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Why Is ADHD On The Rise?-My Opinions

25 Apr

rising-graphThere have been a few studies and reports highlighting the rise of the diagnosis of ADHD in our children…

Here’s one of the more popular ones from the NYTimes if you haven’t seen one yet:

A.D.H.D. Seen in 11% of U.S. Children as Diagnoses Rise

Historic estimates have put the incidence at 3-7% just to give you an idea of what 11% means.

So, I expect if you’ve read this far, you are expecting my opinion of why this is…Remember that this is my opinion from a few years of pediatric practice and counseling many families on the the diagnosis (or not) and treatment of ADHD.

I think there are multiple factors but I will handle them in categories…

Doctors

Doctors have become more and more comfortable prescribing stimulant medications for ADHD.  There is a quote in the article above where a doctor states that he used to tell his families that the stimulant medicines are “safer than aspirin.”  Because of this, I believe doctors will be a bit lax in their requirements that children actually meet criteria for ADHD.

Couple this together with a developing medical marketplace that favors competition and convenience as well as online ratings, etc and it makes standing up against a families demands more difficult.  I’m definitely not saying that this is the right thing to do but you can certainly see how a doctor is put in a difficult place.

It is important as physicians that we consider the information carefully and evaluate the child in front of us based on appropriate criteria.  Treatment decisions should be made based on this information and not based on the pressure from the family.

Parents

I have to remind my families in diagnostic consultations and follow up appointments to evaluate treatment that talking back, aggression and “being bad” are not the core symptoms of ADHD.  It is not uncommon for me to be sitting with parents who tell me that I need to “fix this kid.”  Well, unfortunately, there isn’t a medicine that can fix a child.

ADHD can be managed but many of the behaviors that parents want fixed need to be addressed with counseling and parenting skills.  I commonly refer the children of this type of parents for counseling because they need it but also because my counselors will help the parents come up with more effective parenting techniques.

Because of the growing awareness of ADHD, parents are more pushy about getting their children diagnosed and treatment started and I believe that this increases the incidence of ADHD.

Society

In some arenas, there is a still a small stigma associated with having ADHD.  This is sad and I wish it weren’t true.  But, in reality, this has significantly decreased even in the past couple of years.

It used to be common for parents to give their children “vitamins” each morning that were actually stimulants to keep from having to explain to their children about the diagnosis.  Things are different now and I almost feel like it’s to the point that ADHD is a trendy diagnosis.  I have teenagers that come in wanting to be diagnosed and start treatment and you can almost feel they are there because “everybody else is doing it.”

While I’m proud that any mental illness carries less stigma than it did in the past, it does create a problem when ADHD becomes so commonplace that it’s almost “cool” to have it.

Schools

Schools are different now than even 20 years ago when I was in junior high and elementary school.  We didn’t start phonics until 1st grade, most kindergardeners finish reading now.  Early school used to be about centers and getting up and moving around but now it has become much more about sitting still for lectures and worksheets.

Don’t get me wrong…I’m not saying that individual schools or teachers are to blame.  Many of our teachers feel tied to doing things a certain way in order to prepare their students for standardized tests, etc.  School ratings are dependent upon performance on these tests as well.

However, because of this culture, there is little flexibility for the little boy who is smart but is bouncing around the room like a bouncy ball. I hope no one takes this the wrong way, I’m not blaming schools.  This is simply just the way it is.  The requirements for sitting still and paying attention for longer periods have changed and have gotten younger and younger.

So, as you can see, I have lots of opinions about what might be contributing to the increase in ADHD diagnoses.

Is there anything to do about all this?  Probably not.  We just need to be aware of what’s going on and make sure that diagnoses are appropriately made based on the child’s symptoms and not the result of some outside pressure or trend.

Here is the full table of contents for the ADHD Series:

ADHD-What is it?

