Pediatric Primary Care (131 page)

iv.  Increased blood pressure.

v.  Nervousness.

vi.  Headache.

vii.  Dizziness.

viii.  Irritability.

ix.  Rebound moodiness.

x.  Leukopenia/anemia.

xi.  Skin rash.

xii.  Abnormal liver function tests.

xiii.  Exacerbations of tics and Tourette syndrome.

•  Management of side effects:

i.   Administer dose after meals to improve appetite; frequent high-calorie snacks.

ii.  Avoid caffeine intake.

iii.  Modify time of administration if sleep problems.

K.  Follow up.

1.  Monitor height, weight, heart rate, blood pressure every 3 months in children younger than 12 years of age. School nurse can play integral role in monitoring these measurements in child every 3 months and report these findings to primary care provider.

2.  In children older than 12 years of age, monitor height, weight, heart rate, blood pressure every 6 months.

3.  Monitor CBC or hemoglobin every 6 months. Children are at increased risk for leukopenia/anemia while on psychostimulant drug therapy.

4.  Perform interval history, physical assessment every 6 months to evaluate child's response to treatment program.

5.  Consult with teacher and school psychologist prior to each 6-month healthcare evaluation for continuity of care.

6.  Follow up with psychiatric referrals, as appropriate.

L.  Complications.

1.  Complications from medication therapy include weight loss, increased heart rate and blood pressure, growth suppression, exacerbations of tics and Tourette syndrome.

2.  Once medication is discontinued, symptoms related to complications of medication therapy resolve; however, evidence shows that ADHD symptoms return even with continuous behavior-modification therapy.

M.  Education.

1.  Parent education is key to successful management.

a.  Parents should receive initial and updated education related to behavior modification strategies for successful treatment as child reaches each new developmental stage.

b.  Parents need to understand medication management.

c.  Know possible side effects of medication therapy.

d.  Support groups.

e.  Group and family therapy.

f.  Internet resources.

•  American Academy of Child and Adolescent Psychiatry:
www.aacap.org
.

•  American Academy of Pediatrics:
www.aap.org
.

•  National Association of Pediatric Nurse Practitioners:
www.nap-nap.org
.

•  Children and Adults with Attention Deficit/Hyperactivity Disorder (CHADD):
www.chadd.org
.

•  National Resource Center on ADHD:
www.help4ADHD.org
.

III.  AUTISTIC SPECTRUM DISORDER (ASD)

A.  ASD is a biologically based, neurobiological disorder that includes autistic spectrum disorder, Asperger's syndrome, childhood disintegrative disorder, pervasive developmental disorder, not otherwise specified, Rett syndrome (which will be removed in the DMS-V). Characterized by impairment in verbal and nonverbal communication, impaired cognitive abilities, and impaired social interactions.

B.  Etiology.

1.  Genetic susceptibility: children with a diagnosis of tuberous sclerosis; fragile X; Rett syndrome (identified gene mutation).

2.  Genetic susceptibility and environmental factors:
no
single environmental factor identified, however, may be linked to prenatal exposure to thalidomides, valproic acid, and mesoprostol.

3.  There is
no
evidence that links the measles-mumps-rubella (MMR) vaccine or any immunizations to the autistic spectrum disorders.

C.  Occurrence.

1.  Male-to-female ratio 3:1.

2.  In the United States: 1% of the population is affected.

3.  In the United States 1 child is affected for every 100 live births.

4.  Recurrence rate in siblings of affected children is 2-8%.

5.  Present in all racial, ethnic, and socioeconomic groups.

D.  Clinical manifestations.

1.  Red flags.

a.  Significant impairment in social communication and interaction.

b.  Repetitive, restricted, and stereotyped patterns of behavior.

2.  Symptoms develop before 30 months of age.

a.  Lack of (or poorly developed) verbal and nonverbal communication skills.

•  Abnormal speech patterns; echolalia, nonsense rhyming.

•  Bruxism.

b.  Abnormal social play, solitary play, no friendships.

•  No eye contact.

•  No social smile.

•  Regression in language or social skills.

•  Repetitive body movements.

•  Ritualistic behaviors; need for sameness.

•  Preoccupation with an object.

•  Tantrums when ritual is disrupted.

•  Rocking behaviors.

c.  Impaired intellectual functioning.

•  Mental retardation (I.Q. < 70 in 40-62% of the children).

•  Occasionally child has particular talent (e.g., art, music).

E.  Physical findings.

1.  Physical examination is most often normal.

2.  May have dysmorphic features.

a.  Long face and large eyes.

b.  Large head size not observed in infancy but observed in preschool years.

c.  May have microcephaly.

3.  Lack of communication skills and psychosocial skills in interactions in the home and during the office exam.

F.  Diagnostic tests.

1.  No specific tests.

2.  Lead screening (children under 7 years old) and genetic testing may be indicated for identification of comorbid conditions.

3.  Refer to psychologist for cognitive and psychological testing.

4.  Refer to neurologist for full neurologic diagnostic workup including blood work, MRI with contrast, CT scan, EEG.

5.  Refer for early intervention services.

6.  Autistic measures
(
Box 34-6
).

G.  Differential diagnosis.