EH, Pijl S, Van Tol DG, Hadders-Algra M. Childhood ADHD: a stepped diagnosis approach. J Psychiatr Pract 2014;20:169-77. 10. American Academy of Pediatrics. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/ hyperactivity disorder in children and adolescents. Pediatrics 2011;128: 1007-22. 11. National Institute for Health and Clinical Excellence (NICE) Clinical Guideline 72. Attention deficit hyperactivity disorder: diagnosis and management of ADHD in children, young people and adults. NICE clinical guideline. http://guidance.nice.org.uk/CG72/NICEGuidance/pdf/ English. Accessed April 13, 2015. 12. Chronis A, Jones HA, Raggi VL. Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder. Clin Psychol Rev 2006;26:486-502. 13. Bussing R, Zima BT, Gary FA, Garvan CW. Barriers to detection, helpseeking and service use for children with ADHD symptoms. J Behav Health Serv Res 2003;30:176-89.
Vol. 166, No. 6 14. Ahmed R, McCaffery KJ, Aslani P. Factors influencing parental decision making about stimulant treatment for attention-deficit/ hyperactivity disorder. J Child Adolesc Psychopharmacol 2013;23: 163-78. 15. Meyers K, Stoep AV. Children’s telemental ADHD health treatment study (CATTS). http://depts.washington.edu/catts/zdocs/OTHER_ INFORMATION.pdf. Accessed March 5, 2015. 16. Chronis AM, Lahey BB, Pelham WE Jr, Kipp HL, Baumann BL, Lee SS. Psychopathology and substance abuse in parents of young children with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 2003;42:1424-32. 17. Power TJ, Mautone JA, Soffer SL, Clarke AT, Marshall SA, Sharman J, et al. Family-school intervention for children with ADHD: results of randomized clinical trial. J Consult Clin Psychol 2012;80:611-23. 18. Clarke AT, Marshall SA, Mautone JA, Soffer SL, Jones HA, Costigan TE, et al. Parent attendance and homework adherence predict response to a family-school intervention for children with ADHD. J Clin Child Adolesc Psychol 2015;44:58-67. Epub 2013 May 20. 19. Singh I. Boys will be boys: fathers’ perspectives on ADHD symptoms, diagnosis, and drug treatment. Harv Rev Psychiatry 2003;11: 308-16. 20. Fabiano GA, Chacko A, Pelham WE, Robb J, Walker KS, Wymbs F, et al. A comparison of behavioral parent training programs for fathers of children with attention-deficit/hyperactivity disorder. Behav Ther 2009;40: 190-204. 21. Garner AS, Shonkoff JP, Siegel BS, Dobbins MI, Earls MF, McGuinn L, et al. Early childhood adversity, toxic stress and the role of the pediatrician: translating developmental science into lifelong health. Pediatrics 2011;129:e224-31. 22. Zwi M, Jones H, Thorgaard C, York A, Dennis JA. Parent training interventions for attention deficit hyperactivity disorder (ADHD) in children aged 5 to 18 years. Cochrane Database Syst Rev 2011;7: CD003018. 23. DuPaul GJ, Young KL. Young children with ADHD: Early identification and intervention. Washington, D.C: American Psychological Association; 2011. 24. Jones K, Daley D, Hutchings J, Bywater T, Eames C. Efficacy of the incredible years programme as an early intervention for children with conduct problems and ADHD: long-term follow-up. Child Care Health Dev 2011;34:380-90. 25. Singh I, Wessely S. Childhood: a suitable case for treatment? Lancet Psychiatry 2015 (in press).
Liver or Combined Liver-Kidney Transplantation for Patients with Isolated Methylmalonic Acidemia: Who and When?
