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School-Related Medical Issues 2011

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John L. Digges, MD, PhD, MPH, FAAP
(Fellow of the American Academy of Pediatrics)
Behavioral Pediatrician

Dr. Digges practiced general and behavioral pediatrics in Oklahoma and California for 14 years. For ten of the past 12 years, he has served as the Forensic (Child Abuse) Pediatrician for Kern County, California; and he has had a private practice limited to ADHD consultations for the past 12 years. He has been a CME surveyor for the Institute of Medical Quality (CMA) since 2000, and is a recent past-President of the Kern County Medical Society. Dr. Digges has been at the DCN since August, 2008.

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  • I have heard conflicting information about the whooping cough vaccine. What are the current recommendations concerning this vaccine, both for students and for faculty and staff?

Question:

I have heard conflicting information about the whooping cough vaccine. What are the current recommendations concerning this vaccine, both for students and for faculty and staff?

Marissa Teague,
Middle School Principal, Sacramento, CA


Answer:

Pertussis or “whooping cough” is the disease caused by the organism Bordatella pertussis, which can cause weeks of significant coughing in children and adults, but can be fatal to infants. The most recently developed formulation is called Tdap, which stands for Tetanus toxoid, reduced-content diphtheria toxoid, and acellular pertussis.

Pertussis represents the gravest threat to infants, especially those less than 4 months of age. This population has historically been unimmunized, since the first dose is administered at 6-8 weeks and primes the pump immunologically. It is the subsequent doses which actually prompt a significant antibody response.

The recommended immunization series consists of DTaP (Diphtheria, Tetanus and acellular Pertussis) given at 2, 4, 6, and 15-18 months and from 4-6 years of age. It is now recommended that children from ages 7-10 years who have not had the complete series or whose immunization history is incomplete be given a single dose of Tdap. Older children are recommended to receive a Tdap booster from 11-12 years of age.

Regrettably, an outbreak of pertussis in California in 2010 resulted in 11 deaths in infants and produced significant illness in 9100 individuals > 1 year of age. Since most of the reported cases occurred in fully immunized children from 8-12 years of age, this research suggests that a booster dose is probably needed to protect children from 8-12 years of age.

Protecting against whooping cough has two main goals: prevent illness in the immunized individual and reduce the reservoir of pathogenic organisms to prevent illness in the most vulnerable populations. Even in healthy older children and adults, whooping cough can make people feel miserable for 2-3 months. Until treated appropriately with antibiotics, infected individuals who are coughing have the potential to spread pertussis to others via droplet transmission.

Recently, it has been recommended that individuals >10 years of age who are likely to be exposed to infants receive the Tdap vaccine. As reported in a recent MMWR (Morbidity and Mortality Weekly Report) issue, the FDA has extended the age indication for the Boostrix vaccine to 10 years of age and older. This suggests that all teachers and staff who are likely to have contact with infants, who do not wish to experience pertussis themselves; or who do not wish to expose non-infants to a serious illness, should discuss the Tdap vaccine with their health care provider and receive the vaccine if it is deemed to be indicated for them.

Another new development in pertussis vaccination practice has to do with pregnant women. Some experts are recommending giving the Tdap vaccine to mothers (who have not previously received it) during the pregnancy instead of after the pregnancy. The rationale is that the antibodies produced by the mother will protect the mother from pertussis and should transfer some passive immunity to the infant, thereby reducing their susceptibility to a fatal outcome from contracting pertussis in early infancy.

I hope this is helpful.

John L. Digges, MD, PhD, MPH, FAAP
Diagnostic Center North, Fremont CA


  • Are there any specific recommendations you would make in regards to working with a child with Tourette that would be different than for a child with ADHD?

This question overlaps School Related Medical Issues and Mental Health, so this response is from the DCN behavioral pediatrician and clinical psychologist.

Question:

I am a speech therapist in the Oakland school district. And I have a kindergarten student whose father has Tourette Syndrome.  My student has pretty significant articulation and expressive language delays, and also has a hard time focusing on one task long enough to see it through to completion. I have seen other children with more severe deficits and therefore am reluctant to say he has ADHD.  I am wondering what I should be looking for and when to become concerned that he has inherited the disorder.  I have not noticed any “tics” per se.  Also, are there any specific recommendations you would make in regards to working with a child with Tourette that would be different than for a child with ADHD?


