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Abdominal Pain, Recurrent
What is recurrent abdominal pain?
What causes abdominal pain?
Who gets recurrent abdominal pain?
How does recurrent abdominal pain cause disease?
What are the common findings?
How is recurrent abdominal pain diagnosed?
How is abdominal pain treated?
What are the complications?
How can abdominal pain be prevented?
What research is being done?
Links to other information
Jeffrey Hyams, M.D.
Head, Division of Digestive Diseases and Nutrition
Connecticut Children’s Medical Center, Hartford, Connecticut and Professor of Pediatrics
University of Connecticut School of Medicine
Farmington, Connecticut
What is recurrent abdominal pain?
The most formal definition of recurrent abdominal pain, published almost 50 years ago, states that children have recurrent abdominal pain when there are at least three bouts of abdominal pain, which are severe enough to affect activities, over a period of three months. In reality, children are diagnosed with recurrent or chronic abdominal pain after a period of one or two months.
The pain may occur on a daily basis, or it may be intermittent. The pain may occur at any part of the abdomen, but, as a general rule, it is classified as upper abdominal (between the bottom of the breast bone and the belly button), around the belly button, or in the lower abdomen.
What causes abdominal pain?
Recurrent abdominal pain in children generally is categorized in one of three groups. The first group includes an obvious disease, i.e., there is a structural, biochemical, or other abnormality that is shown by examination or testing. Examples include, among others, peptic ulcer disease, inflammatory bowel disease, infections, gynecologic pathology, and kidney disease. As a group, these conditions generally are found in about 10% to 20% of children with recurrent abdominal pain. The second group includes “functional gastrointestinal disorders.”
These disorders have a fairly standard set of symptoms, and, despite evaluation, no organic disease can be found. The two most common conditions are irritable bowel syndrome and functional dyspepsia. Children in the third group also have functional abdominal pain (no obvious disease can be found). However, their symptoms are not as readily describable as the symptoms associated with irritable bowel syndrome or functional dyspepsia. In children in the third group, “somatization” is often more prominent. Somatization is the process of experiencing and communicating physical distress and symptoms, which are not explained by physical findings, and excessively seeking medical care for the complaints.
Who gets recurrent abdominal pain?
Studies have shown that abdominal pain is a very common problem. Up to 75% of middle school and high school students have abdominal pain over the course of the year, with almost 1 in 5 having the pain on at least 6 occasions. From 15% to 25% of younger school age children also may complain of recurrent abdominal pain. Abdominal pain accounts for up to 5% of visits to pediatricians’ offices.
How does recurrent abdominal pain cause disease
Doctors can find a specific organic disease as a cause of the symptoms associated with recurrent abdominal pain in about 10% to 20% of children. However, the majority of children with recurrent abdominal pain have no obvious disease. That is not to say that they do not have real symptoms. Indeed, it is rare to find children who fake symptoms. Nonetheless, the lack of obvious abnormalities on testing often leads to a sense of frustration and anxiety on the part of the child, the parents, and, occasionally, the care givers.
Although it is not known the exact way that symptoms are caused in irritable bowel syndrome and functional dyspepsia-two common causes of recurrent abdominal pain-there are several current theories. The most current theory is that in both of these conditions, there is “visceral hypersensitivity.” This means that the intensity of the signals from the gastrointestinal system, which travel by nerves to the brain, seems to be exaggerated. This may occur following illnesses that cause inflammation in the intestine (e.g., viral gastroenteritis), or they may occur following psychologically traumatic events that “sensitize” the brain to stimuli.
These traumatic events may be as severe as physical or sexual abuse, or they may occur in the course of family life, such as marital discord. In most cases, however, no specific cause can be found. This visceral hypersensitivity is thought to lead to symptoms when the intestine undergoes peristalsis (motility or movement) or when it is distended by gas or stool. In some patients with functional dyspepsia, it is thought that even normal amounts of acid in the upper small intestine may cause discomfort.
What are the common findings?
Irritable bowel syndrome occurs in both children and adults. The symptoms include recurrent abdominal pain-usually around the belly button or the lower abdomen-that is associated with abnormalities in stooling. Lower abdominal symptoms may include constipation, diarrhea, or a variable pattern of defecation. Commonly, the pain is relieved by defecation. Patients often complain of a sense of rectal urgency, and they may have a sense of incomplete evacuation following a bowel movement. They often complain of bloating, dizziness, and, occasionally, nausea. Weight loss, fever, or blood in the stool is unusual in irritable bowel syndrome.
In functional dyspepsia, the discomfort is centered in the upper abdomen. This discomfort may be pain-like and occasionally burn. Alternatively, some individuals only complain of a sense of nausea or early fullness after eating. Another occasional cause of recurrent functional abdominal pain is an abdominal migraine. In this condition, children develop severe abdominal pain, often in the middle of the night or early morning. Occasionally, it is accompanied by vomiting, and there may be a history of headaches. In about one-third of the cases, there is a family history of migraine headaches. Additionally, in about one-third of the cases, the child will have a history of carsickness.
How is recurrent abdominal pain diagnosed?
Recurrent abdominal pain is diagnosed based on a patient’s history and a physical examination. There are no specific tests to diagnose it. It is the responsibility of the clinician and the family to use a cost-sensitive approach to this problem. However, when there are accompanying warning signs of a more serious disease, further evaluation is recommended. The warning signs include the following:
Weight loss
Blood in the stool
Fever
Persistent vomiting
Arthritis
Certain types of rash
Growth retardation
Delayed pubertal development
Difficulty swallowing
Nighttime awakening from the pain
Family history of ulcer disease or inflammatory bowel disease (e.g., Crohn’s disease, ulcerative colitis)
Depending upon the child’s specific history and the physical findings, the physician may order screening blood work, including a complete blood count, erythrocyte sedimentation rate to look for inflammation in the body, serum chemistries, and, possibly, radiographic studies and an ultrasound. In the presence of diarrhea, a flexible sigmoidoscopy or a colonoscopy frequently is performed. In the presence of upper gastrointestinal symptoms, an upper endoscopy commonly is performed.
An additional diagnostic consideration for the symptoms is lactose intolerance. This condition is found in all ethnic groups, but it is more common in African-American, Latino, and Asian populations. It is diagnosed with a non-invasive procedure called a breath hydrogen test.
How is abdominal pain treated?
During the course of the evaluation, if a specific disease is found, then appropriate treatment is given. More often than not, the clinician will diagnose functional abdominal pain. If irritable bowel syndrome is diagnosed, reassurance is offered, and the patient and the family are informed that no serious or threatening disease exists. If there are specific triggering factors associated with the symptoms, such as school or family difficulties, then these issues need to be addressed.
If the child has diarrhea as a prominent symptom, then medications, such as dicyclomine or hyosycamine, which slow down bowel transit, occasionally are used. Low doses of medications, referred to as tricyclic antidepressants, also are used. However, these medications are not used as antidepressants; they are used to decrease the intensity of the pain signals coming from the gastrointestinal system to the brain. Dietary manipulation by increasing dietary fiber can be helpful.
Functional dyspepsia is treated with medications (e.g., ranitidine, cimetidine, omeprazole, and lansoprazole) that reduce the secretion of stomach acid. Low dose tricyclic antidepressants also may be used for severe functional dyspepsia. Patients can only be diagnosed as having functional dyspepsia after disease has been ruled out by an upper gastrointestinal endoscopy.
In cases of functional abdominal pain, where reassurance, diet, and medications do not help, a psychologist may help with biofeedback and pain control.
What are the complications?
The greatest complication of functional gastrointestinal disorders is that they are misunderstood, and the child is thought to have a serious illness. When that occurs, or when the symptoms are particularly severe, functional disability may occur. It is the responsibility of both the physician and the family to help the child to return to a normal schedule as soon as possible. While there should be no attempt to minimize the intensity of the symptoms, it also is important to not let the symptoms control the life of the child or the family.
How can abdominal pain be prevented?
Recurrent abdominal pain cannot be prevented. If the child has recurrent abdominal pain that is caused by a specific organic disease, then that disease needs to be treated. Certain diseases tend to run in families, such as peptic ulcer disease (which is caused by an infectious agent, Helicobacter pylori) and inflammatory bowel disease. Functional gastrointestinal disorders, especially irritable bowel syndrome, also may run in families; however, these disorders are so common that it is difficult to determine a particular mode of inheritance.
What research is being done?
Irritable bowel syndrome and functional dyspepsia are extremely common causes of chronic gastrointestinal symptoms in adults; therefore, the pharmaceutical industry has an aggressive research program that is focused on finding better treatments.
Links to other information
The International Foundation for Functional Gastrointestinal Disorders, located in Milwaukee, Wisconsin, may provide an excellent source of further information on irritable bowel syndrome.
About the Author
Dr. Hyams is the Head of Digestive Diseases and Nutrition at the Connecticut Children’s Medical Center in Hartford, Connecticut, and a Professor of Pediatrics at the University of Connecticut School of Medicine.
Dr. Hyams is an accomplished clinician and investigator, and he has a special interest in functional gastrointestinal disorders in children and adolescents.
Copyright 2012 Jeffrey Hyams, M.D., All Rights Reserved
Acne
What is acne?
What causes acne?
Who gets acne?
How does acne cause disease?
What are the common findings of acne?
How is acne diagnosed?
How is acne treated?
What are the complications?
How can acne be prevented?
Leslie Capin, M.D. Peggy Vernon, RN, MA, C-PNP Aurora/Parker Skin Care Center Aurora, Colorado
What is acne?
Acne is the most common skin disorder seen in the United States today. It is most commonly associated with whiteheads, blackheads, and pustules (small bumps under the skin containing pus); although, severe acne patients also experience tender red nodules and acne cysts.
What causes acne?
Prior to and during puberty, increased hormones cause an over-production of oil, which then plugs the oil glands, called sebaceous glands. These glands are most prominent on the face, chest, shoulders, and back-the most common areas of acne lesions. Poor diet or dirt does not cause acne. However, a well-balanced diet and proper washing make acne treatment more successful.
A number of other factors also contribute to acne. Stress and emotions.can make acne worse. Conversely, acne can create stress. Oil-based soaps, lotions, cosmetics, and hair products cause increased plugging of the oil glands, and can make acne worse. Certain medications, such as epilepsy drugs, steroids, anti-tuberculosis medications, and some antidepressant medications, can cause acne or make it worse.
Who gets acne?
Derived from the Greek word akme, meaning “peak of life,” and the Latin word acme, meaning “prime of life,” acne is most prominent during adolescence. However, 40% of children aged 8 to 10 years begin to experience acne, and up to 10% of individuals in their midlife years continue to struggle with acne lesions. There appears to be a familial or hereditary tendency; if one or both parents had acne, it is more likely that their children will also have the disorder. Although it is more common in males, females seek medical help more often.
How does acne cause disease?
Acne appears on the skin in the form of blackheads and whiteheads (“comedones”), as well as pustules, nodules, and cysts-the result of the bacteria, Propionibacterium acnes, that cause inflammation of the oil glands. Although the bacteria do not cause serious illness, the psychological effects of acne and resultant scars can be devastating. Advances in acne treatment offer successful management. Therefore, acne should never be dismissed as a minor condition that will be outgrown.
What are the common findings of acne?
There are two types of acne: comedonal acne, which appears as whiteheads and blackheads, and inflammatory acne, which includes pustules, nodules, and cysts. Generally, acne begins as whiteheads and blackheads that progress to inflammatory acne. Most adolescents have a combination of comedonal acne and inflammatory acne, consisting of whiteheads, blackheads, and pustules. Cystic acne is the most severe type of acne and requires intensive treatment.
How is acne diagnosed?
Although acne is easily recognized, a thorough history is important in treating this disorder properly. The duration of acne, past treatment, and products used (including soaps, lotions, and cosmetics) are helpful in developing an appropriate and effective treatment plan. Family history, medical history, and current medications also are very important. It is usually not necessary to perform laboratory tests to diagnose acne, unless a hormonal abnormality is suspected.
How is acne treated?
Acne treatment and management take weeks to months to see improvement. Patience and compliance are crucial.
Goals of treatment include decreasing oil production; opening the plugged oil glands; reducing the bacteria, Propionibacterium acnes; and eliminating or reducing scarring. Mild soaps and lotions are recommended. Gentle washing in the morning and at bedtime to remove cosmetics and debris is essential. Buff puffs and grainy soaps cause additional irritation and should be avoided. Moisturizers, make-up, and hair products should be water based.
Squeezing and picking acne lesions cause irritation and injure the underlying tissue, resulting in scarring, and should be avoided unless performed by a health care professional.
ical agents, called keratolytics, relieve plugging of the oil glands. Over-the-counter preparations, such as Benzoyl peroxide and salicylic acid, are beneficial for mild comedonal acne. Applied twice daily after washing, results are usually seen within six to eight weeks. Consult your health care provider if results are not satisfactory. Prescription medications, such as Retin A, Differin, and Azelex, may be used once daily after washing. These medications are applied to the entire area, not just to the acne lesions.
ical antibiotics also may be prescribed in combination with a keratolytic agent. These antibiotics reduce bacteria on the skin and control inflammation. They are beneficial for comedonal and inflammatory acne treatment, as well as for maintenance after control has been achieved with oral antibiotics. They are applied once daily to the entire area after washing. The most common ical antibiotics include Erythromycin, Clindamycin, and Sulfonamides. It is important to advise your health care provider if you have had an allergic reaction to any of these medications in the past.
Oral antibiotics reduce the bacteria, Propionibacterium acnes. They are used in combination with ical medications for more severe inflammatory acne. Common oral antibiotics are Erythromycin, Doxycycline, Tetracycline, and Minocycline. They must be taken for three to four weeks to begin to see improvement, and treatment often lasts several months.
