Thursday, November 03, 2011
Guidelines changed for Attention Deficit Hyperactivity Disorder

By Dr. Anthony Policastro
On Oct. 16th, the American Academy of Pediatrics announced a new practice guideline on ADHD. The media jumped all over part of the guidelines that were related to the age limits for diagnosis. The old guidelines indicated that you could not make the diagnosis before age 6. The new guidelines dropped that age to 4 years. It was big news. And now for the rest of the story. There were a few things that the media did not bother to mention. The first is that most of the drugs that we now use for ADHD are not yet approved for use under age 6. The second item was more important. That was related to treatment. The guidelines do not say we should now give medications for ADHD in children under 6. They say we can make the diagnosis in 4 and 5 year olds. The guidelines also have a recommendation for treatment. The treatment is for the parents to go to a parenting class. This makes the symptoms disappear entirely in 1/3 of the children. The other 2/3 will need to be considered for medication. What that means is that there is now a plan for this age group. I have many parents who come to see me with their young children. They feel the child has ADHD and they want a drug for the child. When I tell them that they need to try behavior modification first, I get a standard answer. "I already tried everything. Nothing works." Therefore, the expectation is that I will write a prescription which will make their job of being a parent easier. It does not work that way. You have to work hard at being a parent. You have to devote the hours that are needed to teach your child to behave. Now when these parents come in, I can point to the guidelines. I can ask them to show me the certificate that they have completed the 14 week parenting course that is the first line of treatment. If they have not, they can come back when the course is completed. There was another piece of the guidelines that the media did not cover. That is likely because it was not as big a headline. The guidelines used to have an upper age limit of 12 years for making the diagnosis of ADHD. That has been changed to 18 years. It implies (correctly) that many children with ADHD will need to continue treatment in high school and college. That means that they will need to continue being followed by their physician after they turn 18 years of age. There are two related issues. The first is that when they turn 18, they will no longer go to the doctor's office with their parents. They will go on their own and they will have to speak to their physician about what is going on with them. Those of us who treat adolescents will need to prepare them for that. It means a different approach as they become older teenagers. The second is that ADHD is a pediatric condition. There are physicians who will not treat adults with it. There are physicians who do not feel comfortable treating it. There are physicians who do not know a lot about the condition. These physicians will try to send the patient to a psychiatrist. While that is a reasonable approach, it is not necessary. ADHD is a condition that affects 5% of the population. That makes it one of the more common things that we see. Internists and family physicians can easily treat it. However, the one who knows the condition the best are the patients. They have been dealing with it for years. They know which medication works best. They know which dose works best. Therefore, it is up to the 18-year-old adult patient to be able to discuss all of this with the new doctor. That will allow him/her to get the best treatment for his/her chronic condition. It is sometimes interesting how much can be tied to a little change. The age limits have moved from 6 to 12 years to 4 to 18 years. That small change has created a number of issues that need to be addressed.

Do you know how to give CPR?
What would you do if somebody you loved suffered a sudden cardiac arrest? Would you know what to do? A Millsboro mom can attest first-hand to the value of cardiopulmonary resuscitation after her own nine-year-old daughter went into cardiac arrest while playing lacrosse. The incident happened this past April 14, when little Sierra Hall collapsed on the lacrosse field and was found to have no pulse. Mother Melanie Hall cried for help and, moments later, a bystander performed CPR to save Sierra and keep her stabilized until paramedics arrived. "I have no doubt that (the bystander) saved my daughter's life. The CPR kept Sierra breathing and kept her alive until the ambulance got there," said Mother Melanie Hall. "We were very fortunate there was somebody nearby who knew how to perform CPR." According to Hall, her daughter was born with a congenital heart condition and received two open heart surgeries before she was a full year old. Doctors had cleared Sierra for physical activity and there had never been a problem until that scary day on the lacrosse field. After the cardiac incident that day, Sierra Hall was airlifted to Bayhealth-Kent General Hospital where she stabilized before being transported to A.I. Dupont Children's Hospital for treatment. "It's true that cardiopulmonary resuscitation saves lives and you'll never know when you may need to use it to save somebody. We encourage everybody to consider taking a CPR class," said Bayhealth Emergency Department Advanced Practice Nurse Susan Ebaugh, MSN, RN. According to Ebaugh, the Bayhealth Education Department offers Adult CPR, Child CPR and First Aid. To sign up for a class, call 302-744-7135 or 877-453-7107.

HPV vaccine is recommended
The Delaware Division of Public Health (DPH) reminds Delawareans of the Centers for Disease Control and Prevention's recommendation that both girls and boys at age 11 or 12 be vaccinated for the Human Papillomavirus (HPV), a common virus spread through sexual contact. Most people with HPV have no symptoms so they are unaware they have it. There are approximately 40 types of genital HPV. Some cause cervical cancer in women, others cause additional forms of cancer in both men and women and other types cause genital warts in both males and females.
The CDC recommendation for girls and boys may seem an early age to vaccinate against a sexually transmitted disease, but it is the best time because prevention should begin well before the age of sexual activity. "Vaccinating a young child at age 11 or 12 is by no means permission for that child to be sexually active. It is simply a tool for prevention, best given during that time in a child's life and well before they are likely to become sexually active," said Dr. Karyl Rattay, director of the Delaware Division of Public Health. "Once a person has been infected by HPV, it is too late to prevent it and the secondary diseases that may result."
The HPV vaccine works by preventing the types of HPV that most commonly cause cervical cancer and genital warts. It is given as a three-dose vaccine, and protection requires all three doses. Other vaccines recommended for pre-teens include meningococcal vaccine, which protects against bacterial meningitis, and Tdap, which boosts immunity against pertussis (whooping cough). All teens should be protected against Varicella. Plus, everyone six months and older should get an annual flu vaccine. To learn more, visit or call 800-CDC-INFO.