T
he hereditary disorders of vitamin B12 (cobalamin) and mens remain ill-defined. In many patients, severe symptoms methylmalonic acid metabolism comprise a major persist despite conventional medical and nutritional therapy, group of organic acid disorders that are collectively comwhich stands in contrast to the recent practices adopted in mon inborn errors of metabolism.1 Affected patients are medithe US and other countries to screen all newborns for a large number of metabolic diseases including MMA.3 cally fragile and suffer multisystemic complications, such as lethal metabolic instability, metabolic stroke, Isolated methylmalonic acidemia See related article, p 1455 pancreatitis, end-stage renal failure, growth (MMA) has 3 major distinct genetic etiolimpairment, osteopenia, optic nerve atrophy, and neurocogniogies related to the activity of the 50 deoxyadeno-sylcobala2 tive delay. The frequency of these complications and their min-dependent enzyme methylmalonyl-CoA mutase precipitants, long-term sequelae, and optimal treatment regi-
LKT MMA MUT
Liver-kidney transplantation Methylmalonic acidemia Methylmalonyl-CoA mutase
Supported by the Intramural Research Program of the National Human Genome Research Institute, National Institutes of Health. The authors declare no conflicts of interest. 0022-3476//$ - see front matter. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jpeds.2015.03.026
1346
www.jpeds.com
19. Sampson MR, Bloom BT, Lenfestey RW, Harper B, Kashuba AD, Anand R, et al. Population pharmacokinetics of intravenous acyclovir in preterm and term infants. Pediatr Infect Dis J 2014;33:42-9.
Vol. 166, No. 6 20. Menon S, Kirkendall ES, Nguyen H, Goldstein SL. Acute kidney injury associated with high nephrotoxic medication exposure leads to chronic kidney disease after 6 months. J Pediatr 2014;165:522-7.e2.
Can Guidelines Help Reduce the Medicalization of Early Childhood?
T
he 2011 publication of the American Academy of Pediservices, even when combined treatment approaches have atrics’ (AAP) clinical practice guidelines for the diagbeen recommended as the most effective intervention stratenosis, evaluation, and treatment of attention-deficit gies.4 Likewise, almost no ADHD care follows AAP ADHD hyperactivity disorder (ADHD) in children and adolescents consensus guideline recommendations for the collection of emphasized special circumstances and concerns in specific ratings for monitoring treatment outcomes and potential age groups.1 In particular, the guidelines stimulant medication side effects.3 The study See related article, p 1423 provided new recommendations to include by Visser et al provides valuable benchmark preschool-aged children—expanding the lower age range data prior to the 2011 AAP guidelines for monitoring future from 6 years of age to 4 years of age. In the diagnosis and national ADHD diagnostic and treatment patterns. These treatment of ADHD, the guidelines considered confounding findings also provide an opportunity to reflect, in general, factors such as value judgments, parental preferences, and on the scope and nature of behavioral problems in prebenefit-harm assessments while acknowledging that specific schoolers in modern society. cultural differences were beyond the scope of the guidelines. Many persons with severe attention deficits, impulsivity, In young children with concerning ADHD behaviors, clear and other ADHD symptoms leading to social and educaemphasis was placed on the importance of parent training tional difficulties will be helped by pharmacologic treatprograms that “must include helping parents develop agements. ADHD can be a controversial diagnosis when its appropriate developmental expectations and specific signs and symptoms are mild, or even moderate. Recent stamanagement skills for problem behaviors.” For preschool tistics indicate that most US children diagnosed with ADHD children ages 4 and 5, the action statement stressed “the prihave mild (46.7%) or moderate (39.5%) problems, similar to mary care clinician should prescribe parent and/or teacherthe parent-reports in the current study from Visser and administered behavior therapy as the first line of treatment collagues.2,5 Hence, only about 1-in-5 or 1-in-6 children (quality of evidence A/strong recommendation).” diagnosed with ADHD are considered to have severe ADHD. Leading up to these 2011 clinical practice guidelines, the These dimensions (mild, moderate, and severe) of ADHD AAP Subcommittee on ADHD must have recognized many are widely recognized as representing the underlying strucgrowing concerns about the diagnosis of ADHD in preschool ture of the disorder; but DSM (5th edition) relies on categorchildren. In this issue of The Journal, evidence for such concern ical diagnosis to motivate any type of intervention.6,7 has become apparent. Visser et al examine the 2009-2010 ChilOrthogonal to the concept of dimensionality is the concept dren with Special Health Care Needs national parentalof impairment—the extent to which symptoms are impairing reported