For severe cystic acne, Accutane may be prescribed. This vitamin A derivative is taken orally for four to five months. The response rate is as high as 90%, with most patients experiencing prolonged remissions. Careful monthly follow-up by a dermatologist during treatment is required.
Oral contraceptives have proven helpful in some females with inflammatory acne, either alone or in combination with other acne treatment.
What are the complications?
Scarring and pigment change result from squeezing acne lesions. These can be treated by a dermatologist or plastic surgeon with dermabrasion, chemical peels, or laser resurfacing. These procedures are costly, and they are not covered by most insurance plans. Therefore, picking at acne lesions should be avoided.
Cystic acne can cause thickened scars called keloids. These are unsightly and often painful. Keloids can be treated with steroid injections, or they can be surgically removed by a dermatologist or plastic surgeon after acne treatment is completed.
Benzoyl peroxide, keratolytics, and some ical antibiotics cause dryness and redness in the areas of application. Applying a water-based lotion or moisturizer (that is non-acne causing) can relieve these side effects.
Some keratolytics and oral antibiotics cause sensitivity to the sun. Therefore, sun exposure should be limited, and sunscreens should be used daily.
Accutane causes dry skin, mucous membrane irritation, sun sensitivity, and elevated triglycerides. It should be used in combination with appropriate moisturizers and sunscreens. Close follow-up with a health care professional and monitoring of triglyceride levels are necessary during treatment. Accutane can cause birth defects and miscarriages, and pregnant women should not take it.
How can acne be prevented?
Currently, acne cannot be prevented. However, proper treatment and home compliance offer successful management and remission of this frustrating disorder. Acne is not contagious, and it should not be allowed to take over one’s life. Psychological support and encouragement aid in treatment and promote well being.
References
Buttaro, T., Trybulski, J., Bailey, P., Sandberg-Cook, J.: Primary Care: A Collaborative Practice, ed. 1, St. Louis, 1999, Mosby, Inc.
Hurwitz, S.: Clinical Pediatric Dermatology, ed. 2., Philadelphia, 1993, W.B. Saunders Company
Weston, W.L., Lane, A.T., and Morrelli, J.G.: Color Textbook of Pediatric Dermatology, ed. 2, St. Louis, 1996, Mosby, Inc.
About the Author
Dr. Capin received her medical education and completed her dermatology residency at the University of Colorado. A Fellow of the American Academy of Dermatology, she is board certified in Dermatology.
She has been in practice at the Aurora/Parker Skin Care Center for twelve years, and recently opened CARA MIA Medical Day Spa in Parker, Colorado.
She enjoys teaching, and often has students with her during office hours. She is experienced in medical and surgical dermatology, as well as cosmetic dermatology. She is often asked to participate in conferences, and speaks internationally.
Peggy Vernon received her nurse practitioner education at the University of Colorado and is a certified Pediatric Nurse Practitioner. In addition, she holds a Master in Counseling from the University of Northern Colorado.
She is on the Clinical Faculty at Regis University and Associate Faculty at the University of Colorado in the Masters Nurse Practitioner programs. Her special interests are pediatric dermatology, patient education, and research. She speaks nationally on various dermatology ics.
Copyright 2012 Leslie Capin, M.D., All Rights Reserved
Acute Lymphoblastic Leukemia
What is leukemia?
What is acute lymphoblastic leukemia?
What causes acute lymphoblastic leukemia?
Who gets acute lymphoblastic leukemia?
What are the common symptoms at diagnosis?
How is acute lymphoblastic leukemia diagnosed?
How is acute lymphoblastic leukemia treated?
What are the complications?
What research is being done?
Links to other information
Linda C. Stork, M.D.
Associate Professor, Pediatrics
University of Colorado School of Medicine
Pediatric Oncologist, The Children’s Hospital
What is leukemia?
Leukemia is a cancer of the blood cells that begins in the bone marrow or the lymph glands where the blood cells are made. Bone marrow occupies the center of all bones, especially bones of the pelvis, the lower spine, and the thighs. Lymph nodes are all over the body, but they usually are too small to feel.
Like all cancers, leukemia is caused by uncontrolled cell division and growth. There are “signals” and “switches” within the genetic material and proteins of each cell of the body that strictly control whether the cells start or s dividing to make more cells. For example, when a finger is cut, these “signals” and “switches” tell the skin cells to regrow just enough to replace the area of damaged skin and then to s, without forming big lumps of skin.
Leukemia usually develops in the white blood cells that normally circulate through the blood stream and the lymph nodes to defend the body against infection. Leukemia begins in one cell whose “signals” and “switches” have sped working correctly. This one abnormal cell divides into two abnormal cells, which divide into more and more abnormal cells. These leukemia cells eventually fill up the bone marrow space, thereby crowding out normal bone marrow cells and spreading into the blood stream and the lymph nodes. As a result, the cells that carry oxygen (red blood cells), the cells that help clot blood (platelets), and the normal white cells that fight infection are reduced greatly in number.
What is acute lymphoblastic leukemia?
Acute lymphoblastic leukemia is the most common leukemia and cancer of childhood. The word “acute” refers to the fact that patients diagnosed with this leukemia in the early 20th century survived for only a short time. The word “lymphoblastic” refers to the type of white cell that has become cancer. Normal lymphoblasts mature over days to weeks into lymphocytes that defend against infection. Lymphoblasts of leukemia cannot mature or fight infection.
What causes acute lymphoblastic leukemia?
The cause of this type of leukemia is unknown; therefore, it cannot be prevented at the present time. Several changes that occur in a normal lymphocyte over a period of time probably turn it into a leukemic cell. For some cases of acute lymphoblastic leukemia, the first change occurs in fetal life before birth.
Exposure to electrical power lines, toxic chemicals, radon, or radiation has not been proven to cause this leukemia. Although a specific virus causes leukemia in cats, viruses do not appear to cause acute lymphoblastic leukemia in children. This type of leukemia does not appear to be inherited because it very rarely occurs in more than one child per family.
Who gets acute lymphoblastic leukemia?
Acute lymphoblastic leukemia is rare. Its incidence is fairly similar worldwide. In the United States, about 3,000 children are diagnosed with this disease each year. For children between infancy and 15 years, acute lymphoblastic leukemia occurs yearly in 1 child among every 25,000 children. For patients aged 2 to 6 years, acute lymphoblastic leukemia occurs yearly in 1 child among every 5,000 to 10,000 children. Although very rare, even newborns and adults can develop acute lymphoblastic leukemia. In the United States, acute lymphoblastic leukemia is much less common among African Americans than Caucasians; however, the reason for this difference is unclear.
What are the common symptoms at diagnosis?
The symptoms of acute lymphoblastic leukemia often mimic more common illnesses of childhood. These symptoms are related to reduced numbers of normal bone marrow and blood cells. Patients develop anemia because of low numbers of the red blood cells; they often appear pale with fast heart rates, and, sometimes, they feel lightheaded and tire out easily. Patients with acute lymphoblastic leukemia often bruise more easily and get more nosebleeds because the cells that clot blood (platelets) are low in number. Patients often have several weeks of unexplained fever before acute lymphoblastic leukemia is diagnosed. Sometimes, these fevers are because of infections; other times, they are because of the leukemia itself. About 25% of patients experience bone pain for days to weeks before the diagnosis, especially in the pelvis, the spine, and the legs. About 50% of patients develop swollen lymph nodes in the neck, under the armpits, or in the groin. The liver and the spleen, usually tucked beneath the right and left lower rib cage in the abdomen, can enlarge and become painful as leukemic cells fill the many blood vessels within these organs. Occasionally, a boy’s testicles swell as leukemic cells invade them. The lymph nodes deep within the chest may become swollen with leukemic cells, causing a child to breathe faster and harder than normal.
How is acute lymphoblastic leukemia diagnosed?
The symptoms described above will prompt a physician to draw the child’s blood for a complete blood count (CBC). Often, this CBC shows that the number of red blood cells, and/or platelets, and/or type of white cell called “neutrophils” is low. The total number of white cells in the CBC may range from very low to very high. The lymphoblasts may be recognized on the blood smear when viewed in the laboratory under the microscope.
The final diagnosis of acute lymphoblastic leukemia is made by a bone marrow examination. The bone marrow procedure entails placing a needle into the pelvic bone a few inches to the right or left of the spine and a few inches above the buttocks. This needle goes through the skin, the muscle, and the bone, and into the bone marrow space. From here, liquid bone marrow, filled with leukemic cells, is aspirated into an attached syringe. The bone marrow aspiration procedure is painful; a child usually is sedated and given pain medicine during the procedure.
Children with symptoms similar to those of patients with leukemia may have a different diagnosis. In those cases, the CBC is either completely normal or has abnormalities of only one blood cell type. Certain viral infections, joint diseases, or other blood diseases can mimic the symptoms of leukemia. Occasionally, children with acute lymphoblastic leukemia have symptoms of fever and bone or joint pain and a completely normal CBC. In such cases, the diagnosis is uncertain until the bone marrow aspiration shows the leukemia.
How is acute lymphoblastic leukemia treated?
If untreated, acute lymphoblastic leukemia is a fatal disease. However, with modern day treatment, the majority of children with acute lymphoblastic leukemia are cured. Since the 1960s, many children with acute lymphoblastic leukemia and other cancers have participated in randomized clinical trials sponsored by national cooperative organizations, such as the Children’s Cancer Group and the Pediatric Oncology Group. Major progress in the treatment of childhood cancers has been made because of the research efforts of these groups.
Children with leukemia are treated by pediatric oncologists and nurses in specialized facilities; patients and families usually are supported by social workers and child life specialists.
The medicines used to treat leukemia and other cancers are called chemotherapy. Chemotherapy drugs can be taken by mouth or injected into the blood stream through a vein, into soft tissue, or into muscle. Because leukemic cells tend to “hide out” in the lining of the brain and the spine, specific chemotherapy is injected into the spinal fluid by a procedure called a lumbar puncture. This procedure involves inserting a small needle into a space between two vertebrae of the lower spine, removing some spinal fluid, and injecting chemotherapy into the spinal fluid space. This procedure usually is performed with ical anesthetic and sedation.
Some of the chemotherapy drugs originally came from products of nature, such as the periwinkle and may apple plant or the bark of the yew tree, or from microorganisms, such as fungus. Other chemotherapy drugs were designed in laboratories. The first chemotherapy drug was developed in the late 1940s. Before that time, patients with acute lymphoblastic leukemia did not survive; all of them died of infection or bleeding within several months of diagnosis.
Treatment of acute lymphoblastic leukemia has evolved during the past 40 years; today, a child may receive up to 15 different chemotherapy drugs during a 2- to 3-year period. Occasionally, radiation therapy is given to the brain. After the first month of treatment, the child is usually in “remission”; 99% of the leukemia cells have been killed, and the CBC and the bone marrow look normal. During the next 2 to 3 years of treatment, chemotherapy attempts to kill the remaining 1% of leukemic cells, which are heartier than those initially killed.
For at least 70% of children, the leukemia never reappears, and these children grow up normally. If the leukemia recurs, it is called a “relapse” and is found in the blood and the bone marrow, the spinal fluid, or the testicles. A relapse can occur any time after remission, but it usually is between 18 months and 5 years after the initial diagnosis. A CBC is performed frequently, along with a physical exam, throughout the course of treatment and for many years thereafter to document continued remission or to diagnose a relapse. About 50% of patients who relapse can be cured with either bone marrow transplantation or several more years of intensive therapy.
What are the complications?
Most patients require treatment with antibiotics and transfusions of red blood cells and platelets at diagnosis and during treatment. Once a child is in remission, complications of treatment are from side effects of chemotherapy and not from the leukemia itself. Chemotherapy drugs circulate throughout the entire blood stream and affect normal cells, especially those cells that are dividing rapidly. One common side effect is hair loss, which usually grows back after the first year of treatment. Some side effects can be prevented; most of them are reversible. Occasionally, a child in remission dies from a complication of treatment, usually an overwhelming infection.
What research is being done?
Randomized clinical trials that aim to improve the cure rate of leukemia are being conducted by the Children’s Oncology Group in most children’s hospitals in the United States and Canada. Research on leukemic cells is being carried out in many laboratories throughout the world. The purpose of this research is to develop new strategies to treat leukemia; to determine what changes occur in a cell to cause leukemia; and, ultimately, to prevent a child from developing leukemia.
Links to other information
For more information on acute lymphoblastic leukemia, log on to the following Web sites:
NCI Web site: http://www.nci.nih.gov
Leukemia Society Web site: http://www.leukemia.org
CCG Web site: http://www.nccf.org
POG Web site: http://www.pog.ufl.edu
References
Lilleyman JS. Childhood Leukemia: The Facts. Oxford, England: Oxford University Press; 1994.
Laszlo J. The Cure of Childhood Leukemia: Into the Age of Miracles. New Brunswick, NJ: Rutgers University Press; 1995.
Albano EA, Stork LC, Greffe BS, Odom LF, Foreman NK. Neoplastic disease. In: Hay W, Hayward A, eds. Current Pediatric Diagnosis and Treatment. Stanford, CT: Appleton & Lange; 1999:774-777.
About the Author
Dr. Stork is an associate professor of pediatrics at the University of Colorado Health Sciences Center and The Children’s Hospital in Denver. She earned her undergraduate degree from Yale University and her medical degree from Columbia University. Dr. Stork is actively involved in clinical trials that treat children with acute lymphoblastic leukemia.
Copyright 2012 Linda C. Stork, M.D., All Rights Reserved
Acute Otitis Media
What is acute otitis media?
What causes acute otitis media?
How does it cause disease?
How common is acute otitis media?
Who gets an ear infection?
Is an ear infection contagious?
How do you know if your child has an ear infection?
What does the eardrum look like when it is infected?
How is an ear infection treated?
What are the complications?