ADHD Behavioral Treatment-8 Tips

ADHD-Medical Management Concepts

ADHD-Medication Types and My Thoughts

Preschool Child with ADHD Symptoms

Why Is ADHD On The Rise?-My Opinions

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Shot Promises

31 Mar

There’s two promises I want my parents to stop making to my patients about shots…

#1) You’re not getting any shots today.  Sometimes this one is necessary just to get the kid in the office and I can understand that but be careful because you never know when you might be wrong.  Nothing is worse than having told your kid that they don’t need a shot only to discover that they had missed one along the way or we got flu shots in early that year.  Kids don’t do well with surprises and they don’t forget promises that you’ve made them.  Sometimes they need shots when they are sick even when you weren’t expecting it.  

I don’t like making medical decisions or having pressure on me to avoid a shot because children were told they wouldn’t get one that day.  If a child is in front of me, due for an immunization and there is no contraindication, I prefer to give the vaccine.  Or, if a child is sick and would significantly benefit from a shot; why take a chance with a less aggressive approach.  Of course, I always consider the family’s wishes but prefer not to make decisions because a child wasn’t expecting a shot that day.

#2) “If you don’t behave (or eat  your veggies, or whatever else), Dr Smith is going to give you a shot.”  Actually, no, I’m not.  Merck has yet to develop the “listen to your mother” shot and I’m pretty sure it’s not in development either.  

I really view the shots I give in the office as protective procedures and consider providing vaccines one of the most caring things I can do in the office.  When my nurse is giving shots to my own kids and I’m holding them down I tell her thanks for helping to protect them from all those yucky germs running around out there.

Because of the way I view vaccines, I don’t like to hear them used as threats.  So please don’t….

The Computer Distraction-A Question for My Patients

22 Feb

This is a post that is really more than a question for patients than anything else…

It was inspired by a NYTimes article about physician’s being distracted by their computers and smart phones…You can find this article here.

Does my laptop annoy you?

Do you see it as a distraction or a necessary part of the practice of medicine?

One of the things that we stressed over when we went to electronic medical records was how the presence of the computer in the room with us would affect our ability to connect with our patients.

I take my computer everywhere and work while I am talking to my patients but I try to be skillful about continuing to pay close attention to make eye contact more than looking at the computer screen.

I’d love to hear your thoughts on this…

My Questions for Urgent Care Clinics

27 Jan

I see a strong trend towards my families moving towards using walk-in/urgent/retail care clinics for their ill care.  We do our best to keep ill visits open for the same day although this time of year it does get a little more difficult given the overwhelming demand.  

So, I can’t say that I completely blame our patients when they do use the urgent care facilities but it still eats at me, especially when they use them during our normal business hours assuming they’ll get in and out “faster.”  We don’t have evening hours at this point so I can’t really blame my patients for using the clinics in the evenings.  I really feel that most of these visits could wait till the next day but I also understand that this isn’t necessarily keeping up with what the market desires at this point.

However, I do have a few questions that I think need to be answered by the walk-in care clinics so that patients still get good care.  We have a few practitioners in our town who do a great job and I feel our patients receive good care but issues still present themselves:

What do we do about continuity/communication?

I commonly have this conversation in my office…

Me: Well, he’s got an ear infection and since he hasn’t been on antibiotics for a year (judging by his medical record), I would recommend that we use amoxicillin.

Mom: Yeah, except he was on amoxicillin last month for an upper respiratory infection and then they changed him to some other antibiotic cause he wasn’t getting better, I think it started with a C or maybe it was a K.  I think it was either once or twice a day.  I’m not really sure.

Me: That’s ok…I have 30 minutes for you to wait in my room while I try to get those records faxed over to see what the heck is going on (sarcasm of course, and not really said)

I’ve thought about the ways I would like for this to go down better.  The only way I can figure it out is to have notes faxed to the PCPs for everyone that is in the walk-in clinic the morning after.  I think if I were designing a clinic that is how I would do it.  In the age of EMRs I don’t think that would be too difficult.  If you are a walk-in clinic that does this or somehow communicates with PCPs I commend you because when I need the records and they aren’t there it is difficulty.

What do you do about your incentives?