Answer:

It appears that your student has delays in expressive language and articulation difficulties; and that you are concerned that he may have other, possibly inherited, conditions.  In the event that he has made minimal progress in meeting his language goals in the classroom, you might be understandably worried that his limited progress may be due in part to his having possibly inherited Tourette syndrome (TS),  attention-deficit/hyperactivity disorder (ADHD), or both from his father.  Although these are reasonable possibilities to consider, a comprehensive evaluation will be needed to accurately determine his diagnoses. Once he has been thoroughly evaluated and diagnoses have been established, then we would be in a better position to advise you about specific symptoms to watch for and particular strategies which have been effective in the past for students having the same diagnoses.

Genetic factors appear to play a significant role in the transmission of both TS and ADHD. Although only about 7% of the children diagnosed with ADHD will also meet the diagnostic criteria for TS, somewhere between 60-90% of the individuals who have TS will meet the diagnostic criteria for ADHD.  If your student’s father indeed has TS, then it is quite possible that he meets the diagnostic criteria for ADHD as well. If so, his son has an increased probability, relative to the general population, of having TS (inheritable), ADHD (inheritable), or both conditions simultaneously.

Tourette’s Syndrome

In order to be diagnosed with TS, there must have been multiple motor tics along with at least one vocal tic occurring several times nearly every day for more than one year. The onset of the tics must have occurred prior to 18 years of age, there can never have been a “tic-free” period of 3 months or longer, and the individual cannot be taking a medication or have another medical condition which could better account for the tics.

Tics are sudden, purposeless, involuntary muscle movements or vocal sounds. Some common motor tics include head jerking, twitching, squinting or grimacing. Common vocal tics include tongue-clicking, throat clearing, yelping, or whistling. These movements and sounds are not dangerous or harmful, but are often embarrassing. Tics usually show up during childhood or early adolescence, most commonly around 5-7 years of age and occur more frequently in males than in females. Transient tic disorder of childhood (a period of time with occasional tics) is not uncommon and is not the same thing as TS. 

ADHD


When a student’s excessive distractibility, inattentiveness, impulsivity and hyperactivity seem to interfere significantly with their success in school, this student might very well meet the diagnostic criteria for ADHD (see DSM IV TR). If you have such concerns, then it is reasonable to communicate your concerns to the child’s parents. You might explain that you have observed that he appears to be struggling and is not performing at the level you feel he may be capable of performing. You might suggest that this is not due to lack of motivation or effort and suggest that there could indeed be a neurobiological condition which is responsible for the gap you perceive between their child’s potential and productivity. The parents might then consider referral to a clinician who is knowledgeable about and experienced in diagnosing children with such symptoms.

Obtaining Accurate Diagnoses

The first step for the clinician typically involves obtaining a thorough history, including records from the school and other involved professionals. A physical exam and occasionally laboratory testing can help rule out other medical conditions that could cause the child’s symptoms. Once all of the relevant information has been gathered and analyzed, the clinician should be able to ascertain which diagnosis or diagnoses best fit the student.

In the event that a student is determined to meet the diagnostic criteria for both TS and ADHD, it is generally desirable to consider which disorder is causing the most severe impairment for the child. In most cases, the ADHD will be more pervasive and would therefore be addressed first. However, there are certainly instances in which the TS symptoms are particularly severe and disruptive; and in such situations, it would be prudent to address those symptoms first.

Approaches to Treatment

You also asked about treatment recommendations for children with TS and ADHD.  Making an accurate diagnosis or diagnoses is critical, as that will help determine the optimal treatment strategy. Non-pharmacologic interventions are important components of the treatment approach in both conditions. In some cases of TS and in some cases of ADHD, non-pharmacologic strategies may produce sufficient symptom reduction so that medications may not be indicated.
Medications also may be considered as part of the treatment regimen.  One approach  to figuring out optimal medication(s) and dosage(s) is to focus first on a key symptom (or symptom cluster) of the condition felt to be most debilitating. Start with a low dose of a single medication to target the symptom, then titrate the dose upwards gradually until significant symptom reduction is observed. This approach favors the sequential introduction of medications as opposed to beginning two or more medications simultaneously. Although this approach requires some patience, it makes it much easier to identify the medication and dose which are most likely responsible for any deleterious side effects noted during the course of therapy. This strategy also may reduce the incidence of drug-drug interactions, which can be very challenging to identify. After the symptoms responsible for the most severe impairment have been addressed, then a treatment decision can be made about how best to approach any significant symptoms which remain.

