Should ADHD in preschool-aged children be treated with medication?

A new clinical practice guideline on ADHD from the American Academy of Pediatrics is making some waves among pediatricians and family physicians for its recommendation to evaluate and treat children as young as age 4 years. Past AAP guideline statements focused on identifying and treating children between the ages of 6 and 12 years. Although the AAP recommends behavior therapy as first-line treatment for younger children with inattentiveness or hyperactivity, it includes the option of starting medications in children who do not respond to behavior therapy. "In areas where evidence-based behavioral treatments are not available," the guideline adds, "the clinician needs to weigh the risks of starting medication at an early age against the harm of delaying diagnosis and treatment." It may only be a matter of time, then, before stimulants are being prescribed to large numbers of preschool-aged children.

Although unrecognized ADHD can cause significant social problems and learning difficulties in affected children, data on the incremental benefits and harms of detecting ADHD in younger (as opposed to school-aged) children and the long-term effects of stimulant medications is limited. As you consider how to incorporate information from this new guideline to the care of children your practice, we hope that you will find the AFP By Topic Collection on ADHD to be an indispensable resource.

Family physicians and the Goldilocks principle

A recent national survey of internal medicine and family physicians published in the Archives of Internal Medicine found that 42 percent of physicians felt that their patients were getting "too much" health care, while only 6 percent thought that patients were receiving "too little." These opinions contrast with multiple previous studies showing that primary care clinicians fall short when it comes to providing guideline-recommended care; a 2007 study, for example, found that children received less than half of indicated care.

So which is it: too much care, too little, or some of both? And how can AFP help family physicians avoid these extremes and strive for the happy medium, which in other fields is known as the "Goldilocks Principle"? In addition to bringing readers the latest Practice Guideline updates, such as the Centers for Disease Control and Prevention's 2011-12 recommendations for influenza vaccination, we provide information that allows you to evaluate these guidelines against the best design criteria previously proposed by AFP Deputy Editor Mark Ebell, MD, MS:

The best guidelines share several characteristics: they begin with a comprehensive review of the literature; they carefully assess the quality of the literature to identify the best studies; they base their recommendations on the best studies; and they tell us the strength of the evidence that supports each key clinical recommendation. In other words, they are founded on the principles of evidence-based medicine, which strives to make decisions on the best available information—“best” implying that the evidence is graded, so that one has a sense of what is good evidence and what is not, and “available” implying that the literature search is comprehensive. Transparency is the key: readers should know why each recommendation is made and whether it represents opinion, theory, or fact. Finally, guidelines should be independent of industry support (an all-too-common occurrence) and should clearly identify any potential conflicts of interest of the authors. Ideally, guideline authors should have no conflicts of interest, which can diminish the quality and validity of the guideline.

There are, of course, many reasons - financial, medical-legal, and practical, to name a few - that care may diverge from that supported by the best evidence-based guidelines. Still, we hope that every section of the journal makes it easier for family physicians to provide care that is "just right."

Prostate screening resources for you and your patients

According to an article in today's New York Times, U.S. Preventive Services Task Force officials have confirmed that they plan to release an updated recommendation statement on screening for prostate cancer early next week that changes their current "I" (insufficient evidence) statement to a "D" grade ("recommends against"). Our AFP By Topic collection on Cancer includes several resources that may help you explain this upcoming change in practice to your colleagues and patients:

Cochrane for Clinicians: PSA Testing Is Not Effective

Practice Guidelines: ACS Recommendations on Prostate Cancer Screening

Review Articles: Prostate Cancer Screening: The Continuing Controversy and Treatment Options for Localized Prostate Cancer

Patient Education handout from FamilyDoctor.org: Prostate Cancer

Over-the-counter drug abuse: a growing concern

Physicians who regularly treat patients with upper respiratory infections are familiar with the 2005 federal law that moved the decongestant pseudoephedrine "behind the counter" to make it more difficult to illegally manufacture the stimulant methamphetamine. Unfortunately, "meth" abuse is only the tip of the iceberg of over-the-counter medication abuse. In an editorial in the October 1st issue of AFP, Drs. Chih-Wen Shi and Margaret Bayard provide helpful tips on recognizing and treating this common problem in the primary care of adolescents and young adults:

When treating a patient for a drug overdose, it is important to screen for multiple drugs, because many OTC cough and cold medications contain more than one active ingredient. Furthermore, overdoses can occur with a combination of OTC, prescription, and illicit drugs, as well as alcohol and other substances. In such instances, toxicity may be additive. Reporting overdoses to poison control centers is crucial so that data can be collected to support policy changes, such as placing an OTC drug behind the pharmacy counter or taking it off the market.

You can find additional current AFP content on the prevention, diagnosis, and treatment of substance abuse in our AFP By Topic collection.

For cardiovascular prevention, is this Figure worth a thousand words?

A previous AFP Community Blog post discussed challenges involved in recommending aspirin prophylaxis. Although aspirin reduces the risk of cardiovascular events in persons with no history of coronary artery disease, the absolute risk reduction is relatively small, and needs to be balanced against the inconvenience of taking a daily medication and side effects such as gastrointestinal bleeding. Family physicians who engage in shared decision-making with patients about aspirin may find it difficult to put these statistical risks and benefits in perspective.