The incentives for providing care in a walk-in clinic are very different than what I see as my incentives.  I have a relationship with my patients such that I don’t feel pressure to do what they are asking of me.  I’ve never worked in one before but I would imagine there is a huge motivation to do what the patient is asking because you need to motivate them to come back to you.  I would hope that good doctors/NP/PAs would be staffing these clinics such that this would not be a big issue but I do commonly see things that make me wonder: antibiotics for UTIs with normal U/As, antibiotics for “strep throat” with a negative screen and a cbc, u/a, rsv, flu screen done on a 12 year old with fever to 103, body aches and an exposure history for flu in the past week…

Again for those of you out there doing this right….ignore me.  But I can’ imagine what it’s like to be trying to please people who are walking in and end up not needing any specific treatment.  I would love to hear from some who have worked in an urgent care clinic for their thoughts on this.

What do you do when you can’t provide definitive care?

 I got a phone call this week on about a child who was in a walk-in care clinic with strep throat and severe dehydration.  Fortunately, I knew the NP well who was calling me and we were able to work it out so that they patient could swing by my office on their way up to the pediatric floor for admission.  Also fortunately, the family was very nice and understanding.  But, can you imagine if they hadn’t been?  Here they have waited 3 hours (per the mom) at the urgent care clinic to then be told that they could provide the care that they needed and they were going to have to go wait again in the pediatrician’s office to be seen prior to getting any definitive treatment…My understanding is that commonly in the evenings, our local walk-in clinics send patients to the ER when they cannot provide the care that is needed.  Maybe this isn’t true, I hope it isn’t.  I would propose that it would be better for the walk-in clinics to have some arrangement whereby they can arrange for admissions with providers etc when they feel it is necessary rather than have the family start over again.  Or, if the patient has a PCP that they would call them to discuss the case with them.

Again, these are just some thoughts I had about urgent care and the issues I see beginning to present themselves.  I don’t see this as a trend that is going to come and go so i’m hoping that I can find a better way to interact with our urgent care clinics in a way that benefits my patients in the end.  Any thoughts would be appreciated?

Social Media Mommy Guilt

9 Jan

Screen Shot 2013-04-08 at 11.28.14 PM

“I wanted to make my own baby food, but I just couldn’t find the time.”

“Breastfeeding was just really hard and my milk supply never came in.  Will my baby be OK?”

“The cloth diapers were just too much trouble.  I just couldn’t keep enough clean.”

These are all statements that were made to me in clinic over the last few weeks by moms with dejected, self-dissapointed looks on their faces.  There are so many places to get advice about raising your children today: books, websites, your friends/family, and now my blog (I guess I just thought I should add another), the message can get really messy.

I just want to send a message out to my readers that says, “You are doing great.”

If you read your friends’ Facebook pages, Twitter feeds and pins on Pinterest, you would be led to believe that they prepare great meals, create home-made projects, do awesome daily “school time” with their toddler, their house is always in perfect order and all the while are able to blog and make elaborate instructions for all of these activities on their Pinterest boards.

They don’t post the fact that their house was actually a wreck until just minutes before they picked up to take the pictures, their husband had to pick up dinner because they had two kids puking (and the other in time out) when they were trying to make dinner, just before (or in the middle of school time) there was a huge screaming match that ended with 10 total time out minutes and 3 spankings, the 1st four tries (of 4 hours each) of their craft were complete failures and their kids watched Toy Story twice back-to-back so they could blog about everything they did together that day…

OK, a little sarcasm and I don’t mean to only poke fun at my blogging moms and I know there are moms who post and blog in their spare time after their kids are in bed (dads too) but I want to caution you that you shouldn’t compare your every day life with what you see on your social media sites.  If you do, you are comparing yourself with the best that everyone else has to offer with your own messy junk.  This is not a fair comparison and only a cause for guilt and depression.

I recommend that you pick the things that are important to you and focus on doing them well. Don’t stress about what it appears like everyone else is doing.  Do your best.  That’s all your kids are asking for.

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