survey data estimating the geographic prevalence of a child’s quality and progress of life. Both International ClasADHD and the general pattern of its behavioral and pharmasification of Disease and DSM diagnoses now take impaircologic treatments (alone or in combination) by state, age, dement into account, and there is evidence that evaluations mographics, and severity level.2 Their most striking finding is of impairment decrease ADHD prevalence rates.8 However, that only about one-half of the 4- to 5-year-old preschoolers impairment is a poorly operationalized concept, left largely received the recommended first-line behavioral therapy. Other to subjective clinical opinion.9 Thus, neither the acknowlrecent studies also show that the utilization of ADHD guideedgement of ADHD dimensionality nor the application of lines in US community-based pediatric practices remains the impairment criterion seem likely in the near-term to poor.3 Pediatricians use parent and teacher rating scales during address the problem of appropriate recognition and management of ADHD-type behaviors in early childhood. The ADHD assessments in only approximately one-half of their current level of use of stimulant drug treatments in the 4patients, and document Diagnostic and Statistical Manual to 5-year-old preschool population makes this an especially (DSM) criteria in only approximately two-thirds of patients. important problem to address quickly. In community-based practices, the vast majority of children with ADHD receive medication, yet few receive psychosocial
AAP ADHD DSM
American Academy of Pediatrics Attention-deficit hyperactivity disorder Diagnostic and Statistical Manual
The authors declare no conflicts of interest. 0022-3476//$ - see front matter. Copyright ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2015.03.049
1344
EDITORIALS
June 2015 An obvious route to decreasing the use of stimulants in very young children is to increase effectiveness, accessibility, and awareness of the first-line recommended treatments— behavioral interventions. Both the AAP and the United Kingdom National Institute for Clinical Care and Excellence recognize the effectiveness of parent behavior training in preschool children with behavioral problems.10,11 The United Kingdom National Institute for Clinical Care and Excellence guidelines specifically do not mention the need for diagnosis in management of child behaviors at this age. The programs of intervention are the same as those recommended for conduct disorder, and the guidelines state that only when “more help is needed” should a child be “referred to a tertiary (psychiatric) service.”11 If it is the case that ADHD diagnosis tends to trigger stimulant drug treatment, then providing families access to non-drug interventions without the requirement of a diagnosis at an early stage may reduce the use of stimulant drugs. Such a process might also ensure that only children with more severe cases go forward to diagnosis and drug treatment. Although this may be a common sense approach, behavioral interventions in ADHD are also beset by problems that need to be systematically investigated and resolved. A foundational question is to ask why health professionals are not following guidelines or evidence that opposes use of ADHD drugs among preschoolers. A related question is to ask why parents are accepting drugs to treat behaviors in very young children. Other contextual concerns must also be addressed (and may well intersect with responses to the previous 2 questions). Access to behavioral interventions is unequally distributed across geographic regions.12 Poor access intersects with other barriers to mental health services, which includes parental beliefs, ethnicity, and other factors.13,14 Part of the problem of poor access is limited access; that is, access to a very limited set of evidence-based interventions. Nevertheless, “behavioral interventions” is a broad spectrum, including parent, home, school, and camp-based programs, often focused on specific impairments and outcomes.12 Although there is some good evidence for these programs, health professionals require training in ensuring a good fit between a family and a particular behavioral intervention. One key to making behavioral and psychological interventions more accessible is the development of internet and mobile technologies-based tools. Telemedicine is reshaping the landscape of mental health service provision, but much more needs to be done both to develop innovative technologies in this area, and to ensure that interventions are safe and effective.15 Adherence to behavioral intervention programs also presents an ongoing challenge, particularly where parents themselves present with stress and psychopathology.16 In resolving the problem of adherence, the requirement for “evidence-based” interventions may itself result in a paradoxical problem: the “evidence” for a particular intervention is derived from controlled research studies, in which compliance with an intervention is usually highly valued by parents and researchers alike.17 More studies of natural-