In their clinical review "Global Risk of Coronary Heart Disease: Assessment and Application," which appeared last year in AFP, Drs. Anthony Viera and Stacy Sheridan included an easily understandable Figure that illustrated the benefits of 10 years of aspirin chemoprevention among 1,000 persons with a 10 percent 10-year global risk of coronary heart disease. However, as pointed out in a Letter to the Editor published in the September 15th issue, that Figure did not include an illustration of the potential harms of aspirin chemoprevention. In response, Drs. Viera and Sheridan have proposed modifying the figure as follows:

The pictograph shows a population of 1,000 men 45 to 59 years of age who have a 10 percent global risk of a coronary heart disease (CHD) event and who have been receiving aspirin for 10 years to reduce their risk. Green faces represent the number of men who would not benefit because they are not among the 10 percent predicted to have a CHD-related event. The red faces represent the approximate number of men who would have an event despite receiving aspirin. The yellow faces represent the men who would not have an event because it was prevented by aspirin. The reddened rectangle highlights the approximate number of people who would have a gastrointestinal bleed. The red X indicates the one person on average who would sustain a hemorrhagic stroke as a result of receiving the aspirin.

Reprinted with permission from Dr. Chris Cates' EBM Web site. http://nntonline.net/visualrx. Accessed May 23, 2011.

Does this figure exemplify the adage that "A picture is worth a thousand words," or does it oversimplify a complex medical decision? What do you think?

Clinical problem-solving is a strength of family medicine

Working with family physicians since 1978, I have noticed two things in particular.

First, they take great pride in their interest in relationship-based care. They talk about the value of continuity. They tell stories that describe how much they treasure relationships with patients. They tell these stories in their teaching. They write books about it. It's a powerful force that energizes their work and their career satisfaction.

They rarely, if ever, mention the power of their clinical problem-solving abilities. Why is that? The absence of mention and the seeming lack of pride (my assumption) in this area makes me wonder if FPs really believe they are effective in the area of clinical problem-solving.

From my earliest days in family medicine, I came to believe that FPs' impact as physicians was a result of their patient/relationship-centered approach that included effective communication skills, their fund of knowledge, and their clinical problem-solving skills. All three are essential; any two working alone, except in special circumstances, will not lead to the best results.

Family physicians embraced the work of Barbara Starfield, MD, MPH, who told the world that FPs, in particular, and primary care clinicians, in general, had a positive effect on population health while reducing the cost of care. When I hear FPs take pride in their relationship centered approach to care but never mention their approach to clinical problem-solving, it leads me to believe they think that continuity alone produces the impact documented by Dr. Starfield.

I put this issue to a number of colleagues and heard the following.

"Because of the variety of patients and undefined illnesses that family physicians see, they become better at development of realistic differential diagnosis than any other medical specialty." - Doug Smith, MD, Orono Family Medicine, Orono, Minnesota

Shantie Harkisoon, MD, director of the Phelps Family Medicine Residency Program in Sleepy Hollow, New York, told me that she thinks the strength of FPs is strong skill with differential diagnosis of the patient as person while sub-specialists are generally more effective at differential diagnosis of a disease.

I have been talking to a documentary film maker who wants to tell a story about family medicine and primary care innovation. In his interviews with FPs, all he hears about is the value of relationship centered care. He can't understand how the care provided by FPs costs less money. When I told him that FPs are effective clinical problem-solvers and their approach to decision making is a key piece of this story, he almost did not believe me. When he interviewed FPs, he was not hearing about this. Why do we not hear more about family physicians' clinical problem-solving prowess?

Laurence Bauer, MSW, MEd

Chief Executive Officer

Family Medicine Education Consortium

Laurence.Bauer@gmail.com

Compromising the medical literature

To ensure that our clinical review articles reflect current medical literature, American Family Physician requires prospective authors to consult several evidence-based resources that synthesize the best available evidence from clinical trials and other high-quality studies. The goal of this process is to produce unbiased recommendations for primary care physicians. But what if the authors of clinical reviews are actually professional scientific writers paid by pharmaceutical companies, rather than the physicians whose names are listed as authors?

In fact, drug-company funded "ghostwriters" have been publishing articles in the medical literature for years. A study by the editors of JAMA found that from 2 to 11 percent of articles published in 2008 in six major journals (including the New England Journal of Medicine) were actually written by people who were not named as authors. While the study could not establish that these ghostwriters had been directly financed by industry, the practice of writing up a scientific study and then recruiting a lead author (usually an academic physician under pressure to "publish or perish") has been well-documented in the case of previous "blockbuster" drugs that were taken by millions of patients for common conditions but later turned out to have dangerous or fatal side effects, including Wyeth's Prempro and Merck's Vioxx.

Ghostwriting is not the only way that the pharmaceutical industry is able to influence the interpretation of evidence in its favor. A Letter to the Editor in the Sept. 1 issue points out that a 2005 Cochrane Review on medications for diabetic neuropathic pain (cited in a 2010 AFP article on this topic) unintentionally exaggerated the effectiveness of gabapentin in treating this condition due to the manufacturer's selective publication of favorable trials and suppression of unfavorable ones. In an accompanying editorial, Drs. Adriane Fugh-Berman and Jay Siwek review these and other "stealth marketing" tactics that can potentially compromise the medical literature, along with ways that readers can help correct these biases:

Distorted information, once ensconced in the medical literature, is propagated by industry and by well-intentioned authors who unwittingly cite these studies. The medical literature is a permanent record that scientists and physicians rely on for decisions that ultimately affect patient care. Although the scientific process is never linear, the self-correcting process by which evidence is continually refined can be corrupted by the infiltration of medical journals with research studies and review articles distorted by a hidden marketing agenda.

Although there is no foolproof way for readers to detect undue industry influence, readers should be alert for marketing messages that disparage older, generically available drugs or that position newer branded (or upcoming) drugs as more effective, more convenient, safer, or filling an unmet need. The last sentence of the abstract is typically where the marketing spin is inserted. Readers should alert medical journals to suspicious articles by writing letters to the editor.