How can an ear infection be prevented?
What research is being done?
by Stan L. Block, M.D. Associate Clinical Professor of Pediatrics University of Louisville and University of Kentucky
What is acute otitis media?
Acute otitis media is an infection of the middle ear, generally caused by bacteria. In acute otitis media (i.e., an ear infection or an infection of the middle ear), pus and infected fluid accumulate in the middle ear space.
The tympanic membrane (eardrum) appears inflamed, reddened, and often protrudes outward. Usually, an ear infection begins after the eustachian tube (a small tube connecting the back of the nose to the middle ear space) has become swollen, congested, and closed, most commonly resulting from an ongoing viral respiratory infection.
Acute otitis media should not be confused with: 1) external otitis (“swimmer’s ear”)-a painful bacterial infection of the superficial skin of the ear canal, or 2) otitis media with effusion (secretory otitis or “fluid ears”)-an accumulation of non-inflamed fluid behind the eardrum. Otitis media with effusion is not considered infected, and most doctors do not treat it with antibiotics. This uninfected fluid in the middle ear is a remnant in 50% to 60% of resolved ear infections. It is frequently a mild complication of colds, respiratory illnesses, or nasal allergies.
What causes acute otitis media?
Acute otitis media usually is caused by one of four bacteria:
Streptococcus pneumoniae (pneumococcus) in 30% to 45% of cases.
Haemophilus influenzae (Haemophilus-but not the Haemophilus strain in the HIB or meningitis vaccine) in 20% to 30% of cases.
Moraxella catarrhalis (Moraxella; sometimes called Branhamella catarrhalis) in approximately 10% of cases.
Group A Streptococcus (like the strep bacteria of strep throat) in 5% of thecases.
The pneumococcus bacteria is now the most difficult to treat. Some strains have become very resistant to antibiotics by using their unique ability to transform their genes and cell wall into a bacterial form, which is resistant to most of the antibiotics that commonly are used to treat ear infections. These resistant strains frequently are cultured from children who do not respond to several courses of antibiotics. When a child has an ear infection that does not respond to antibiotics, resistant pneumococcus bacteria may cause it.
Pneumococcus has 90 different types, which are all genetically related; however, 7 types account for the majority of ear infections in childhood and nearly all of the antibiotic resistant strains. In addition, pneumococcus is the leading cause of meningitis, bloodstream infections, and serious pneumonia in children, sometimes as a result of a preceding ear infection.
Up to half of Haemophilus and nearly all Moraxella bacteria produce an enzyme (beta-lactamase), which makes these bacteria resistant to some of the commonly used antibiotics. This enzyme may destroy many antibiotics when they come in contact with the bacteria. Nonetheless, several available antibiotics are still quite effective against these strains.
Viruses play a critical role in the development of acute otitis media by enabling the bacteria to travel into the middle ear (see below). By themselves, though, viruses account for only 6% to 10% of ear infections.
How does it cause disease?
As long as air entering from the back of the nose is able to reach the middle ear space via the eustachian tube, the middle ear rarely becomes infected. The eustachian tube in younger children is flimsy and easily collapses. As the child grows, the cartilage tissue surrounding the eustachian tube becomes stiffer, longer, and more angulated inside the skull.
Pneumococcus, Haemophilus, and Moraxella commonly reside in the back of the nose, and do not infect the child. Once a child becomes infected with a respiratory virus, it not only causes congestion of the nose and the lungs, but also of the eustachian tube. When this tube becomes clogged, the cells in the middle ear space produce a fluid-like substance, which allows bacteria to grow and infect the middle ear space. A virus infection precedes up to 90% of cases of acute otitis media.
Respiratory virus infections also trigger ear infections by upsetting the body’s normal defenses in the nose and the eustachian tube, and allowing certain normal bacteria that reside in the nose to “stick” better to the lining of the nose and the eustachian tube. Certain viruses, such as the flu (influenza) and RSV (a respiratory syncytial virus, or the “bronchiolitis bug”), are more frequently associated with ear infections. Occasionally, the child’s nose becomes colonized by a new aggressive strain of bacteria, which rapidly invades the middle ear. Unfortunately, more exposures (e.g., via daycare attendance) to viruses and new strains of bacteria increase the likelihood of ear infections.
How common is acute otitis media?
Acute otitis media is predominantly an infection of young children, primarily occurring in the first three years of life. Children in the 1990s experience 30% more episodes of acute otitis media as compared with children in the 1970s, probably as a consequence of high rates of day care. Currently, acute otitis media accounts for one-fourth of all pediatric office visits in the first three years.
Nearly 94% of children will experience at least one ear infection in the first three years of life, with an average of about three episodes in the first and second years, and one and one-half episodes in the third year. As many as 5% to 8% of children will undergo the placement of ventilating tubes in their first 24 months of life. Much of this is related to the high rate of daycare attendance in the United States, with increased exposure to infectious agents.
Who gets an ear infection?
At the highest risk for ear infections include those children who:
are male;
are of the white, American Indian, or Eskimo races;
attend daycare;
have Downs syndrome;
are immunocompromised;
have a strong family history of otitis media;
were not breastfed during the first 12 months of life; and/or
reside in a smoking household.
Children with a cleft palate or HIV have particularly severe problems with recurrent ear infections.
Age affects the rate of acute otitis media, with a dramatic decline in frequency in children older than three years. However, some children with a history of ventilating tubes or frequent recurrent otitis media, severe allergies, or large adenoids may still be plagued with ear problems.
Is an ear infection contagious?
To some degree, the bacteria that cause ear infections are contagious because they may colonize, or set up residence, in the nose of children or close contacts. However, only a small proportion of children colonized with a new strain of bacteria will develop an ear infection. For example, in the case of pneumococcus, only about 15% of children colonized in the nose with a new strain of it will develop an ear infection, and usually only within the first month. Also, some bacterial strains appear more aggressive than others and will directly invade the middle ear.
What may be even more important than new bacterial colonization is the spread of respiratory viruses, particularly among children in daycare and pre-schools. Respiratory viruses are very contagious in close quarters. They frequently make a child more susceptible to an ear infection by upsetting the normal balance between the child’s local nose immunity and the co-inhabitant bacteria. When the child’s defenses are down, or the eustachian tube becomes clogged, the bacteria tend to infect the middle ear.
How do you know if your child has an ear infection?
Children with an ear infection display a wide range of symptoms, from none at all, to a high fever, to a screaming earache. Many infants and toddlers with an ear infection show less obvious symptoms, such as sleeplessness, irritability, decreased feeding, or a fever. Ear pain and ear tugging are helpful clues, but are fairly unreliable. Even in older children with a respiratory illness, mild to moderate ear complaints and earaches frequently occur in children with normal ears. In these children, a sore throat often causes the ear complaints. Fever occurs in only one-fourth of ear infections, and it does not signify an ear infection.
One of the more reliable indicators of an ear infection in younger children is when a child, who has had a cold and a runny nose for three to seven days, suddenly develops sleeplessness and inconsolability during the night, along with increasing fussiness throughout the day. Children with a persistent ear infection who have recently received antibiotics often show few symptoms.
Antibiotics should not be prescribed over the phone for a presumed ear infection, without an examination by a physician. Only a careful examination of the eardrum by a doctor can determine whether the ear is truly infected. Often, when the child is brought into the office in the early phase of a cold or a mild respiratory infection, the eardrum will be normal, only to become infected several days after the office visit. If the child has only a mild cough and a runny nose, it is best to wait at least five to seven days into the illness before making an office visit.
The new EarCheckTM (acoustic reflectometry instrument) may help parents to determine whether a young child is getting an ear infection. If a previously healthy child, who now has an illness, develops an abnormal reading on the instrument, parents can assume a 70% chance of fluid behind the eardrum. It will not distinguish between infected or uninfected fluid. More importantly, if the readings are normal and the child’s symptoms are mild, parents can assume that it is very unlikely that the child has an ear infection, and an office visit may be avoided.
What does the eardrum look like when it is infected?
When a doctor examines the eardrum through the otoscope instrument, the eardrum normally appears as a thin gray, translucent membrane (like wax paper). When infected, it will look opacified (cloudy), very reddened, and yellowish. Sometimes, it shows a small layer of pus-like material. During an infection, the eardrum usually becomes rigid because of the accumulation of fluid, and it will not wiggle when the doctor puffs a small amount of air against the eardrum with an otoscope. Use of tympanometry or acoustic reflectometry (i.e., the EarCheck instrument) may help to determine if there is fluid behind the eardrum. Neither instrument distinguishes between infected or uninfected fluid.
From the appearance of the eardrum, the doctor cannot determine the type of bacteria, or whether bacteria or viruses are causing the infection. The eardrum in children with otitis media with effusion appears as an orangish or dull, straw-colored fluid, and it also does not move when air is applied to it.
How is an ear infection treated?
The intense ear pain of acute otitis media can be partially relieved by adequate doses of ibuprofen or acetaminophen. For more severe earaches, some doctors may prescribe codeine. Numbing eardrops provide minimal relief, and only for a short time. A warm washcloth or sweet oil (olive oil) directly instilled in the ear canal may temporarily distract from the child’s ear pain.
Nearly all doctors in the United States believe that acute otitis media should be treated with antibiotics by mouth, particularly if the child has symptoms. Antibiotics generally provide prompt and dramatic relief of the ear pain. Oral antibiotics for acute otitis media are safe and effective, with exceedingly rare serious side effects.
In a few European countries, ear infections are not treated in children older than two years, unless symptoms persist for more than 48 hours. A few U.S. physicians recommend this same tactic.
Most experts in the United States are concerned about the tendency for pneumococcus in an ear infection to cause more serious infections. When pneumococcus causes an ear infection, if left untreated, it will persist in the ear of 80% of children for up to a week. However, most episodes of acute otitis media will resolve on their own from 3 to 10 days. Yet, non-treatment may be dangerous, not only because of the risk of serious pneumococcus infections, but also because of the possibility of other serious complications. Furthermore, few parents are willing to watch a child suffer with an earache, a fever, and crying for several days.
Amoxicillin (the “pink ink”) is the drug of choice for initial ear infections, except in the penicillin allergic child. In an attempt to enhance the effectiveness of this inexpensive and safe antibiotic, many doctors are now prescribing amoxicillin twice a day and in double the daily standard dose. Effectiveness for initial therapy with most antibiotics approaches 70% to 80%. There are other antibiotics to treat children who do not respond to amoxicillin or who never seem to respond to initial amoxicillin therapy.
Children who do not respond after two or more standard courses of antibiotics can be expected to respond to another antibiotic only about 50% to 60% of the time. Most children who fail antibiotic therapy are younger than 24 months, have poor eustachian tube function, and tend to be infected with more resistant bacteria. At this point, the easy-to-treat bacteria usually have been eliminated. The persistent bacteria are the most resistant strains of the three most common ear bacteria. The emergence of more resistant strains is outpacing the development of new effective drugs. A child’s doctor should be relied upon to select the most effective second-line antibiotic choices.
The new “one-shot” (ceftriaxone) for acute otitis media also is effective for simple cases of acute otitis media. However, “the shot” should only be used in select children, such as those with vomiting and diarrhea, very cantankerous toddlers, or children with an associated moderately serious illness. Three daily doses of ceftriaxone also may be very effective in children who have failed three to four consecutive courses of antibiotics, and are destined for tube placement.
The Centers for Disease Control (CDC) has convincingly pointed out that antibiotic overuse is one of the major culprits for the increasing antibiotic resistance problem. Parents should not insist on an antibiotic prescription for fevers, minor colds, and respiratory illnesses.
Physicians almost never know which bacteria they are treating. Thus, the CDC and other otitis experts advocate the use of tympanocentesis (lancing the ear or ear tap) for children who have failed antibiotic therapy.
Tympanocentesis:
relieves instantly the pain of the child with a crying earache; enables the physician to culture the bacteria and to select the best antibiotic for the infection; and allows the ear infection (like an abscess) to drain, which may improve the healing process.
The procedure can be performed nearly pain free. Only physicians who have been trained in the procedure perform it.
No medication is currently available to treat viruses that precipitate ear infections, either before or during the illness. An exception is the flu virus. Anti-flu medications and the flu vaccine could help prevent some wintertime ear infections, but only for the small number of children with ear infections related to the flu.
What are the complications?
The most serious complications secondary to ear infections are mastoiditis (infection of the skull bone behind the ear) and meningitis (infection of the lining of the brain). Both are extremely rare.
Chronic draining ears and chronic perforations (holes in the eardrum) are uncommon, but occur more frequently as a result of resistant pneumococcus. However, these complications are commonly seen in developing countries where antibiotics are not readily available. Permanent hearing loss from very severe recurrent infections is a major concern, but is still rarely observed with effective antibiotic therapy. Children with an ear infection (even ones that rupture and drain) suffer only some temporary, low grade hearing loss. As the fluid resolves, which may take months, the hearing returns to baseline levels.
Your child’s doctor may work with an ear-nose-and-throat doctor to help treat the more severely afflicted child, or one who has suspected chronic hearing loss. Children with chronic fluid persisting for more than four months, or with more than five or six ear infections in a year, may require the insertion of “tubes.” This is most important during the first two years of life when hearing is critical for speech and language development. Chronic ear infections may aggravate learning and later school problems, but cause and effect on this issue remains speculative.
Severe complications from ear infections nearly have been eliminated, and there is an array of antibiotics to treat them; however, the rate of highly resistant bacteria infecting children has increased. Physicians cannot continue to wastefully prescribe antibiotics, and parents should not demand them to treat everyday colds and viral infections. Although the new Prevnar vaccine may prevent many strains of highly resistant pneumococcus, with continual antibiotic misuse, microbiologic history will repeat itself in other pneumococcal strains or in other bacteria.
How can an ear infection be prevented?