istic intervention settings are required to understand the reasons for and value of adherence to behavioral interventions. Recent studies suggest that more precise operationalization of “adherence” will also be valuable: in citing “poor adherence” to behavioral intervention programs, many studies give statistics on the drop-out rate among parents. However, it may be that parental engagement is more predictive of good outcomes in children, at least on some dimensions, than the number of program sessions attended.18 A related, longstanding problem in studies of parenting and ADHD, is that most studies have focused on mothers rather than parents.19 Much work needs to be done to develop parent training programs that acknowledge the realities of modern families, in which fathers, same sex partners, and grandparents have taken on an increasing parenting role.20 One-size parent behavior training is unlikely to fit or appeal to all. Because of the ambiguity surrounding ADHD diagnosis, it is difficult to predict the risks of medicalization and misdiagnosis. This same ambiguity contributes to the problem of over diagnosis and overuse of ADHD medications. However, the increased emphasis on early intervention in child health and well-being presents important opportunities for ecologically oriented research with preschoolers.21 Early intervention programs for toddlers at high risk of developing ADHD are underway.22-24 Such studies enable prospective investigation of the clinical and contextual factors that mediate and moderate good outcomes in very young children with behavioral problems. These can include factors as those discussed in this editorial such as early labeling with or without diagnosis, dimensional assessment, and intervention, adherence to and acceptability of treatments.25 The opportunity to add knowledge about the risks and benefits of early intervention programs for preschoolers at risk of ADHD should not be missed. n William D. Graf, MD Departments of Pediatrics and Neurology Yale University School of Medicine New Haven, Connecticut Ilina Singh, PhD Department of Psychiatry Uehiro Center for Practical Ethics University of Oxford Oxford, England Reprint requests: William D. Graf, MD, Departments of Pediatrics and Neurology, Yale University School of Medicine, P.O. Box 208064, 333 Cedar St, New Haven, CT 06510. E-mail: [email protected]
References 1. Management Steering Committee on Quality Improvement and Subcommittee on Attention-Deficit/Hyperactivity Disorder. ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics 2011;128:1007-22. Epub October 16, 2011. 1345
THE JOURNAL OF PEDIATRICS
www.jpeds.com
2. Visser SN, Bitsko RH, Danielson ML, Gandhour R, Blumberg SJ, Schieve L, et al. Treatment of attention-deficit/hyperactivity disorder among children with special health care needs. J Pediatr 2015;166:1423-9. 3. Epstein JN, Kelleher KJ, Baum R, Brinkman WB, Peugh J, Gardner W, et al. Variability in ADHD care in community-based pediatrics. Pediatrics 2014;134:1136-43. 4. The MTA Cooperative Group, Multimodal Treatment Study of Children with ADHD. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Arch Gen Psychiatry 1999;56:1073-86. 5. Centers for Disease Control and Prevention (CDC). Increasing prevalence of parent-reported attention-deficit/hyperactivity disorder among children—United States, 2003 and 2007. MMWR Morb Mortal Wkly Rep 2010;59:1439-43. 6. Marcus DK, Barry TD. Does Attention-deficit/hyperactivity disorder have a dimensional latent structure? A taxometric analysis. J Abnorm Psychol 2011;120:427-42. 7. American Psychiatric Association. Diagnostic and statistical manual of mental health disorders: DSM-5. 5th ed. Washington, DC: American Psychiatric Publishing; 2013. 8. D€ opfner M, Breuer D, Wille N, Erhart M, Ravens-Sieberer U. How often do children meet ICD-10/DSM-IV criteria of attention deficit/hyperactivity disorder and hyperkinetic disorder? Parent-based prevalence rates in a national sample–Results of the BELLA study. Eur Child Adolesc Psychiatry 2008;17(S1):59-70. 9. Batstra L, Nieweg EH, Pijl S, Van Tol DG, Hadders-Algra M. Childhood ADHD: a stepped diagnosis approach. J Psychiatr Pract 2014;20:169-77. 10. American Academy of Pediatrics. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/ hyperactivity disorder in children and adolescents. Pediatrics 2011;128: 1007-22. 11. National Institute for Health and Clinical Excellence (NICE) Clinical Guideline 72. Attention deficit hyperactivity disorder: diagnosis and management of ADHD in children, young people and adults. NICE clinical guideline. http://guidance.nice.org.uk/CG72/NICEGuidance/pdf/ English. Accessed April 13, 2015. 12. Chronis A, Jones HA, Raggi VL. Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder. Clin Psychol Rev 2006;26:486-502. 13. Bussing R, Zima BT, Gary FA, Garvan CW. Barriers to detection, helpseeking and service use for children with ADHD symptoms. J Behav Health Serv Res 2003;30:176-89.
