- Email: [email protected]
EPIDEMIOLOGY AND HEALTH CARE REFORM
LETTERS TO THE EDITOR ultrasensitive TSH than to obtain an endocrinology consult? The last question is pertinent because small goiters or nodules can be missed by psychiatrists or primary care physicians not experienced in palpating the thyroid. In conclusion, we suggest that guidelines for thyroid function studies in ADHD be developed. Vinod S. Bhatara, M.D., M.S. Mark Kummer, M.D. J. Michael McMillin, M.D. Francis Bandettini, D.O. University of South Dakota Sioux Falls, SD Cromer BA, McLean CS, Heald FP (1992), Acritical review ofcomprehensive health screening in adolescents: thyroid disease. 1 Adolesc Health 13:125-135
Elia J, Gulotta C, Rose SR, Marin G, Rapoport JL (1994), Thyroid function and attention-deficit hyperactivity disorder. j Am Acad Child Adolesc Psychiatry 33:169-172
Spencer T, Biederman J, Wilens T, Guite J (1993), Attention-deficit hyperactivity disorder and thyroid abnormalities. In: Scientific Proceedings, 40th Annual Meeting of the American Academy of Child and Adolescent Psychiatry, San Antonio, TX, October 26-31, Vol IX, p. 42
Surkis MI, Chopra IJ, Mariash CN, Nicoloff JT, Solomon DH (1990), American thyroid association guidelines for use of laboratoty tests in thyroid disorders. lAMA 264:1529-1532 Weiss RE, Stein MA, Trommer B, Refetoff 5 (1993), Attention deficit hyperactivity disorder and thyroid function. 1 Pediatr 123:539-545
Drs. Rapoport and Elia reply: Our paper provided the first in what will, undoubtedly, be a large series of reports on the prevalence of thyroid disturbances among hyperactive children. The available data indicate that the rate mayor may not be slightly increased, but in any event, that thyroid evaluation in unselected series is unlikely to become recommended practice. The letters from Dr. Preuss and from Dr. Bhatara and colleagues point up the need for guidance about clinical evaluation of hyperactive children for the practitioner, even with incomplete population data. Dr. Preuss is correct in her reading of the abstract in our article that, based on our own data, we do not see a need for routine measurement of thyroid function in nonfamilial ADHD. The last sentence in our paper, however, was intended as an unrelated point. It suggests that ADHD symptoms may be secondary to any hyperthyroid condition and not necessarily specific to GRTH or they may be a complication of thyroid hormone replacement. In both cases, however, the onset of ADHD symptoms occurs simultaneously with onset of illness or treatment can be attributed to such. Dr. Bhatara and colleagues cogently discuss what would be reasonable guidelines based on available data. Their
1058
conclusions, that goiter and/or falling growth velocity are indications, seem entirely sensible and their point about the cost-effectiveness to laboratory screening is important. Judith 1. Rapoport, M.D. National Institute of Mental Health Bethesda, MD Josephine Elia, M.D. The Medical College of Pennsylvania Philadelphia, PA
EPIDEMIOLOGY AND HEALTH CARE REFORM
To the Editor: In the year since our paper on epidemiology and children's mental health services was published in the Journal (Costello et al., 1993), health care reform has become a serious possibility. The events of recent months heighten the urgency for developing a carefully considered research agenda that will advance the interests of children with mental disorders. Data about the effectiveness of alternative treatments, and factors that affect the use, cost, and outcomes of care are urgently needed. The debate about expanding the coverage for mental health services relied on cost and benefits data that the government actuaries considered to be incomplete and insufficiently detailed. The Clinton administration recognizes that there are many children and adolescents who suffer with psychiatric disorders. However, the lack of convincing data resulted in proposals for very limited coverage for child mental health services. Pressures on service delivery systems for child mental health are likely to be as fierce, or even fiercer, in the future. Without accurate information about the need for, availability of, and effectiveness ofservices and systems, there is a risk that the type and extent of services for children with psychiatric disorders will be dictated by other than clinical concerns. We are glad that the Journal published our paper and invited a distinguished group of respondents to contribute to the discussion of these issues. We hope that the discussion will continue, in your pages and elsewhere. We would like to clarify the sense in which we use the term epidemiology in our paper: The general aims of epidemiologic research are to (1) describe the health status of populations ... ; (2) explain the etiologyof diseases by determining factors that "cause" specific diseases or trends and by discovering modes of transmission; (3) predict the number of disease occurrences and the distribution of health status within populations; and (4) control the distributions of disease by prevention of new occurrences, eradicationof existingcases, prolongation of life with the disease, or otherwise improving the health status of affiicted persons (Kleinbaum et al., 1982, p. 21). The modern epidemiology of chronic diseases, on which
]. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 33:7, SEPTEMBER 1994
LETTERS TO THE EDITOR