The simplest preventive measures include the following:
Breastfeed an infant during the first 12 months of life
For bottle-fed infants, never prop the bottle and wean off the bottle by 12 months
Do not smoke around the baby, particularly in the household or the car
Do not smoke during pregnancy
Consider a private sitter or a smaller daycare, instead of a high volume daycare
Avoid the introduction of solid foods in the first four months of life
Administer the flu vaccine annually after six months of age
Consider allergen avoidance and allergy shots in older children (over three years) with chronic fluid
Administer Prevnar vaccine to infants less than 24 months of age
More controversial preventive measures include the following:
Avoid the pacifier
Give the pneumococcal vaccine (Prevnar) to infants and children older than 24 months who are unvaccinated with Prevnar and still getting recurrent ear infections
Ineffective measures include the following:
Covering a child’s head with a hat during the winter
Using decongestants and antihistamines to “prevent” ear infections
Chiropractic manipulation
Herbal remedies
What research is being done?
The most important recent development to potentially reduce the frequency of ear infections is a new pneumococcal conjugate vaccine. A study from Northern California suggests that this vaccine could prevent about 7% of overall episodes of ear infections, and up to 23% of recurrent ear infections.
The new pneumococcal vaccine contains 7 of 90 types of pneumococcus, which are the most common and the most resistant bacteria. Elimination of these resistant types could have an impact on the number of antibiotic failures in children. This also could mean a reduction in the placement of tubes, possibly by one-fourth, as observed in the California study.
This vaccine is administered to infants at 2, 4, 6, and 12 months of age. Side effects have been minimal, and it has been a very safe vaccine. It uses the same technology as the universally administered HIB vaccine.
ome new antibiotics are about to undergo testing in children with acute otitis media. In preliminary testing, these drugs appear to work against the resistant pneumococcus.
In the future, there may be alternate ways of treating or preventing ear infections. A new antibiotic may be able to penetrate the eardrum directly by instilling eardrops. A nasal spray squirted in the nose of infants a few times a day may prevent the common bacteria of acute otitis media from gaining access to the nose. Some Scandinavian investigators have shown slight reduction in the number of ear infections in children who regularly used an experimental sugar called xylitol.
About the Author
Dr. Block is a full-time practicing pediatrician in rural Bardstown, Kentucky who serves on the clinical faculties at both the University of Kentucky and the University of Louisville as an Associate Clinical Professor of Pediatrics.
His pediatric practice is one of the leading pediatric research groups in the United States and, in fact, Dr. Block was awarded the American Academy of Pediatrics 1998 Practitioner Research Award.
He has authored and published over 20 articles and 40 abstracts on pediatric infectious diseases. He has also lectured on Otitis Media extensively to pediatricians and other physicians throughout the U.S. and Canada.
Copyright 2012 Stan L. Block, M.D., All Rights Reserved
Acute Strep Throat
What is Strep Throat?
What causes sore throats?
Who gets strep throat?
How does strep cause disease?
Common findings
How do you diagnose strep throat?
Treatment
What are the complications of strep throat?
How do you prevent strep complications?
What research is being done?
by Michael E. Pichichero, M.D.
Professor of Microbiology and Immunology, Pediatrics and Medicine
University of Rochester Medical Center
Elmwood Pediatric Group
What is Strep Throat?
Streptococcal pharyngitis (“strep throat”) is one of the most common bacterial infections in children. Although there are over 20 types of streptococci, the group A strain is the most frequently encountered as a cause of sore throat. The changes of acute strep throat are confined to the tonsils, back of the throat, and the draining lymph nodes in the front of the neck. Changes in the infected tissues reflect an inflammation which produces redness, swelling, and pus on the surface of the tonsils and back of the throat.
Blisters and ulcers are uncommon. In infants, the nose is more typically involved in the infection as opposed to the throat. Infection may be transferred from the back of the throat or the nose to the skin, causing facial impetigo. Localized extension of strep may occur to adjacent cites to include the sinuses, the middle ear (acute ear infection), the epiglottis, and regional lymph nodes. Further extension may lead to meningitis in rare cases.
What causes sore throats?
The largest proportion of children (15-40%) and adolescents (30-60%) with sore throat have a viral infection. About 8-30% of children and 5-9% of teenagers with fever and throat inflammation have a strep infection. Other bacteria infrequently cause throat infection. Particularly among teenagers, the differential diagnosis includes other species of streptococci (group C and group G) and even the possibility of gonococci (gonorrhea germ) causing a sore throat. Other bacteria include Mycoplasma pneumoniae, Chlamydia pneumoniae and Arcanobacterium haemolyticum as causes of symptomatic sore throat.
In developing countries, diphtheria remains a cause of sore throat. Very often sore throats are of unknown course and this may represent viruses which at present cannot be identified, post nasal drip, allergy, etc.
Who gets strep throat?
Strep throat infections are spread person-to-person. Humans are the natural reservoir of this bacteria. The nose and back of the throat are the main sources of carriage of this bacteria. The skin and feces are potential sites. Aerosolized upper respiratory mucus serves as the primary source of the strep germ spreading to others. Direct contact with infected nose and throat tissues (by kissing) is of less importance as is contact with contaminated objects, such as toothbrushes.
Spread of strep throat requires the presence of a susceptible child and is facilitated by close contact.
Acquisition of infection is rare in infancy due to mothers’ immunity conferred transplacentally. Infection is uncommon below the age of two years. When infection occurs during the toddler years, it most often involves the nose. Children in day care and grade school more frequently contract and spread strep throat. Teenagers and adults usually have had contacts with the bacteria over time to provide immunity, thereby rendering strep uncommon in these age groups.
How does strep cause disease?
Strep produces a self-limited localized inflammation of the throat, generally lasting 3-5 days. Antibiotic treatment, if prompt and appropriate, reduces the duration of symptoms, shortens the period of contagion and reduces the risk of localized spread and complications. A major objective of administering antibiotics is to prevent heumatic fever and possibly reduce the occurrence of post-strep kidney damage.
Common findings
Strep throat cannot be accurately diagnosed on the basis of history and examination in most patients. Classically, strep throat patients have fever, redness and swelling of the throat with pus on the tonsils and back of the throat. Swollen and tender lymph nodes in the front of the neck typically occur. It is quite unusual for a patient with strep throat to also have a runny nose and a cough. Strep throat occurs most commonly in mid-winter to early spring. If all of the typical history and symptoms of strep throat are present, then the likelihood of strep approaches 60-70% in children and 20-30% in teenagers.
How do you diagnose strep throat?
In 1954, the first reports of using a throat culture in an office setting initiated an era of office based laboratory diagnosis for pediatricians and family doctors. The use of a throat culture to confirm the presence of strep throat has become a common practice and has grown steadily such that by the early 1980’s the Centers for Disease Control estimated that between 28-36 million throat cultures were performed annually in the United States. The value of this simple laboratory test in avoiding unnecessary antibiotics and in identifying children and teenagers requiring treatment is considerable.
Rapid strep detection tests came into wide use in the 1990’s. These tests can be performed quickly at a cost that is comparable to a 10 days supply of penicillin. These tests, if properly performed, have the same reliability as a throat culture.
Treatment
Treatment should relieve the symptoms of acute strep throat, eliminate transmission and prevent complications. Ideally, the chosen antibiotic should be easy to administer free of side effects and affordable. None of the antibiotics used in the treatment of strep throat achieves all of these goals in all infected patients-including penicillin which is the gold standard of therapy. In considering treatment of strep throat, the physician is faced with a large number of generic and brand name antibiotics with wide ranges of effectiveness, side effects and costs.
Strep germs are highly susceptible to penicillin, amoxicillin, Augmentin, and the cephalosporins (Keflex, Duracef, Ceclor, Lorabid, Cefzil, Ceftin, Vantin, Omnicef and Cedax). 90-95% of strep strains are susceptible to erythromycin, Biaxin, Zithromax and Cleocin. Ten days of oral penicillin and erythromycin are necessary to achieve a maximum cure of strep throat. However, completion of 10 days therapy is often problematic as parents and teenagers forget to administer or take the antibiotic as symptoms improve over the first few day of treatment.
A five day course of therapy with several cephalosporins has been shown to produce a similar or superior cure compared with 10 days of oral penicillin. The cephalosporins tested for five days include Duracef, Ceftin, Vantin and Omnicef. Zithromax may be administered for five days because the antibiotic persists in the throat tissues for five days after discontinuation of the drug.
What are the complications of strep throat?
The main concern with strep throat relates to the development of acute rheumatic fever. This is an infection of the heart valves which leads to permanent heart valve damage with the possibility of progression to heart failure. Strep throat also causes kidney damage if not prevented by use of antibiotics. The kidney damage of the filtering system can lead to both acute kidney failure and chronic kidney problems. Of course, strep can also spread to tissues in the upper airways (for example, deep throat infections and infections of the draining lymph nodes at the front of the neck. Extension from the throat to the brain rarely occurs thereby producing meningitis or brain abscess.
How do you prevent strep complications?
Antibiotics, if promptly initiated, will prevent virtually all of the complications of strep. Rheumatic fever can be prevented if antibiotic therapy is begun within 9 days of the onset of first symptoms.
What research is being done?
New antibiotics are usually tested for their effectiveness in the treatment of strep throat and antibiotics which can be administered for shorter durations of time do represent the possibility of a treatment advance because of the tendency for everyone to prefer shorter treatment durations for a complete cure. Vaccines for the prevention of strep throat have now reached clinical studies in humans. The difficulty in development of an effective vaccine for strep throat has been the diversity of strep strains.
About the Author
Dr. Michael E. Pichichero is currently a Professor of Microbiology and Immunology, Pediatrics and Medicine at the University of Rochester in Rochester, NY.
A graduate of the University of Rochester School of Medicine, Dr. Pichichero completed his postgraduate pediatric residency at the University of Colorado in Denver, followed by a Chief Residency and two fellowships resulting in board certification in Pediatrics, in Adult and Pediatric Allergy and Immunology and in Pediatric Infectious Disease.
Dr. Pichichero is a partner in the Elmwood Pediatric Group where he continues to practice in primary care and as a subspecialist consultant.
A recipient of numerous awards and a member of most professional societies in his fields of interest, Mike has over 300 publications in infectious diseases, immunology, and allergy.
His major practice and research interests are in vaccine development, streptococcal infections, and otitis media: in each of these areas he is a prominent international authority.
Reviewed 11/4/2010
Copyright 2012 Michael E. Pichichero, M.D., All Rights Reserved
Addison
What is Addison’s disease?
What causes Addison’s disease?
Who gets Addison’s disease?
How does it cause disease?
What are the common findings?
How is Addison’s disease diagnosed?
How is Addison’s disease treated?
What are the complications?
How is Addison’s disease prevented?
What research is being done?
Michael S. Kappy, M.D., Ph.D.
Chief, Pediatric Endocrinology, The Children’s Hospital
Denver, Colorado
What is Addison’s disease?
Addison’s disease is a condition where the adrenal glands fail to secrete the normal amounts of two hormones-cortisol and aldosterone. These hormones are vital to maintain the balance of salt, blood sugar, and blood pressure in an individual. An English physician, Thomas Addison, first described this disease almost 150 years ago.
What causes Addison’s disease?
When Thomas Addison first described it, the disease primarily was caused by a tuberculosis infection that resulted from consuming the milk of tuberculous cows. In modern times, the cause of Addison’s disease is the production of antibodies against the adrenal glands for reasons unknown. It is known that “autoimmune” diseases of the endocrine glands can run in families, and more than one gland can be involved. Thus, individuals with Addison’s disease may have problems with their thyroid glands, or they may develop diabetes.
Who gets Addison’s disease?
This condition is sporadic. That is, although Addison’s disease may run in families, there is no clear mechanism of inheritance. Infected milk or any other contaminated food no longer causes the disease.
How does it cause disease?
The two major hormones of the adrenal gland-cortisol and aldosterone-are extremely important in regulating the balance of salts and blood sugar in the body. In addition, cortisol is a very important hormone in maintaining a normal blood pressure and a normal reaction to physical stresses, such as infections, surgeries, or trauma. The absence of these hormones during times of physical stresses can lead to shock; a serious metabolic imbalance; and, if not treated rapidly, death.
What are the common findings?
In the untreated state, Addison’s disease may be accompanied by weakness, weight loss from decreased appetite, nausea and vomiting, and salt craving. Low blood pressure and metabolic imbalance also may result in a decreased level of consciousness or a coma. Addison’s disease is rare in childhood, but children who are affected with it may not have a normal growth pattern.
A hormone that darkens the skin often is elevated in untreated Addison’s disease. Thus, a person with this condition may show a tanning of the skin out of proportion to sunlight exposure, and without a tan line. There also may be darkening in the creases of the palms, soles, and fingers; along the gum line; and on the nipples.
How is Addison’s disease diagnosed?
Aside from the clinical signs and the signs found upon physical examination, including low blood pressure, a diagnosis of Addison’s disease is usually made using laboratory tests. Typically, a patient has low blood sodium, high potassium (occasionally to life-threatening levels), and low blood sugar. The antibodies against the adrenal glands also can be measured; however, this test is just to confirm the diagnosis, since the results may not be available for many days.
How is Addison’s disease treated?
Fortunately, Addison’s disease is treatable with oral forms of the missing hormones. Cortisol is available in tablet form, and it is given 2 to 3 times a day. Aldosterone is not available, but a substitute drug, Florinef, is available in tablet form, and it is given 1 to 2 times daily. In emergencies, such as physical stresses (e.g., a fever of over 101 degrees or trauma), the daily dose of cortisol is tripled.
If the patient has an illness that is accompanied by vomiting, an intramuscular injection of cortisol (Solu-Cortef) must be given at home. Then, the patient must be taken to an emergency room for further treatment. All patients or their parents must have a dose of Solu-Cortef at home and be instructed on the proper technique to administer it.