Vol. 166, No. 6 14. Ahmed R, McCaffery KJ, Aslani P. Factors influencing parental decision making about stimulant treatment for attention-deficit/ hyperactivity disorder. J Child Adolesc Psychopharmacol 2013;23: 163-78. 15. Meyers K, Stoep AV. Children’s telemental ADHD health treatment study (CATTS). http://depts.washington.edu/catts/zdocs/OTHER_ INFORMATION.pdf. Accessed March 5, 2015. 16. Chronis AM, Lahey BB, Pelham WE Jr, Kipp HL, Baumann BL, Lee SS. Psychopathology and substance abuse in parents of young children with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 2003;42:1424-32. 17. Power TJ, Mautone JA, Soffer SL, Clarke AT, Marshall SA, Sharman J, et al. Family-school intervention for children with ADHD: results of randomized clinical trial. J Consult Clin Psychol 2012;80:611-23. 18. Clarke AT, Marshall SA, Mautone JA, Soffer SL, Jones HA, Costigan TE, et al. Parent attendance and homework adherence predict response to a family-school intervention for children with ADHD. J Clin Child Adolesc Psychol 2015;44:58-67. Epub 2013 May 20. 19. Singh I. Boys will be boys: fathers’ perspectives on ADHD symptoms, diagnosis, and drug treatment. Harv Rev Psychiatry 2003;11: 308-16. 20. Fabiano GA, Chacko A, Pelham WE, Robb J, Walker KS, Wymbs F, et al. A comparison of behavioral parent training programs for fathers of children with attention-deficit/hyperactivity disorder. Behav Ther 2009;40: 190-204. 21. Garner AS, Shonkoff JP, Siegel BS, Dobbins MI, Earls MF, McGuinn L, et al. Early childhood adversity, toxic stress and the role of the pediatrician: translating developmental science into lifelong health. Pediatrics 2011;129:e224-31. 22. Zwi M, Jones H, Thorgaard C, York A, Dennis JA. Parent training interventions for attention deficit hyperactivity disorder (ADHD) in children aged 5 to 18 years. Cochrane Database Syst Rev 2011;7: CD003018. 23. DuPaul GJ, Young KL. Young children with ADHD: Early identification and intervention. Washington, D.C: American Psychological Association; 2011. 24. Jones K, Daley D, Hutchings J, Bywater T, Eames C. Efficacy of the incredible years programme as an early intervention for children with conduct problems and ADHD: long-term follow-up. Child Care Health Dev 2011;34:380-90. 25. Singh I, Wessely S. Childhood: a suitable case for treatment? Lancet Psychiatry 2015 (in press).
Liver or Combined Liver-Kidney Transplantation for Patients with Isolated Methylmalonic Acidemia: Who and When?
T
he hereditary disorders of vitamin B12 (cobalamin) and mens remain ill-defined. In many patients, severe symptoms methylmalonic acid metabolism comprise a major persist despite conventional medical and nutritional therapy, group of organic acid disorders that are collectively comwhich stands in contrast to the recent practices adopted in mon inborn errors of metabolism.1 Affected patients are medithe US and other countries to screen all newborns for a large number of metabolic diseases including MMA.3 cally fragile and suffer multisystemic complications, such as lethal metabolic instability, metabolic stroke, Isolated methylmalonic acidemia See related article, p 1455 pancreatitis, end-stage renal failure, growth (MMA) has 3 major distinct genetic etiolimpairment, osteopenia, optic nerve atrophy, and neurocogniogies related to the activity of the 50 deoxyadeno-sylcobala2 tive delay. The frequency of these complications and their min-dependent enzyme methylmalonyl-CoA mutase precipitants, long-term sequelae, and optimal treatment regi-
LKT MMA MUT
Liver-kidney transplantation Methylmalonic acidemia Methylmalonyl-CoA mutase
Supported by the Intramural Research Program of the National Human Genome Research Institute, National Institutes of Health. The authors declare no conflicts of interest. 0022-3476//$ - see front matter. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jpeds.2015.03.026
1346