School Support

Of course, selection of school accommodations and strategies are determined by an individual student’s needs of a particular child rather than by diagnoses.  Some approaches have been found useful for many children with similar characteristics and these provide a good place to start.
Some general things to keep in mind about TS and ADHD:

  • Both disorders increase the likelihood of disruptive classroom behavior; these disorders involve limited capacities for inhibition, so students may interrupt or blurt things out more frequently than other students do. To some, these behaviors may appear to be willfully defiant, oppositional, and manipulative. However students with these disorders actually have very limited control over many of the behaviors that disrupt instruction. Negative or punitive reactions by staff are ineffective and may lead to negative student attitudes about school.

  • Difficulties with handwriting are commonly associated with ADHD and TS. Students may need extra time to complete work, shorter assignments, or greater assistance.

  • Students with both ADHD and TS are at increased risk of developing anxiety disorders and should be monitored for anxiety symptoms, particularly obsessive-compulsive behaviors (described in a previous Mental Health AAS question).

  • Students with either or both disorders are easily overwhelmed by an ordinary day of school.  “Holding it in” or exerting effort to stay under control all day leads to an accumulation of stress, frustration, and/or fatigue; creating a strong need for restorative time. Some students may shut down or become hyper-irritable or explosive toward the end of the school day or when they arrive home from school. 
     
  • When a student has both disorders, keep in mind that TS may magnify the ADHD symptoms. For example, efforts expended to suppress tics may cause further interference with attention and concentration.
  • When students have both disorders, ADHD generally interferes with school performance more than does TS. We recommend that you first try standard ADHD accommodations; such as preferred seating, visual reminders, checklists, and graphic organizers. Help the student with transitions, organization of materials, checking completed work, and getting the completed work actually turned in.
  • TS accommodations should include unobtrusive ways for the student to signal the teacher and take breaks from classroom when necessary.

  • For students with TS, after obtaining permission from their parents, consider arranging for disability awareness training to help classmates understand why the student jerks or growls or displays other tic-related behaviors.

For all students, but especially students with ADHD, TS or both:

  • Help develop and nurture the student’s strengths and interests;

  • Maximize the student’s emotional connections to the material being learned by utilizing the student’s favorite topics to illustrate concepts;

  • Provide a calm, supportive, and structured, yet flexible, classroom environment with clear expectations and predictable routines;

  • Alter types of activities throughout the day and include sufficient breaks and opportunities for movement; and

  •  Accommodate the child’s need to fidget, as long as the fidgeting is not disruptive to the teacher or other students.

Thank you for your question. We hope that our discussion and suggestions are helpful.

John L. Digges, M.D., Ph.D., Behavioral Pediatrician
Marji Stivers, Ph.D., Clinical Psychologist


  • Is there research that connects neonatal meningitis with AD/HD?

Question:

Do you know of any research that connects neonatal meningitis with AD/HD?

Susan Bier,
MA Special Education Teacher


Answer:

Dear Susan,

Thank you for your question. I was not aware of any such research, so I conducted an online literature search using “neonatal bacterial meningitis” and “AD/HD” as search elements.  A retrospective study reported in 1992 examined 79 children with a history of bacterial meningitis, but the onset was anywhere from 2 days to 15 years of age.  The incidence of “hyperactivity” is reported as 4.2%, but it is not clear how many of the cases occurred among those children diagnosed with bacterial meningitis as neonates.

In a 1998 study from Sweden, 5 of 62 children with AD/HD symptoms had a history of significant perinatal events (including septicemia, hypoglycemia and meningitis), while none of the 51 matched controls had such a history.  The “p” value is reported as .063    (non-significant).

A study published in the journal Indian Pediatrics from 2002 reported a 4% incidence rate of AD/HD in their population of 100 children ages 0-5 years who were diagnosed with bacterial meningitis.  Only 9 of the 100 children were neonates, and it is not clear how many of the 4 cases of AD/HD occurred among the 9 neonates. If 2, 3 or 4 of the cases were neonates, that would represent incidence rates from ~22-44%, which would be well above expected rates. However, the small “n” involved would make it impossible to generalize.

Since maternal smoking has been associated with an increased incidence of AD/HD and some sources attribute up to ¼ of the variance in AD/HD to environmental (versus genetic) factors, consideration of bacterial meningitis as a risk factor seems like a reasonable hypothesis.  I was unable to identify any studies which provided strong evidence for such a link, however.

Sincerely,

John L. Digges, MD, PhD, MPH, FAAP


  • Does my child have an auditory processing disorder or AD/HD and how does that impact learning?

Question:

My 13 year old junior high son has an auditory processing disorder along with suspected AD/HD (inattentive). The school psychologist says he has AD/HD, but my pediatrician disagrees. We are currently considering a specialist to evaluate him.  