Protection against air pollution
The Delaware Department of Justice is seeking to intervene in a lawsuit in support of the Environmental Protection Agency's proposed rule that targets air pollution flowing into the First State. Delaware, five other states and the District of Columbia filed a motion on Oct. 19, in the District of Columbia Circuit Court of Appeals to intervene in a lawsuit filed by the State of Kansas that challenges the EPA's ability to implement rules that target air pollution that travels across state lines in states such as Delaware. EPA has determined that air pollution from 27 states, including New Jersey and Pennsylvania, contribute significantly to downwind states' inability to comply with federal air quality standards. EPA promulgated the Cross-State Air Pollution Rule (CSAPR) to require significant reductions of nitrogen oxides and sulfur dioxide, emitted by these 27 states beginning Jan. 1, 2012. Delaware and its co-interveners will ask the court to uphold EPA's efforts to gain the air pollutant reductions on behalf of their citizens. Specifically, Delaware, Maryland, Connecticut, Massachusetts, Rhode Island, Vermont and the District of Columbia are asking the federal appeals court to uphold the EPA rules and allow them to go into effect Jan. 1, as scheduled. The rules require the 27 states to undertake significant efforts to reduce nitrogen oxides, sulfur dioxide, precursor pollutants of ozone and other fine particulates.

Diabetes educational offerings
Nanticoke Memorial Hospital, Seaford, will hold a four-session diabetes educational program on Nov. 9, 16, 30 and Dec. 7, from 5 to 7 p.m., at the hospital. Registration is required. The cost of the four-session program may be reimbursable by insurance. This four-session program includes weekly education sessions and individualized meal planning for diabetes self-management. The goal is to give you the self-management skills to control your diabetes. Family members/significant others are welcome to attend the weekly sessions. For more information and to register, contact Nanticoke Memorial Hospital's Diabetes Education department at 629-6611, ext. 2446.

New depression support groups
If you have been diagnosed with depression, are currently receiving treatment and need extra support, join the Mental Health Association in Delaware's newest depression support groups. The support groups provide a safe and comfortable environment for adults who may be struggling with depression to find others who may be going through similar experiences, learn coping skills and take back control of their life by being proactive. A support group meets in Seaford every Wednesday from 6 to 7:30 p.m. The location of the meeting is provided only to registered members. To register, contact the Mental Health Association in Delaware at 302-654-6833 or 800-287-6423. These new groups are made possible due to a grant received from Blue Cross Blue Shield of Delaware's BluePrints for the Community program.

Relay for Life fundraiser
Dr. Marie Wolfgang is again sponsoring a 12 night Winter Getaway Cruise to the Southern Caribbean as a fundraiser for Relay for Life, sailing from Cape Liberty, N.J. on Feb. 10. The itinerary includes St. Thomas, St. Kitts, St. Johns (Antigua), St. Lucia and St. Maarten (Philipsburg). Transportation to and from the dock is available. For a brochure, call or visit Dr. Wolfgang's office at One Cedar Ave. in Seaford, 629-4471. Space is limited.

Grief Support Group
A six-week support group for adults on "Grieving the Loss of a Loved One" will be offered by Delaware Hospice at the Cancer Care Center of Nanticoke Memorial Hospital. Any adult who would like to give and receive support from others who have experienced a loss is invited to participate in these sessions facilitated by Paul A. Ganster, LCSW, Delaware Hospice bereavement counselor. Many people find that sharing in a support group reduces the loneliness and heartaches of grief. Topics include what to expect when grieving, mistaken ideas about grieving, managing and coping with grief, the impact of grief and loss upon family relationships, spiritual issues, how to handle special days and holidays, and ways to find a renewed sense of purpose. There is no fee for this service which is provided as a community outreach by Delaware Hospice. Registration is requested by calling Paul A. Ganster, LCSW, at 302-357-7147, or by emailing no later than Nov. 1.

Bereavement luncheons
Delaware Hospice's "New Beginnings" bereavement luncheons are an informal way to meet and talk with others, who have had similar loss experiences. Lunch begins at noon and is followed by a brief program. The location rotates each week of the month throughout Sussex County. "New Beginnings" luncheons are open to the public. Registration is not required. There is no fee except the cost of your lunch. For more information, call Midge Dinatale or Paul Ganster at 856-7717.

Breast cancer support group
Delaware Breast Cancer Coalition, Inc. (DBCC) has expanded its Beginning Your Pink Ribbon Journey, a program for women newly-diagnosed with breast cancer, by partnering with Nanticoke Memorial Hospital Cancer Center in Seaford. The free, monthly program is offered at the Cancer Center located at 801 Middleford Road, Seaford, the third Thursday of each month from 3 to 4 p.m. To learn more, call Lois Wilkinson at 672-6435. Registration is required and light refreshments and small gifts are provided.