What are the complications?
The complications of untreated Addison’s disease include cardiovascular collapse, coma, and death.
How is Addison’s disease prevented?
Since there is no clear cause for the development of the antibodies against the adrenal glands, Addison’s disease cannot be prevented at this time.
What research is being done?
Research is being conducted to clarify the relationship between Addison’s disease and other autoimmune diseases of the endocrine glands and other organs. Early recognition and treatment of this condition, especially during physical stresses, are key in preventing the complications caused by Addison’s disease.
References
Gotlin RW, Kappy MS, Slover RH, et al. Endocrine disorders. In: Hay WW, Jr., et al. Current pediatric diagnosis and treatment. 14th ed. Stamford, CT: Appleton and Lange, 1999:841-3.
About the Author
Dr. Kappy is a professor of pediatrics at the University of Colorado Health Sciences Center and the Chief of the Pediatric Endocrinology Department at The Children’s Hospital in Denver, Colorado.
He was a recipient of the Johns Hopkins University Distinguished Alumnus Award in 1996. His research interest include the treatment of precocious puberty and the effects of growth hormone in growth hormone-deficient individuals.
Copyright 2012 Michael S. Kappy, M.D., Ph.D., All Rights Reserved
AIDS/HIV
What is HIV/AIDS?
What causes HIV/AIDS?
Who gets HIV/AIDS?
How does HIV cause disease?
What are the common findings?
How is HIV/AIDS diagnosed?
How is the HIV infection treated?
What are the complications?
How is HIV prevented?
What research is being done?
Links to other information
Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome
by Elizabeth J. McFarland, M.D.
University of Colorado Health Sciences Center
Denver, CO
What is HIV/AIDS?
Acquired immunodeficiency syndrome (AIDS) is a condition in which the immune system has lost the ability to defend the body against infection and certain cancers. It is caused by infection with human immunodeficiency virus (HIV).
What causes HIV/AIDS?
The cause of AIDS is infection with HIV. HIV is a member of the family of viruses called retroviruses. This type of virus enters human cells and becomes incorporated into the cell’s genes (i.e., DNA). Once the infection has occurred, the body cannot rid itself of the virus. The effect of the virus on the immune system leads to AIDS.
Who gets HIV/AIDS?
HIV/AIDS affects people of all ages and racial/ethnic backgrounds. Usually, infants and children acquire the infection from the mother during pregnancy, delivery, or breastfeeding. The most common mode of transmission for teens and adults is sexual contact. Currently, the largest number of HIV-infected people lives in Africa, India, and Southeast Asia. In the United States, homosexual men and injecting drug users have the highest prevalence of infection. However, adolescents and women, particularly those of African-American and Hispanic background, have the highest rates of new infections.
Casual, classroom, or household contact with an HIV-infected person poses no risk. Transmission cannot occur from sharing dishes, towels, or bathroom facilities. Saliva, urine, and stool are not contagious unless there is visible blood in the fluid.
HIV is transmitted through contact with infected semen or cervical secretions. People who have sexual contact with an infected person are at risk of acquiring the infection. The virus can be transmitted by both heterosexual and homosexual contact. Men and women, adults and teenagers can become infected with HIV.
HIV is transmitted from mother to infant during pregnancy, delivery, and breastfeeding. An infected woman who does not receive treatment during pregnancy has a 25% to 30% chance of passing the virus on to her baby. With treatment, the chance of having an infected baby can be reduced to 1%.
HIV is transmitted through contact with infected blood or body fluids contaminated with visible blood. Donated blood is screened for HIV so there is almost no risk of an infection from blood transfusion products. However, people who use injection drugs sometimes share their injection equipment. If an HIV-infected person shares a needle or other injection equipment, the virus can be transmitted to the other people. A health care professional who is exposed to blood from an infected person has a risk of being infected with HIV. This risk is greatest when a contaminated sharp instrument penetrates the skin. There also is a small risk of infection when blood splashes into the eye or the mouth of the worker. There is no risk of infection with blood contact to intact skin (i.e., skin without cuts, scratches, or a rash). Under usual circumstances, there is no risk of transmission of HIV from a health care professional to a patient. However, all people should handle blood and bloody body secretions carefully.
How does HIV cause disease?
HIV infection, without treatment, causes a progressive dysfunction of the immune system. When the immune system is defective, the body cannot defend itself against infections. HIV infects immune cells that are critical components of the immune system, particularly helper T lymphocytes (T4 cells). When the cells are infected with HIV, they do not function normally, and some cells are destroyed.
What are the common findings?
Teens and adults may have symptoms in the first two to six weeks after the initial infection with HIV (acute primary infection). The most common symptoms of the primary infection are fever, fatigue, muscle aches, headache, sore throat, and swollen lymph nodes (glands in the neck, under the arms, and in the groin). These symptoms are not specific to HIV infection since many viral infections cause similar symptoms. Some other symptoms more particular to primary HIV infection are mouth ulcers, a rash, and meningitis. However, even these symptoms do not prove HIV infection because they can occur with other infections. Some people have no symptoms after the acute infection. The symptoms of the primary infection resolve without treatment. Most people do not seek medical attention, and they are not aware that they have acquired HIV.
After the primary infection, most people infected with HIV have no symptoms in the early stages of the disease. For adults and adolescents, progression of the disease usually occurs several years after the primary infection. About 30% of infants infected at birth will have disease progression within 12 to 18 months of life.
When the disease progresses, common first symptoms include enlargement of the lymph nodes, liver, and/or spleen; poor growth; frequent minor infections, such as ear infections and sinusitis; cold sores that do not heal; thrush or diaper rash that persists despite treatment; shingles; night sweats; and recurrent fever. When the disease reaches advanced stages, most patients have weight loss; infections of the lungs, blood stream, bones, joints, intestines, and eyes; and certain cancers. Some people develop neurologic symptoms manifested by developmental delay in children and by memory loss and dementia in teens and adults.
How is HIV/AIDS diagnosed?
The most commonly used diagnostic test for HIV infection detects antibodies to HIV in the blood. The body makes antibodies as a part of the immune defense against infections. If antibodies against HIV are present (a “positive” test), this indicates that the person is infected with HIV. This is why infected people are called “HIV positive.”
The antibody test is done in two parts. The first part is called an ELISA. Occasionally, a person will test positive on an ELISA even though they are not HIV infected. Therefore, a positive ELISA test must have a confirmatory test done on the same blood sample showing that the antibodies are truly specific for HIV. A negative ELISA indicates that the person is not infected and usually does not require a follow-up test.
In some patients, antibody tests are not reliable. In this case, tests that directly detect the virus are used. The most commonly used tests detect the virus genetic material (DNA or RNA) or protein (p24 antigen) in the blood. Virus tests are used to diagnose HIV infection in infants born to HIV-infected mothers. Antibody tests on the baby are not reliable until after 18 months of age because all mothers will pass antibodies to their babies, but not all mothers will pass the virus. In order to determine if the infant is infected, tests to detect the virus in the baby’s blood are performed. The majority of infected infants will have the virus detected by three to four months of life. Uninfected infants will have negative tests for the virus (even though their antibody test is positive).
Direct virus testing also is used for adults and teenagers who may have been recently exposed to HIV. The virus tests are positive about 10 to 14 days before the antibody tests are positive. Using the direct virus test permits an earlier diagnosis of infection.
How is the HIV infection treated?
Recently, many new medications have been developed to treat HIV infection. These medications are called anti-retroviral drugs, and they inhibit the replication or reproduction of the virus. Effective treatment requires a combination of several different anti-retroviral medications, taken by mouth, one to three times a day. The amount of virus in the blood and the number of helper T cells are monitored closely to determine whether the medications are effective. Although there is no cure for HIV/AIDS, with effective treatment, infected people may live for years without disease progression.
What are the complications?
The complications of HIV infection are primarily related to immune dysfunction. Immune dysfunction leads to infection with other bacteria, viruses, or fungi. Medications can be taken daily or weekly to prevent these infections. In some patients, HIV causes abnormal function of the heart, bone marrow, brain, muscles, intestines, liver, and pancreas.
How is HIV prevented?
The most important method to prevent HIV infection is to avoid exposure by sexual contact. Abstinence is the only certain way to avoid sexual exposure to HIV. The risk of transmission can be greatly reduced by the correct use of condoms during sexual contact. Individuals who do have sexual contact should limit their number of partners and use condoms correctly every time they have sexual contact.
Sharing contaminated needles can transmit HIV. Injection drug users should not share injection equipment. Children should be taught to avoid contact with other people’s blood. They also should avoid sharing sharp personal objects (e.g., razors, body-piercing equipment), which may be contaminated by blood and have not been properly sterilized. When caring for a bleeding wound, a thick layer of paper or cloth should be used to reduce the chances of contact with the blood.
Over 95% of infections passed from mother to infant can be prevented if the mother and infant receive treatment during pregnancy, labor, and the first weeks after birth. All women should be offered testing for HIV during pregnancy so they can receive the preventative treatments if they are HIV positive.
What research is being done?
Research on the treatment and prevention of HIV infection is very active. The areas of most intense interest are the development of a vaccine to prevent infection, the development of improved anti-retroviral medications, and studies to understand how the body’s immune defenses against HIV infection can be enhanced.
Links to other information
http://www.fxbcenter.org/
Sponsor: The Francois-Xavier Bagnoud Center, University of Medicine and Dentistry of New Jersey, The National Pediatric and Family HIV Resource Center (NPHRC). This Web site includes extensive information about HIV that is related to children and youth.
http://www.kidsconnect.org/porch/
This Web site includes information about HIV that is written at a child’s level.
http://hivinsite.ucsf.edu/
This Web site includes information about HIV that is both focused on youth and written in youth-friendly terms.
About the Author
Dr. McFarland is the medical director and co-founder of the Children’s Hospital Immunodeficiency Program (CHIP) in Denver, CO. CHIP provides comprehensive health care to infants, children, adolescents, young adults and pregnant women infected or affected by HIV.
Dr. McFarland is a member of the National Institutes of Health sponsored Pediatric AIDS Clinical Trial Group and is active in basic and clinical HIV research. She is board certified in Pediatric Infectious Diseases and a faculty member at the University of Colorado Health Sciences Center.
She received her MD degree from Duke University School of Medicine and her pediatric and subspecialty training from the University of Colorado Health Sciences Center.
Copyright 2012 Elizabeth J. McFarland, M.D., All Rights Reserved
Anxiety
What is Anxiety Disorder?
Anxiety is a normal reaction to stress and can actually be beneficial in some situations. For some people, however, anxiety can become excessive. While the person suffering may realize their anxiety is too much, they may also have difficulty controlling it and it may negatively affect their day-to-day living. There are a wide variety of anxiety disorders, including post-traumatic stress disorder, obsessive-compulsive disorder, and panic disorder to name a few. Collectively, they are among the most common mental disorders experienced by Americans.
The following anxiety disorders are discussed on this website:
generalized anxiety disorder (GAD)
obsessive-compulsive disorder (OCD),
panic disorder,
post-traumatic stress disorder (PTSD), and
social phobia (or social anxiety disorder).
Causes
NIMH supports research into the causes, diagnosis, prevention, and treatment of anxiety disorders and other mental illnesses. Scientists are looking at what role genes play in the development of these disorders and are also investigating the effects of environmental factors such as pollution, physical and psychological stress, and diet. In addition, studies are being conducted on the “natural history” (what course the illness takes without treatment) of a variety of individual anxiety disorders, combinations of anxiety disorders, and anxiety disorders that are accompanied by other mental illnesses such as depression.
Scientists currently think that, like heart disease and type 1 diabetes, mental illnesses are complex and probably result from a combination of genetic, environmental, psychological, and developmental factors. For instance, although NIMH-sponsored studies of twins and families suggest that genetics play a role in the development of some anxiety disorders, problems such as PTSD are triggered by trauma. Genetic studies may help explain why some people exposed to trauma develop PTSD and others do not.
Several parts of the brain are key actors in the production of fear and anxiety. Using brain imaging technology and neurochemical techniques, scientists have discovered that the amygdala and the hippocampus play significant roles in most anxiety disorders.
The amygdala is an almond-shaped structure deep in the brain that is believed to be a communications hub between the parts of the brain that process incoming sensory signals and the parts that interpret these signals. It can alert the rest of the brain that a threat is present and trigger a fear or anxiety response. The emotional memories stored in the central part of the amygdala may play a role in anxiety disorders involving very distinct fears, such as fears of dogs, spiders, or flying.
The hippocampus is the part of the brain that encodes threatening events into memories. Studies have shown that the hippocampus appears to be smaller in some people who were victims of child abuse or who served in military combat. Research will determine what causes this reduction in size and what role it plays in the flashbacks, deficits in explicit memory, and fragmented memories of the traumatic event that are common in PTSD.
By learning more about how the brain creates fear and anxiety, scientists may be able to devise better treatments for anxiety disorders. For example, if specific neurotransmitters are found to play an important role in fear, drugs may be developed that will block them and decrease fear responses; if enough is learned about how the brain generates new cells throughout the lifecycle, it may be possible to stimulate the growth of new neurons in the hippocampus in people with PTSD.
Current research at NIMH on anxiety disorders includes studies that address how well medication and behavioral therapies work in the treatment of OCD, and the safety and effectiveness of medications for children and adolescents who have a combination of anxiety disorders and attention deficit hyperactivity disorder.
Signs & Symptoms
Unlike the relatively mild, brief anxiety caused by a stressful event (such as speaking in public or a first date), anxiety disorders last at least 6 months and can get worse if they are not treated. Each anxiety disorder has different symptoms, but all the symptoms cluster around excessive, irrational fear and dread.