He currently has a 504 however it is pretty much an empty shell. He is currently failing several classes so I have contacted the school to meet again. 

My son currently comes home from school eats a snack, starts homework, eats dinner, finishes homework, showers and goes to bed.  He does not have the opportunity during the week to watch TV, play video games or play with his friends. 

Yesterday he was very upset because "he feels like a prisoner.”  Due to his low grades, he has to spend his lunch period in "F" Club with the Vice Principal.  He has to attend four days out of the week until he no longer has any "F". Although I do not want to make excuses for him, I'm just not sure this is a productive solution, as it feels more like a punishment than a strategy. Is this something I should discuss with the school and have him excused from or is there any value in it for a child with his difficulties? 

Thank you for your help,

Audrea


Answer:

Dear Audrea,

Thank you for your question. Since there is some overlap in symptoms between Attention Deficit Hyperactivity Disorder (AD/HD) and an auditory processing disorder, it is crucial to achieve diagnostic accuracy. An auditory processing disorder is optimally diagnosed by an interdisciplinary team; and typically includes input from such specialists as a school psychologist, a speech-language pathologist, and an educational specialist.  Auditory processing disorder is believed to result from some problem(s) with the brain’s ability to process and/or interpret sound signals. This condition may cause such symptoms as difficulties paying attention to or remembering information presented verbally, and in completing multistep directions.  As a consequence of the primary disorder of interpreting verbal input, the child may have delayed processing of verbal information; and therefore difficulty with reading comprehension, spelling, and vocabulary.  Academic performance is likely to suffer, and the failure to meet expectations may produce frustration and attendant behavior problems.

Attention Deficit Hyperactivity Disorder (AD/HD), predominantly inattentive type, is much less frequently seen in boys than is the combined type of AD/HD, which includes more hyperactive and impulsive symptoms. Children with both combined and inattentive type AD/HD are believed to have deficits in their ability to self regulate; with significant impairments in attention, active working memory, self-talk abilities and impulse control. They often have problems attending to stimuli with which they have no emotional connection.  Many appear to crave novelty and interest, while avoiding those tasks they perceive to be boring. They are simply unable to “will” themselves to maintain attention if they lack at least some degree of emotional connection. Their ability to remember things can vary widely from having extraordinary recall for seemingly trivial details about the topics which interest them; to being consistently unable to remember their school assignments, chores, or self-care responsibilities.

As there are areas of overlap between these two entities, it is not uncommon to find disagreements among professionals trying to arrive at the appropriate diagnosis. Since distinguishing between various diagnostic entities can be difficult, I believe that your desire to seek specialty evaluation is appropriate. Achieving an accurate diagnosis is critical, because it helps guide the choice of intervention strategy.

Children with auditory processing disorders often respond well to efforts to reduce the interference produced by extraneous sounds in the classroom environment. Preferential seating, exercises to promote language building skills and attempts to distill and simplify the more complex verbal inputs into more basic representations may all be helpful.

AD/HD children will benefit from efforts to provide them with external prompts for the things that they are not likely to be able to self-prompt, i.e. subjects in which they lack interest. They often respond well to having the chance to earn recognition or a tangible reward in exchange for the effort they must expend to complete a non-preferred task. (You might find helpful material at www.chadd.org.)

Children with either an auditory processing disorder or AD/HD will display difficulties fulfilling the demands of school work despite having put forth their absolute best effort. Intervention efforts which are based upon the assumption that the child’s poor performance is due to a lack of effort will appear punitive and unfair to the child. This can contribute further to lowering of their self confidence; and can contribute to increased feelings of anxiety, helplessness and hopelessness. Support for homework and test preparation is desirable; but it should be provided in an environment which is nurturing and supportive, rather than punitive.

I applaud your efforts to contact someone who has expertise and experience in diagnosing and treating AD/HD in children. If your son is diagnosed with AD/HD, there are many strategies (both non-pharmacologic and pharmacologic) which can provide help for him in the form of symptom reduction. He will still need to put forth considerable effort; but with proper treatment, he should become more efficient and productive. Improved productivity coupled with less time being spent on non-preferred activities (like homework and preparing for tests) should help reduce some of the frustration he is experiencing. Increased efficiency might also free up some time for him to participate in more preferred activities, so he can maintain a healthier balance in his life.
Thank you again for your question. I hope this response is helpful, and that you and your son receive the assistance and support you need and deserve.

John L. Digges, MD, PhD, MPH, FAAP