psychiatric epidemiology has begun to model itself in recent years, is at least as concerned with explanation, prediction, and control of disease as it is in the description of who has what. Thus, contemporary epidemiology tends to begin by developing ideas about risk factors, identifying high-risk groups, and using prospective research designs to test causal hypotheses. We invoked the Framingham heart study as an example of a risk-factor based research program that has had a tremendous impact on a major public health problem using such an approach; another example is Richard Doll's 20-year longitudinal study of British doctors' smoking habits that clarified the link between smoking and lung cancer (Doll and Peto, 1976). Given this approach to epidemiological research, our point was that further work needs to be done by the research community to prepare the full spectrum of instruments to assess all the areas listed in our paper under the heading "Areas Needed as Parts of a Research Program in Developmental Epidemiology." Good assessment in these areas is as important as strong diagnostic data for the purpose of assessing the need for and effectiveness of services. The first two discussants, Dr. Shaffer and Dr. Dulcan, took as the focus of their discussion the section of our paper reviewing the extent to which the MECA project was likely to provide the instrumentation and research agenda needed for a major research initiative on mental health services for children and adolescents. Rather than take up the Journal's space with responses to each point in turn, we have addressed them in detail in a letter to our discussants. Additional data substantiating the points in the paper can be found in that letter. We shall be happy to send a copy to any of your readers who are interested. Two general points are worth emphasizing again here: The Diagnostic Interview Schedule for Children (DISC) has gone through a considerable amount of development work in the past decade. Of the various stages necessary for instrument development (Zeller and Carmines, 1977), the DISC has gone through four: (1) composing the measure, (2) testing it for consistency in the hands of different interviewers (test-retest reliability), (3) evaluating its ability to assess the construct in question (validity), and (4) revising it in the light of these findings and resubmitting it to the same series of tests. A fifth phase, testing cultural equivalence, involves using focus groups to evaluate the meaning of each item and concept used from the point of view of the other ethnic or social group or groups. The Service Utilization and Risk Factors (SURF) instrument has reached stage 1, and in some areas stage 2. Our point was that in order to have ready all the instrumentation needed to carry out a national initiative on child mental health service needs, a great deal of work is still needed. Our other point about the process of preparation for a new research initiative underlined the need for, and lack of,
J.
"public theoretical or conceptual discourse" (Costello et al., 1993, p. 1110, emphasis added). We are delighted that the MECA group have been discussing these issues, and look forward to seeing their thoughts and recommendations in print in the near future. Indeed, as Dr. Shaffer and Dr. Dulcan indicated in their responses, one of us (P.J.L.) participated actively in these discussions. A major reason for our paper was to encourage such public discourse at a time when important policy decisions affecting children's mental health services are likely to be made on the basis of economic pressures rather than scientific data. We are particularly pleased that Dr. Offord took our rough outline of a research program a step further, by drawing up a five-stage plan for involving the field in identifying the major scientific and policy questions, determining the appropriate research strategies, critically evaluating our current state of knowledge, and developing a research agenda. We agree with him that there is probably "widespread consensus on the answers to the steps posed" (Offord, 1993, p. 1117), and we enthusiastically endorse his suggestions. This is the kind of discussion of the issues that is necessary if child psychiatry is going to develop a research agenda that results in expansion and improvement of services. E. Jane Costello Barbara J. Burns Adrian Angold Duke University, Durham, NC Philip J. Leaf Johns Hopkins University, Baltimore, MD Costello E], Burns B], Angold A, Leaf P] (1993), How can epidemiology improve mental health servicesfor children and adolescents?JAm Acad Child Adolesc Psychiatry 32: 1106-1113 Doll R, Pero R (1976), Mortality in relation to smoking: 20 years' observations on male British doctors. British Medical Journal ii:I 525-2536 Kleinbaum DG, Kupper LL, Morganstern H (1982), Epidemiologic Research: Principles and Quantitative Methods. New York: Van Nostrand Reinhold Offord 0] (1993), Discussion of "How can epidemiology improve mental health services for children and adolescents?" JAm Acad ChildAdolesc Psychiatry 32:11 16-11 17 Zeller RA, Carmines EG (1977), Measurement in the Social Sciences: The Link between Theory and Data. New York: Cambridge University Press
Note: Drs. Shaffer, Dulcan, and Offord did not feel a reply was indicated. FjL'\l ALCOHOL
EF~
AND ADHD
To the Editor: Is FAE a subtype of ADHD? This letter is written in the context of running a child psychiatric clinic for the last one and a half years with FAS/ FAE children.
AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 33:7, SEPTEMBER 1994
1059
Elia J, Gulotta C, Rose SR, Marin G, Rapoport JL (1994), Thyroid function and attention-deficit hyperactivity disorder. j Am Acad Child Adolesc Psychiatry 33:169-172
Spencer T, Biederman J, Wilens T, Guite J (1993), Attention-deficit hyperactivity disorder and thyroid abnormalities. In: Scientific Proceedings, 40th Annual Meeting of the American Academy of Child and Adolescent Psychiatry, San Antonio, TX, October 26-31, Vol IX, p. 42
Surkis MI, Chopra IJ, Mariash CN, Nicoloff JT, Solomon DH (1990), American thyroid association guidelines for use of laboratoty tests in thyroid disorders. lAMA 264:1529-1532 Weiss RE, Stein MA, Trommer B, Refetoff 5 (1993), Attention deficit hyperactivity disorder and thyroid function. 1 Pediatr 123:539-545
Drs. Rapoport and Elia reply: Our paper provided the first in what will, undoubtedly, be a large series of reports on the prevalence of thyroid disturbances among hyperactive children. The available data indicate that the rate mayor may not be slightly increased, but in any event, that thyroid evaluation in unselected series is unlikely to become recommended practice. The letters from Dr. Preuss and from Dr. Bhatara and colleagues point up the need for guidance about clinical evaluation of hyperactive children for the practitioner, even with incomplete population data. Dr. Preuss is correct in her reading of the abstract in our article that, based on our own data, we do not see a need for routine measurement of thyroid function in nonfamilial ADHD. The last sentence in our paper, however, was intended as an unrelated point. It suggests that ADHD symptoms may be secondary to any hyperthyroid condition and not necessarily specific to GRTH or they may be a complication of thyroid hormone replacement. In both cases, however, the onset of ADHD symptoms occurs simultaneously with onset of illness or treatment can be attributed to such. Dr. Bhatara and colleagues cogently discuss what would be reasonable guidelines based on available data. Their
1058
conclusions, that goiter and/or falling growth velocity are indications, seem entirely sensible and their point about the cost-effectiveness to laboratory screening is important. Judith 1. Rapoport, M.D. National Institute of Mental Health Bethesda, MD Josephine Elia, M.D. The Medical College of Pennsylvania Philadelphia, PA
EPIDEMIOLOGY AND HEALTH CARE REFORM
To the Editor: In the year since our paper on epidemiology and children's mental health services was published in the Journal (Costello et al., 1993), health care reform has become a serious possibility. The events of recent months heighten the urgency for developing a carefully considered research agenda that will advance the interests of children with mental disorders. Data about the effectiveness of alternative treatments, and factors that affect the use, cost, and outcomes of care are urgently needed. The debate about expanding the coverage for mental health services relied on cost and benefits data that the government actuaries considered to be incomplete and insufficiently detailed. The Clinton administration recognizes that there are many children and adolescents who suffer with psychiatric disorders. However, the lack of convincing data resulted in proposals for very limited coverage for child mental health services. Pressures on service delivery systems for child mental health are likely to be as fierce, or even fiercer, in the future. Without accurate information about the need for, availability of, and effectiveness ofservices and systems, there is a risk that the type and extent of services for children with psychiatric disorders will be dictated by other than clinical concerns. We are glad that the Journal published our paper and invited a distinguished group of respondents to contribute to the discussion of these issues. We hope that the discussion will continue, in your pages and elsewhere. We would like to clarify the sense in which we use the term epidemiology in our paper: The general aims of epidemiologic research are to (1) describe the health status of populations ... ; (2) explain the etiologyof diseases by determining factors that "cause" specific diseases or trends and by discovering modes of transmission; (3) predict the number of disease occurrences and the distribution of health status within populations; and (4) control the distributions of disease by prevention of new occurrences, eradicationof existingcases, prolongation of life with the disease, or otherwise improving the health status of affiicted persons (Kleinbaum et al., 1982, p. 21). The modern epidemiology of chronic diseases, on which
]. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 33:7, SEPTEMBER 1994
LETTERS TO THE EDITOR