Anxiety disorders commonly occur along with other mental or physical illnesses, including alcohol or substance abuse, which may mask anxiety symptoms or make them worse. In some cases, these other illnesses need to be treated before a person will respond to treatment for the anxiety disorder.
Effective therapies for anxiety disorders are available, and research is uncovering new treatments that can help most people with anxiety disorders lead productive, fulfilling lives. If you think you have an anxiety disorder, you should seek information and treatment right away.
Who Is At Risk?
Anxiety disorders affect about 40 million American adults age 18 years and older (about 18%) in a given year, causing them to be filled with fearfulness and uncertainty.
Women are 60% more likely than men to experience an anxiety disorder over their lifetime. Non-Hispanic blacks are 20% less likely, and Hispanics are 30% less likely, than non-Hispanic whites to experience an anxiety disorder during their lifetime.
A large, national survey of adolescent mental health reported that about 8 percent of teens ages 13–18 have an anxiety disorder, with symptoms commonly emerging around age 6. However, of these teens, only 18 percent received mental health care.
Diagnosis
A doctor must conduct a careful diagnostic evaluation to determine whether a person’s symptoms are caused by an anxiety disorder or a physical problem. If an anxiety disorder is diagnosed, the type of disorder or the combination of disorders that are present must be identified, as well as any coexisting conditions, such as depression or substance abuse. Sometimes alcoholism, depression, or other coexisting conditions have such a strong effect on the individual that treating the anxiety disorder must wait until the coexisting conditions are brought under control.
Treatments
In general, anxiety disorders are treated with medication, specific types of psychotherapy, or both. Treatment choices depend on the problem and the person’s preference.
People with anxiety disorders who have already received treatment should tell their current doctor about that treatment in detail. If they received medication, they should tell their doctor what medication was used, what the dosage was at the beginning of treatment, whether the dosage was increased or decreased while they were under treatment, what side effects occurred, and whether the treatment helped them become less anxious. If they received psychotherapy, they should describe the type of therapy, how often they attended sessions, and whether the therapy was useful.
Often people believe that they have “failed” at treatment or that the treatment didn’t work for them when, in fact, it was not given for an adequate length of time or was administered incorrectly. Sometimes people must try several different treatments or combinations of treatment before they find the one that works for them.
Medication
Medication will not cure anxiety disorders, but it can keep them under control while the person receives psychotherapy. Medication must be prescribed by physicians, usually psychiatrists, who can either offer psychotherapy themselves or work as a team with psychologists, social workers, or counselors who provide psychotherapy. The principal medications used for anxiety disorders are antidepressants, anti-anxiety drugs, and beta-blockers to control some of the physical symptoms. With proper treatment, many people with anxiety disorders can lead normal, fulfilling lives.
Antidepressants
Antidepressants were developed to treat depression but are also effective for anxiety disorders. Although these medications begin to alter brain chemistry after the very first dose, their full effect requires a series of changes to occur; it is usually about 4 to 6 weeks before symptoms start to fade. It is important to continue taking these medications long enough to let them work.
SSRIs
Some of the newest antidepressants are called selective serotonin reuptake inhibitors, or SSRIs. SSRIs alter the levels of the neurotransmitter serotonin in the brain, which, like other neurotransmitters, helps brain cells communicate with one another.
Fluoxetine (Prozac®), sertraline (Zoloft®), escitalopram (Lexapro®), paroxetine (Paxil®), and citalopram (Celexa®) are some of the SSRIs commonly prescribed for panic disorder, OCD, PTSD, and social phobia. SSRIs are also used to treat panic disorder when it occurs in combination with OCD, social phobia, or depression. Venlafaxine (Effexor®), a drug closely related to the SSRIs, is used to treat GAD. These medications are started at low doses and gradually increased until they have a beneficial effect.
SSRIs have fewer side effects than older antidepressants, but they sometimes produce slight nausea or jitters when people first start to take them. These symptoms fade with time. Some people also experience sexual dysfunction with SSRIs, which may be helped by adjusting the dosage or switching to another SSRI.
Tricyclics
Tricyclics are older than SSRIs and work as well as SSRIs for anxiety disorders other than OCD. They are also started at low doses that are gradually increased. They sometimes cause dizziness, drowsiness, dry mouth, and weight gain, which can usually be corrected by changing the dosage or switching to another tricyclic medication.
Tricyclics include imipramine (Tofranil®), which is prescribed for panic disorder and GAD, and clomipramine (Anafranil®), which is the only tricyclic antidepressant useful for treating OCD.
MAOIs
Monoamine oxidase inhibitors (MAOIs) are the oldest class of antidepressant medications. The MAOIs most commonly prescribed for anxiety disorders are phenelzine (Nardil®), followed by tranylcypromine (Parnate®), and isocarboxazid (Marplan®), which are useful in treating panic disorder and social phobia. People who take MAOIs cannot eat a variety of foods and beverages (including cheese and red wine) that contain tyramine or take certain medications, including some types of birth control pills, pain relievers (such as Advil®, Motrin®, or Tylenol®), cold and allergy medications, and herbal supplements; these substances can interact with MAOIs to cause dangerous increases in blood pressure. The development of a new MAOI skin patch may help lessen these risks. MAOIs can also react with SSRIs to produce a serious condition called “serotonin syndrome,” which can cause confusion, hallucinations, increased sweating, muscle stiffness, seizures, changes in blood pressure or heart rhythm, and other potentially life-threatening conditions.
Anti-Anxiety Drugs
High-potency benzodiazepines combat anxiety and have few side effects other than drowsiness. Because people can get used to them and may need higher and higher doses to get the same effect, benzodiazepines are generally prescribed for short periods of time, especially for people who have abused drugs or alcohol and who become dependent on medication easily. One exception to this rule is people with panic disorder, who can take benzodiazepines for up to a year without harm.
Clonazepam (Klonopin®) is used for social phobia and GAD, lorazepam (Ativan®) is helpful for panic disorder, and alprazolam (Xanax®) is useful for both panic disorder and GAD.
Some people experience withdrawal symptoms if they s taking benzodiazepines abruptly instead of tapering off, and anxiety can return once the medication is sped. These potential problems have led some physicians to shy away from using these drugs or to use them in inadequate doses.
Buspirone (Buspar®), an azapirone, is a newer anti-anxiety medication used to treat GAD. Possible side effects include dizziness, headaches, and nausea. Unlike benzodiazepines, buspirone must be taken consistently for at least 2 weeks to achieve an anti-anxiety effect.
Beta-Blockers
Beta-blockers, such as propranolol (Inderal®), which is used to treat heart conditions, can prevent the physical symptoms that accompany certain anxiety disorders, particularly social phobia. When a feared situation can be predicted (such as giving a speech), a doctor may prescribe a beta-blocker to keep physical symptoms of anxiety under control.
Taking Medications
Before taking medication for an anxiety disorder:
Ask your doctor to tell you about the effects and side effects of the drug.
Tell your doctor about any alternative therapies or over-the-counter medications you are using.
Ask your doctor when and how the medication should be sped. Some drugs can’t be sped abruptly but must be tapered off slowly under a doctor’s supervision.
Work with your doctor to determine which medication is right for you and what dosage is best.
Be aware that some medications are effective only if they are taken regularly and that symptoms may recur if the medication is sped.
Psychotherapy
Psychotherapy involves talking with a trained mental health professional, such as a psychiatrist, psychologist, social worker, or counselor, to discover what caused an anxiety disorder and how to deal with its symptoms.
Cognitive-Behavioral Therapy
Cognitive-behavioral therapy (CBT) is very useful in treating anxiety disorders. The cognitive part helps people change the thinking patterns that support their fears, and the behavioral part helps people change the way they react to anxiety-provoking situations.
For example, CBT can help people with panic disorder learn that their panic attacks are not really heart attacks and help people with social phobia learn how to overcome the belief that others are always watching and judging them. When people are ready to confront their fears, they are shown how to use exposure techniques to desensitize themselves to situations that trigger their anxieties.
People with OCD who fear dirt and germs are encouraged to get their hands dirty and wait increasing amounts of time before washing them. The therapist helps the person cope with the anxiety that waiting produces; after the exercise has been repeated a number of times, the anxiety diminishes. People with social phobia may be encouraged to spend time in feared social situations without giving in to the temptation to flee and to make small social blunders and observe how people respond to them. Since the response is usually far less harsh than the person fears, these anxieties are lessened. People with PTSD may be supported through recalling their traumatic event in a safe situation, which helps reduce the fear it produces. CBT therapists also teach deep breathing and other types of exercises to relieve anxiety and encourage relaxation.
Exposure-based behavioral therapy has been used for many years to treat specific phobias. The person gradually encounters the object or situation that is feared, perhaps at first only through pictures or tapes, then later face-to-face. Often the therapist will accompany the person to a feared situation to provide support and guidance.
CBT is undertaken when people decide they are ready for it and with their permission and cooperation. To be effective, the therapy must be directed at the person’s specific anxieties and must be tailored to his or her needs. There are no side effects other than the discomfort of temporarily increased anxiety.
CBT or behavioral therapy often lasts about 12 weeks. It may be conducted individually or with a group of people who have similar problems. Group therapy is particularly effective for social phobia. Often “homework” is assigned for participants to complete between sessions. There is some evidence that the benefits of CBT last longer than those of medication for people with panic disorder, and the same may be true for OCD, PTSD, and social phobia. If a disorder recurs at a later date, the same therapy can be used to treat it successfully a second time.
Medication can be combined with psychotherapy for specific anxiety disorders, and this is the best treatment approach for many people.
Living With
If you think you have an anxiety disorder, the first person you should see is your family doctor. A physician can determine whether the symptoms that alarm you are due to an anxiety disorder, another medical condition, or both.
If an anxiety disorder is diagnosed, the next step is usually seeing a mental health professional. The practitioners who are most helpful with anxiety disorders are those who have training in cognitive-behavioral therapy and/or behavioral therapy, and who are open to using medication if it is needed.
You should feel comfortable talking with the mental health professional you choose. If you do not, you should seek help elsewhere. Once you find a mental health professional with whom you are comfortable, the two of you should work as a team and make a plan to treat your anxiety disorder together.
Remember that once you start on medication, it is important not to s taking it abruptly. Certain drugs must be tapered off under the supervision of a doctor or bad reactions can occur. Make sure you talk to the doctor who prescribed your medication before you s taking it. If you are having trouble with side effects, it’s possible that they can be eliminated by adjusting how much medication you take and when you take it.
Most insurance plans, including health maintenance organizations (HMOs), will cover treatment for anxiety disorders. Check with your insurance company and find out. If you don’t have insurance, the Health and Human Services division of your county government may offer mental health care at a public mental health center that charges people according to how much they are able to pay. If you are on public assistance, you may be able to get care through your state Medicaid plan.
Ways to Make Treatment More Effective
Many people with anxiety disorders benefit from joining a self-help or support group and sharing their problems and achievements with others. Internet chat rooms can also be useful in this regard, but any advice received over the Internet should be used with caution, as Internet acquaintances have usually never seen each other and false identities are common. Talking with a trusted friend or member of the clergy can also provide support, but it is not a substitute for care from a mental health professional.
Stress management techniques and meditation can help people with anxiety disorders calm themselves and may enhance the effects of therapy. There is preliminary evidence that aerobic exercise may have a calming effect. Since caffeine, certain illicit drugs, and even some over-the-counter cold medications can aggravate the symptoms of anxiety disorders, they should be avoided. Check with your physician or pharmacist before taking any additional medications.
The family is very important in the recovery of a person with an anxiety disorder. Ideally, the family should be supportive but not help perpetuate their loved one’s symptoms. Family members should not trivialize the disorder or demand improvement without treatment.
Clinical Trials
NIMH supports research studies on mental health and disorders. See also: A Participant’s Guide to Mental Health Clinical Research.
Participate, refer a patient or learn about results of studies in ClinicalTrials.gov, the NIH/National Library of Medicine’s registry of federally and privately funded clinical trials for all disease.
Find NIH-funded studies currently recruiting participants in anxiety disorders.
Appendicitis
What is Appendicitis?
What Causes Appendicitis?
Who Gets Appendicitis??
What are the Symptoms of Appendicitis?
What are Some of the Other Possibilities?
How is Appendicitis Diagnosed?
How is Appendicitis Treated?
What are the Complications of Appendicitis?
Can Appendicitis be Prevented?
What is Appendicitis?
Appendicitis is the most common cause of an acute surgical abdomen in children. It occurs when the appendix, a small tube which protrudes from the large intestine, becomes acutely inflamed.
What Causes Appendicitis?
Appendicitis is usually caused by some sort of obstruction of the appendix or it’s opening (appendiceal lumen) by feces, any foreign object or body, or, in a few cases, a tumor. It can also be caused by a twist of the appendix, which can result in ischemic necrosis, a disease in which blood vessels are blocked by this twist so blood supply to the organs decreases and many cells die.
Who Gets Appendicitis?
Though appendicitis usually occurs in children over the age of two years and peaks during the teen and young adult years, it can occur in infants and toddlers. The disease is more commonly found in males than in females. The exact incidence of appendicitis is unknown. In terms of genetics, appendicitis has been found to show a familial tendency.
What are the Symptoms of Appendicitis?
The typical first warning sign of appendicitis is dull pain around the navel. The pain continues and often becomes more localized at the site of the appendix, downward and to the right side of the navel. Usually, pressure applied to this area will cause tenderness and pain. It is important to note that there is variability in the location of the appendix and so the location of the pain may also vary. A loss of or reduction in appetite is always present. Other symptoms may include: nausea, vomiting, and a low-grade fever, however, the vomiting never precedes the pain.
What are Some of the Other Possibilities?
The differential diagnosis for appendicitis is extensive. In the case of gastroenteritis (commonly called the stomach flu), vomiting and diarrhea usually occur before the onset of pain. Constipation can often be confused for appendicitis however this its pain pattern is not located in the lower right quadrant of the abdomen. A pneumonia in the right lower lobe of the lung can present with symptoms similar to appendicitis. Other conditions that may mimic appendicitis are: Urinary tract infection, inflammatory bowel disease, sickle cell crisis, diabetic ketoacidosis, ovarian torsion, ecic pregnancy, dysmenorrhea, Mittelschmerz, intussusception, Meckel’s diverticulitis or post-surgical adhesions in the abdomen.
How is Appendicitis Diagnosed?
If symptoms are present, the health care provider may perform tests while the patient is lying on his or her back to determine the severity and proximity of the pain such as: extending the right leg or rotating a flexed leg. A rectal exam may show right-sided tenderness. He or she may also choose to perform an abdominal ultrasound, an abdominal CT scan, or an exploratory laparotomy, a procedure using a small camera and an incision. Your health care provider may also choose to perform a chest x-ray, a complete blood count (CBC) and/or a urinalysis and urine culture. A pelvic examination may be indicated in a female adolescent with abdominal pain.
How is Appendicitis Treated?
Most commonly, appendicitis is treated by a surgery called an appendectomy whereby the appendix is removed (open surgery). More recently, surgeons have performed laparascopic surgery whereby smaller incisions are made to pass a camera and surgical instruments. A systematic review of 5 studies in 436 children aged 1 to 16 years found that laparoscopic surgery significantly reduced the number of wound infections and the length of hospital stay compared with open surgery. The review did not find any significant difference between laparoscopic surgery and open surgery for intra-abdominal abscesses, in poserative pain, and in the time to mobilization.
Another systematic review of several studies found that prophylactic antibiotics reduce the number of wound infections in children with complicated appendicitis compared with no antibiotics. Further studies are under way to determine whether antibiotics in children with simple appendicitis are indicated.
What are the Complications of Appendicitis?
Due to the variability in symptoms upon presentation and the subsequent progression of symptoms in young children appendicitis sometimes is not diagnosed in time, causing the intestines to perforate before surgery can be performed. Other complications of the disease include peritonitis (an infection in the intra-abdominal fluid and tissues, and/or decay of the intestines (gangrene).
Can Appendicitis be Prevented?
Studies have been done in adults whereby antibiotics were given to try to avoid surgery, but the recurrence rate was too high to make this a viable option. At the present time, there is no evidence that dietary or lifestyle regimens will help to prevent appendicitis.
References
Hoekelman RA, Blatman S, Friedman SB, Nelson NM, Seidel HM. Primary Pediatric Care 1987 C.V. Mosby
Suerland SR, Lefering R, Neugebauer EAM. Laparoscopic vs. open surgery for suspected appendicitis. The Cochrane Library, Issue 4, 2003. Chichester, UK: John Wiley and Sons
Milewczyk M, Michalik M, Ciesielski M. A prospective, randomized, unicenter study comparing laparoscopic and open treatments of acute appendicitis. SURG Endosc 2003; 37: 1317-1320
Reviewed 9/5/2009
By Daniel Feiten M.D.
Greenwood Pediatrics
Copyright 2012 Daniel Feiten M.D., All Rights Reserved
Aic Dermatitis (Eczema)
What is dermatitis?
What is eczema?
What causes eczema?
What is ay?
What causes ay?
Why do aic people get eczema?
What are the common findings?
How is aic eczema diagnosed?
How is aic eczema treated?
What are the complications?
How is eczema prevented?
What research is being done?
Links to other information
by Paul Gillum, M.D.
Aurora/Parker Skin Care Center
Aurora, Colorado
What is dermatitis?
“Dermatitis” literally means “inflamed skin.” The term, dermatitis, is used to describe the skin when it is irritated, red, or inflamed. For example, sunburn, hives, or the rash of measles may be described as dermatitis.
What is eczema?
Eczema is a specific type of dermatitis. With eczema, the skin is not only inflamed (dermatitis), but it also is oozing. Early on, the oozing may show up as small blisters (“vesicles”). After a few days, the blisters usually break open and dry up, leaving scabs or crusts. After several weeks, the oozing is only visible under a microscope. At this stage, eczema looks dry and scaly.
What causes eczema?
Eczema is a reaction pattern of the skin. There are numerous causes, or triggers, of eczema. Some cases are triggered by contact allergy, such as poison ivy. More often, eczema is a reaction to external irritation. For example, rubbing the skin (scratching) may cause an eczema reaction. Harsh chemicals, detergents, and excessive washing also can cause it. Generally, eczema does not result from internal causes, such as foods or medications. More often, internal triggers cause a different type of inflammation (dermatitis), called hives or urticaria.
What is ay?
Ay, meaning “without a place,” is a word invented in 1923 by Drs. Cooke and Coca, who were classifying and categorizing different skin conditions and rashes. They had a group of patients who had unusually sensitive skin, and who were very susceptible to irritation and eczema. Most of these patients also had family members with hay fever, allergies, or asthma. Since this group of patients did not fit in Dr. Coca’s classification system, he made up the word, ay, to describe them. Today, ay is considered an allergic condition that a person may inherit.
What causes ay?
It is not known why aic people have sensitive skin. Most aic people begin having eczema by two years old. If one parent is aic (i.e., has hay fever, asthma, or allergies), there is a 20% chance that the child also will be aic; when both parents are aic, there is a 60% chance. However, to develop eczema, there must be a cause, such as irritation. Therefore, the skin sensitivity and easy irritation is inherited, while eczema is not.
Human skin is designed to act as a barrier to keep water inside the body and to keep irritants outside the body. In aic people, the barrier does not work correctly, and the water evaporates easily, leading to very dry skin. Aic people also perceive the sensation of itch more easily. When clothing slides across the skin, most people feel a sensation of touch or tickle, but aic people feel a sensation of itch. Skin sensitivity and skin barrier function generally improve with time. Fifty percent of people s having skin irritation and eczema by age 5, and 90% of people s by age 9. Sometimes, eczema reappears in adults, usually after age 60.
Why do aic people get eczema?
Aic people itch more easily, more intensely, and more frequently than other people. Scratching-which triggers a rash-is believed to be the cause of eczema in aic people. In fact, eczema in aic people has been called “the itch that rashes.” Two experiments support this theory. If you gently scratch anybody’s skin for 15 minutes every day, you will produce the eczema reaction. Once the eczema reaction appears, the skin usually itches so much that people will keep scratching. Unless you interrupt the itch/scratch cycle, eczema cannot heal. On the other hand, if you put a protective cast over the eczema, it will heal very quickly, even without any other treatment.
Eczema can be triggered by any kind of irritation, not just scratching. Since the skin barrier in aic people does not work correctly, rough wool clothing, strong soap, frequent bathing, or stress can easily trigger eczema. Because aic skin loses water easily, eczema is often worse in dry winter months. Generally, aic eczema is not caused by contact allergy or by food allergy.
What are the common findings?
Aic people often have a small crease on the lower eyelid near the nose (“Dennie’s Pleats”). They may have dark circles under the eyes, probably from the closely associated hay fever/allergies. They may have small acne-like bumps on the backs of the arms. The wart virus and the ringworm/athlete’s foot fungus grow more easily on aic skin. These findings help to identify aic people even if they never have skin irritation or eczema.
Eczema always looks the same, no matter what causes it. It is red, scaly, crusted, or blistered. In infants, eczema is usually located on the scalp (“cradle cap”), cheeks, elbows, and knees. These areas are most affected in infants, because they cannot directly scratch with their fingers, but they can rub against bedding or other surfaces. In toddlers, eczema mostly occurs on the areas where skin can touch itself, like the creases in front of the elbows or behind the knees. In adults, eczema is rare (they usually have only hay fever or asthma), but it may occur on the hands and feet.
How is aic eczema diagnosed?
For aic eczema to be diagnosed, itch and eczema must occur. Eczema also must last for a long period of time, or it must appear frequently. Eczema should be in the classic location for the age of the patient. When a person is diagnosed with aic eczema, another family member usually is aic.
How is aic eczema treated?
The goal in treating eczema is for a child to be comfortable and still be able to function; it is not as important to make every last spot of eczema disappear. To treat the inflamed, itchy rash areas, most pediatricians and dermatologists will use very mild prescription strength cortisone (steroid) creams. These creams are applied two to three times daily until the rash clears, or the itching ss. The cortisone will penetrate the skin better if a damp cloth is applied after the medicine. Damp pajamas or long john underwear also may be used. Oral antihistamines, such as Benadryl, reduce the sensation of itch and increase drowsiness to ensure restful sleep. ical antihistamines do not work. Occasionally, us will prescribe antibiotics when the raw, irritated skin gets infected. Dietary manipulation generally does not work. Severe cases may require a special kind of ultraviolet light treatment or powerful anti-inflammatory medicines.
What are the complications?
Eczematous skin gets infected more easily, especially by the cold sore virus. People with active eczema should not touch a cold sore. In darker skin, eczema and other skin irritation may leave dark spots. Dark spots always resolve without treatment, but it may take several months. The intensity of itching may prevent restful sleep; therefore, young patients may be tired or grouchy during the day.
How is eczema prevented?
Eczema cannot be completely prevented, but it can be less severe and less frequent. Dry skin always itches easier and more severely than moist skin. Humidifiers are helpful. Thick cream moisturizers, applied very frequently, and especially after bathing, also are beneficial. Young children should bathe less frequently with less soap. All soap is very irritating, especially Ivory and deodorant soaps. Soap substitutes, like Cetaphil, are excellent. Soap substitutes can be massaged gently onto the skin and simply wiped off. They do not need to be rinsed. In addition, cotton clothing is less scratchy than most synthetics or wool clothing. To remove irritating soap residue, clothing should be double rinsed in the laundry.
What research is being done?
Currently, most of the research on eczema is focused on developing better and safer anti-inflammatory medications, both ical and oral. Significant research also is underway to better understand and correct the barrier abnormality of the skin. To review recent research articles, go to http://www.nlm.nih.gov and search “pubmed” on your Internet browser.
Links to other information
A list server is available for patients with eczema. Send an e-mail to listserv@sjuvm.stjohns.edu and type “subscribe eczema” in the subject line.
For eczema support group information, call or write to:
National Eczema Society
163 Eversholt Street
London NW1 1BU, United Kingdom
Phone: 0171 388 4097
Fax: 0171 388 5882
Web: http://www.eczema.org
For a pamphlet from the American Academy of Dermatology, go to http://www.aad.org/public/publications/pamphlets/skin_eczema.html
About the Author
After finishing medical school and dermatology training at the University of Oklahoma, Paul came to Colorado to further his knowledge in this specialty.
He is board certified in Dermatology and Dermaathology. He works at a busy private practice with offices in Aurora and Parker, Colorado. He also teaches at the University of Colorado Department of Dermatology.
Copyright 2012 Paul Gillum, M.D., All Rights Reserved
Attention-Deficit Hyperactivity Disorder
The Facts About ADHD
What is ADHD?
What causes ADHD?
How is ADHD diagnosed?
How is ADHD treated?
What research is being done?
Other Information
Sam Goldstein, Ph.D.
Neurology, Learning and Behavior Center
University of Utah
Salt Lake City, Utah
The Facts About ADHD:
Attention-Deficit Hyperactivity Disorder (ADHD) is characterized by inattentive, hyperactive, and impulsive behavior. These problems are often inappropriate and cause difficulty in daily life. ADHD is a “biopsychosocial” disorder. That is, there appear to be strong genetic, biological, life experience, and social factors that contribute to the extent of problems. ADHD affects 3% to 5% of individuals throughout their life. Early identification and proper treatment dramatically reduces the family, educational, behavioral, and psychological problems experienced by individuals with ADHD. It is believed that through accurate diagnosis and treatment, these problems-including school failure and dropout, depression, behavioral disorders, vocational and relationship problems, and substance abuse-can be properly managed or even avoided.
At one time, it was thought that the symptoms of ADHD lessen by adolescence. Research has now found that the majority of individuals with ADHD become adults with a very similar pattern of problems. Adults with ADHD experience problems at work, in the community, and in their families. They also exhibit a greater degree of emotional problems, including depression and anxiety.
Researchers first described the inattentive, hyperactive, and impulsive problems of children with ADHD in 1902. Since that time, the disorder has been referred to by different names, including Minimal Brain Dysfunction, Hyperkinetic Reaction of Childhood, Attention Deficit Disorder, and, currently, Attention-Deficit Hyperactivity Disorder.
What is ADHD?
ADHD interferes with an individual’s ability to stay attentive, particularly in the face of repetitive tasks; to manage effectively emotions and activity level; to respond consistently to consequences; and, perhaps, most importantly, to inhibit, i.e., to s from doing something. Individuals with ADHD may know what to do, but do not do what they know, because they are unable to s and think prior to responding, regardless of the setting or the task.
Characteristics of ADHD occur in early childhood for most individuals. Chronic behaviors last at least six months, with an onset often before seven years of age.
Four subtypes of ADHD have been defined. The first type is ADHD-Inattentive Type, and is defined by an individual experiencing at least six of the following characteristics:
Fails to give close attention to details or makes careless mistakes
Difficulty sustaining attention
Does not appear to listen
Struggles to follow through on instructions
Difficulty with organization
Avoids or dislikes tasks requiring sustained mental effort
Often loses things necessary for tasks
Easily distracted
Forgetful in daily activities
The second type is ADHD-Hyperactive/Impulsive Type, and is defined by an individual experiencing six of the following characteristics:
Fidgets with hands or feet, or squirms in seat
Difficulty remaining seated
Runs around or climbs excessively (In adults, it may be limited to subjective feelings of restlessness.)