psychiatric epidemiology has begun to model itself in recent years, is at least as concerned with explanation, prediction, and control of disease as it is in the description of who has what. Thus, contemporary epidemiology tends to begin by developing ideas about risk factors, identifying high-risk groups, and using prospective research designs to test causal hypotheses. We invoked the Framingham heart study as an example of a risk-factor based research program that has had a tremendous impact on a major public health problem using such an approach; another example is Richard Doll's 20-year longitudinal study of British doctors' smoking habits that clarified the link between smoking and lung cancer (Doll and Peto, 1976). Given this approach to epidemiological research, our point was that further work needs to be done by the research community to prepare the full spectrum of instruments to assess all the areas listed in our paper under the heading "Areas Needed as Parts of a Research Program in Developmental Epidemiology." Good assessment in these areas is as important as strong diagnostic data for the purpose of assessing the need for and effectiveness of services. The first two discussants, Dr. Shaffer and Dr. Dulcan, took as the focus of their discussion the section of our paper reviewing the extent to which the MECA project was likely to provide the instrumentation and research agenda needed for a major research initiative on mental health services for children and adolescents. Rather than take up the Journal's space with responses to each point in turn, we have addressed them in detail in a letter to our discussants. Additional data substantiating the points in the paper can be found in that letter. We shall be happy to send a copy to any of your readers who are interested. Two general points are worth emphasizing again here: The Diagnostic Interview Schedule for Children (DISC) has gone through a considerable amount of development work in the past decade. Of the various stages necessary for instrument development (Zeller and Carmines, 1977), the DISC has gone through four: (1) composing the measure, (2) testing it for consistency in the hands of different interviewers (test-retest reliability), (3) evaluating its ability to assess the construct in question (validity), and (4) revising it in the light of these findings and resubmitting it to the same series of tests. A fifth phase, testing cultural equivalence, involves using focus groups to evaluate the meaning of each item and concept used from the point of view of the other ethnic or social group or groups. The Service Utilization and Risk Factors (SURF) instrument has reached stage 1, and in some areas stage 2. Our point was that in order to have ready all the instrumentation needed to carry out a national initiative on child mental health service needs, a great deal of work is still needed. Our other point about the process of preparation for a new research initiative underlined the need for, and lack of,
J.
"public theoretical or conceptual discourse" (Costello et al., 1993, p. 1110, emphasis added). We are delighted that the MECA group have been discussing these issues, and look forward to seeing their thoughts and recommendations in print in the near future. Indeed, as Dr. Shaffer and Dr. Dulcan indicated in their responses, one of us (P.J.L.) participated actively in these discussions. A major reason for our paper was to encourage such public discourse at a time when important policy decisions affecting children's mental health services are likely to be made on the basis of economic pressures rather than scientific data. We are particularly pleased that Dr. Offord took our rough outline of a research program a step further, by drawing up a five-stage plan for involving the field in identifying the major scientific and policy questions, determining the appropriate research strategies, critically evaluating our current state of knowledge, and developing a research agenda. We agree with him that there is probably "widespread consensus on the answers to the steps posed" (Offord, 1993, p. 1117), and we enthusiastically endorse his suggestions. This is the kind of discussion of the issues that is necessary if child psychiatry is going to develop a research agenda that results in expansion and improvement of services. E. Jane Costello Barbara J. Burns Adrian Angold Duke University, Durham, NC Philip J. Leaf Johns Hopkins University, Baltimore, MD Costello E], Burns B], Angold A, Leaf P] (1993), How can epidemiology improve mental health servicesfor children and adolescents?JAm Acad Child Adolesc Psychiatry 32: 1106-1113 Doll R, Pero R (1976), Mortality in relation to smoking: 20 years' observations on male British doctors. British Medical Journal ii:I 525-2536 Kleinbaum DG, Kupper LL, Morganstern H (1982), Epidemiologic Research: Principles and Quantitative Methods. New York: Van Nostrand Reinhold Offord 0] (1993), Discussion of "How can epidemiology improve mental health services for children and adolescents?" JAm Acad ChildAdolesc Psychiatry 32:11 16-11 17 Zeller RA, Carmines EG (1977), Measurement in the Social Sciences: The Link between Theory and Data. New York: Cambridge University Press
Note: Drs. Shaffer, Dulcan, and Offord did not feel a reply was indicated. FjL'\l ALCOHOL
EF~
AND ADHD
To the Editor: Is FAE a subtype of ADHD? This letter is written in the context of running a child psychiatric clinic for the last one and a half years with FAS/ FAE children.
AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 33:7, SEPTEMBER 1994
1059