Difficulty engaging in activities quietly
Acts as if driven by a motor
Talks excessively
Blurts out answers before questions have been completed
Difficulty waiting in turn-taking situations
Interrupts or intrudes upon others
The third type is ADHD-Combined Type, and is defined by an individual meeting both the inattentive and the hyperactive/impulsive criteria.
The fourth type is ADHD-Not Otherwise Specified, and is defined by an individual who shows some characteristics, but an insufficient number of symptoms to reach a full diagnosis. These symptoms, however, disrupt daily life.
School-age individuals with ADHD have a greater likelihood of not advancing to the next grade level, school dropout, academic underachievement, and social and emotional problems. It has been suggested that the symptoms of ADHD may cause children to fail in two of the most important areas for their development-school and peer relationships.
With increasing medical, educational, mental health, and community knowledge about the symptoms of and the problems caused by ADHD, an increasing number of individuals are being identified, diagnosed, and treated. Nonetheless, it is still suspected that a significant group of individuals with ADHD either go undiagnosed or misdiagnosed. Their problems intensify and create significant hurdles meeting life’s demands.
Often, ADHD has been inaccurately portrayed as a learning disability. ADHD is a performance disorder. Children with ADHD are able to learn, but they have difficulty performing in school due to the impact of the ADHD symptoms. However, approximately 20% to 30% of children with ADHD do have a learning disability, which makes the identification and treatment of ADHD more difficult. In the childhood years, individuals with ADHD also have an increased risk of developing problems related to oppositional defiance, delinquency, conduct disorder, depression, and anxiety. However, research suggests that it is not ADHD alone, but rather ADHD combined with the development of conduct disorder that may cause the most terrible adolescent outcomes, particularly those related to criminal behavior and substance abuse.
Adults with ADHD also experience problems related to anti-social behavior, vocational and educational underachievement, depression, anxiety, and substance abuse. Unfortunately, many adults, today, with ADHD were not properly diagnosed as children. They grew up struggling with a disability that often went undiagnosed, misdiagnosed, or untreated.
The majority of adults with ADHD have symptoms very similar to those experienced by children. They are restless, easily distracted, inattentive, impulsive, and impatient. Often, they are unable to handle stress. Within the workplace, they may not achieve positions or status equal to that of their siblings or intellectual ability.
What causes ADHD?
Commonly suspected causes of ADHD have included toxins, developmental impairments, diet, injury, ineffective parenting, and heredity. It has been suggested that these potential causes affect brain functioning; thus, ADHD is considered a disorder of brain function. A number of studies have shown significant differences in the structure and brain function of individuals with ADHD, particularly in the right hemisphere of the brain, pre-frontal cortex, basal ganglia, corpus callosum, and cerebellum. These structural and metabolic studies, combined with family, genetic, and drug response studies, have indicated that ADHD is a neurobiological disorder. Though the severity of problems experienced by individuals with ADHD may vary based upon life experience, genetics appears to be the primary underlying factor in determining if an individual will show the symptoms of ADHD.
How is ADHD diagnosed?
Diagnosing ADHD is a multifaceted process. Many biological and psychological problems can cause symptoms similar to those shown by individuals with ADHD. For example, inattention is a symptom of depression. Impulsive behavior is a characteristic sign of delinquency.
A comprehensive evaluation is necessary to diagnose ADHD, in addition to considering and evaluating other causes, and determining the presence or absence of other conditions. Obtaining a careful life history is the most important aspect in diagnosing ADHD. Often, an evaluation for ADHD will assess intellectual, academic, social, and emotional functioning. A medical examination is important to rule out other possible causes of ADHD-like symptoms (e.g., adverse reaction to medications, thyroid problems, etc.). The diagnostic process must include gathering information from teachers and other adults who interact routinely with the individual being evaluated. Although office- or laboratory-based paper and pencil, problem solving, and computerized tasks are popular in assessing ADHD, researchers are evaluating their validity.
With adults, it is even more important to obtain a careful history of childhood, academic, behavioral, and vocational problems. Since ADHD has been recognized as a disorder that occurs throughout life, questionnaires and other related tools for diagnosing ADHD in adults have been standardized and are available.
How is ADHD treated?
Treating ADHD in children requires a coordinated effort between medical, mental health, and educational professionals, with the parents. The combined set of treatments offered by various individuals is referred to as “multi-modal intervention.” A multi-modal treatment program for ADHD should include the following:
Parental training about ADHD and effective behavior management strategies
An appropriate educational program
Individual and family counseling, when needed, to minimize family problems
Medication, when required
Psychostimulants are the most widely used medications to manage ADHD symptoms. At least 70% to 80% of children and adults with ADHD respond positively to psychostimulant medications. These medications are considered performance enhancers. Thus, they may, to some extent, stimulate the performance of all individuals. However, given their specific problems, children with ADHD appear to improve, with a reduction in impulsive and hyperactive behavior and an increase in attention span.
Behavior management is important for children with ADHD. The use of positive reinforcement with punishment, in a model referred to as “response cost,” is particularly effective for children with ADHD.
Most children with ADHD can be taught in a regular classroom with minor adjustments in the classroom setting, the addition of support personnel, and/or special education programs provided outside of the classroom. The most severely affected children with ADHD often require specialized classrooms.
Adults with ADHD may benefit from learning to structure their environment; to develop organizational skills; to receive vocational counseling; and, if needed, to have short-term psychotherapy to cope with life experiences and personal problems. For some individuals, with a combination of ADHD and other problems, particularly depression, long-term psychotherapy can be beneficial to teach behavior change and coping strategies.
ADHD treatments are effective in reducing immediate, symptomatic problems. However, the long-term outcome research for children with ADHD has led researchers to conclude that symptom relief alone may not significantly impact the long-term outcome. Thus, ADHD treatments are provided to relieve symptoms, while efforts also are made to assist the ADHD individual in building life success.
To help parents in treating their ADHD child, a nine-point set of strategies is outlined below (Goldstein and Goldstein, 1998).
Step 1: Learn About ADHD. It is important to understand that managing ADHD-driven behavior at home requires accurate knowledge of the disorder and its complications. This is not a problem that can be cured. It will affect children throughout their life. You must be consistent, predictable, and supportive of a child in daily interactions. You will be repeatedly placed in an advocacy position with schools and community resources. It is suggested that you consider joining a parent support organization directed at ADHD.
Step 2: Understanding Incompetence vs. Non-Compliance. You must distinguish between problems that result from incompetence and those that result from non-compliance. The former must be dealt with through education and skill building. The latter is usually quite effectively dealt with through consequences. You must understand that punishing a child for symptoms of ADHD may lead to remorse and a promise of better behavior, but stands little chance of changing behavior in the future.
You must develop a set of strategies to deal with ADHD symptoms by making tasks interesting, payoffs more valuable, and increasing consistency at home, while providing a consistent set of punishments for non-compliant behavior. The best way of dealing with non-compliance is to make certain that you have control over consequences, issue appropriate commands, manage rewards, and use response cost techniques.
Step 3: Give Positive Directions. You must make certain that positive, rather than negative, directions are given. A positive direction tells the child what to begin doing, rather than focusing on what to s doing. Such directions are clear (e.g., “please begin your math homework”), rather than vague (e.g., “pay attention”). The need for repeated trials cannot be overemphasized. You serve as a control system for your child. Your child is going to require more management and supervision in an appropriate, consistent, affirmative way than other children.
Step 4: Provide Ample Rewards. You must provide ample rewards for appropriate behavior. Social and tangible rewards must be provided more frequently when an ADHD child succeeds. Children with ADHD also require more immediate, frequent, predictable, and consistently applied consequences. It is important for the child to learn to consistently act when expected behaviors are required. Most children with ADHD know how to do what is requested, but have difficulty doing so when they are supposed to. Children with ADHD also have been found to receive less positive reinforcement than their siblings.
It is important to avoid negative reinforcement. This only results in removing the negative consequences when the child complies. This often leads to immediate compliance, but, in the long run, it reinforces, rather than discourages, inappropriate behavior.
Token systems, which are particularly effective for children and early teens with ADHD, should be used. Often, token systems fail at home, not because they are ineffective, but because they can be cumbersome and then poorly managed. Tokens should be used with children who are four to seven years old, and points with those children who are eight years and older. Required activities should be kept to a reasonable length, and an extensive list of reinforcers should be available, with at least one third of points or tokens available each day. Children should be able to spend about two thirds of points or tokens earned each day. Bonuses should be paid for a good attitude. You should always allow your children to earn their way off a system through compliant behavior, but a minimum of six to eight weeks on a token system, once it is initiated, should be required.
Step 5: Choose Your Battles. You should choose your battles carefully. While it is essential for you to stay one step ahead, it also is important for you to recognize and accept the difficulties that your child experiences due to ADHD. You should reinforce positive behavior, apply immediate consequences for behaviors that cannot be ignored, and use tokens or points with ADHD children. Consequences, both rewards and punishments, should be provided quickly and consistently.
Step 6: Use Response Cost Techniques. You must understand the use of response cost, a punishing technique in which you might lose what you have earned. If a give and take response cost system is used, you must make certain the child does not go bankrupt. It may be equally effective, especially with older children and teens, to start with the entire payoff and then have the individual work to keep it. For example, instead of providing the child with a $5 allowance at the end of the week when she behaves appropriately, parents may place $5 in nickels in a jar on the shelf that is visible to the child. As long as the child behaves appropriately, the $5 belongs to the child. For every infraction that has been clearly defined and agreed upon between the parents and the child, a nickel is removed from the jar. At the end of the week, the remaining amount is given to the child.
Step 7: Plan Appropriately. You must learn to respond to the child’s limits in a proactive way. Accepting the diagnosis of ADHD means accepting the need to make changes in the child’s environment. Routines should be consistent and rarely vary. Rules should be stated clearly and concisely. Activities or situations in which the child has a history of risk for problems should either be avoided or carefully planned.
Step 8: Punishing Appropriately. Most likely, punishment alone will not reduce the symptoms of ADHD. However, punishment does play a role as a consequence for non-compliant behaviors. Punishment also is partially appropriate if a rule is violated, even as the result of ADHD. However, in this circumstance, punishment must not be provided alone, because it will not change the child’s long-term behavior. For a child with ADHD, you must understand that unless a managing strategy is provided along with punishment, it is not likely that the punishment will cause a change in behavior.
Step 9: Building Islands of Competence. Because of your child’s ADHD, there is a greater likelihood that the relationship between you and your child will be strained. However, in the end, it is what is right about children, rather than what is wrong about them, that best predicts their life outcome. Increasingly, the mental health field is focusing on building strengths, rather than attempting to hammer away at weaknesses. One of the best predictors of building strengths is the parents’ relationship with their child. If you approach each day with a sense of hope, encouragement, acceptance, and honesty, you will empower your child. If you approach each day with a sense of despair, discouragement, anger, and blame, you will not only jeopardize your child’s future, but also further feed their sense of powerlessness and hopelessness.
What research is being done?
Most likely, ADHD will continue to be the most widely researched and debated area in mental health and child development. New ground is broken daily. The five-year, multi-site, multi-modal ADHD treatment study recently completed by the National Institute of Mental Health has provided an expanded set of answers concerning the diagnosis, treatment, and outcome of individuals with ADHD. Ongoing studies of molecular genetics also may soon reliably identify the genes related to this disorder.
Other Information
Organizations, such as CH.A.D.D., 8181 Professional Plaza, Suite 201, Landover, MD 20785, (301) 306-7070, offer parents information, monthly magazines, newsletters, and presentations.
A large trade library of books, videos, and cassette tapes is available for parents, providing accurate information concerning ADHD and research proven effective parenting strategies.
References
Barkley, R.A. (1998). Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, 2nd edition. New York, NY: Guilford Press.
Barkley, R.A. (1997). ADHD and the Nature of Self-Control. New York, NY: Guilford Press.
DuPaul, G.J. & Stoner, G. (1994). ADHD in the Schools: Assessment and Intervention Strategies. New York, NY: Guilford Press.
Goldstein, S. (1997). Managing Attention and Learning Disorders in Late Adolescence and Adulthood: A Guide for Practitioners. New York, NY: Wiley Interscience Press.
Goldstein, S. & Goldstein, M. (1998). Managing Attention Deficit Hyperactivity Disorder: A Guide for Practitioners, 2nd Edition. New York, NY: Wiley Interscience Press.
Greenhill, L.L. & Osman, B.B. (1991). Ritalin: Theory and Patient Management. New York, NY: Mary Ann Liebert, Inc. Publisher.
Matson, J.L. (1993). Handbook for Hyperactivity in Children. Boston, MA: Allyn & Bacon.
Nadeau, K.G. (1995). A Comprehensive Guide to Attention Deficit Disorder in Adults. New York, NY: Brunner/Mazel Publishers.
About the Author
Sam Goldstein, Ph.D. is a member of the faculty at the University of Utah. He is on staff at Primary Children’s Hospital and the University Neuropsychiatric Institute. Dr. Goldstein has served as Chairman of the National Professional Advisory Board for the organization Children and Adults with Attention Deficit Hyperactivity Disorder and is a member of the Professional Advisory Boards for the Attention Deficit Disorder Association and the National Parenting Instructors Association.
Dr. Goldstein’s publications include articles, guides, book chapters and twelve texts on subjects including genetic and developmental disorders, depression, classroom consultation, learning disability and Attention Deficit Hyperactivity Disorder. His most recent texts include the Handbook of Neurodevelopmental and Genetic Disorders in Children (Guildford, 1998) and Managing Attention Deficit Hyperactivity Disorder in Children – 2nd Edition (Wiley, 1998).
Dr. Goldstein serves as Associate Editor for the Journal of Attention Disorders and is a member of the Editorial Boards of the ADHD Report, Archives of Clinical Neuropsychology and the Journal of Learning Disabilities.
Copyright 2012 Sam Goldstein, Ph.D., All Rights Reserved
