CONDITIONS OF CONCERN IN EARLY CHILDHOOD


Attention Deficit Disorder (ADHD)

Anxiety Disorders

Obsessive-Compulsive Disorder (OCD)

Asperger's Disorder

Autistic Disorder


In this discussion, "early childhood" is defined as ages 2-7.

ADHD in this age range usually features Hyperactivity and Impulsivity.  Concentration and "Attention" are relatively less impaired.  Most ADHD children in the 2-7 range are boys, and aggressive behavior toward siblings and peers is common.  About 5-10% of boys in worldwide surveys have ADHD.

Anxiety Disorders are marked by excessive shyness, exceptional fear of new situations, excessive worrying about injury or illness, and often avoidance of interaction with peers.  Extreme fear pf separation from a parent after age 2-3 suggests possible Separation Anxiety Disorder, which is a more specific type of anxiety condition.  Boys and girls are about equal in frequency of these symptoms, and most studies suggest about 3-4% of children have one of these conditions.

Obsessive-Compulsive Disorder is a condition in which children are preoccupied with counting, numbers, order, lining things up, germs, dirt, cleanliness, and /or other issues, often insisting on order or precision.  Boys are far more likely to develop these symptoms in the 2-7 age range in the most flagrant form; girls are usually much more subtle.  About 2.5% of all Americans have OCD, but in most cases diagnosis is delayed into later childhood or adolescence despite some symptoms generating impairment early in school years.

Aperger's Disorder typically involves marked delays in development of understanding and use of social interactions, disinterest in peers with minimal development of peer related play, but fascination with very unusual interests for that age to the point laypeople would label "fixation" instead of mere interest.  Language skills are usually normal, but motor coordination is often delayed, and there are often unusual physical behaviors: hand or arm flapping, odd skipping or hopping, tapping, etc., which have the character of rituals: very repetitive and stereotyped.  Emotional overreaction to corrective or teaching/parenting interventions may be very extreme.  Boys are3 times more often affected than girls.  About 1% of all children have Asperger's symptoms.

Autistic Disorder does not require much explanation here: there is marked/severe delay in language development, virtually no "social" interaction, numerous stereotypical rituals, odd behaviors including flapping arms, spinning, or "stemming," and virtually o ability to cooperate with anything more than the most basic parental instructions, and then very inconsistently.  Extreme emotional overreactions when objects change in position or place are typical.  Incidence is about 1/1000.

There is also a condition known as Pervasive Developmental Disorder (PDD) which has been used for many years in the past, by and large when children exhibit features of Autism, Asperger's Disorder, and ADHD.


This is not intended to be a "complete" discussion of all conditions evident in early childhood, but the others are rare.


Diagnosis


None of these conditions may be readily diagnosed during any pediatric office visit.  There are no physical findings, and there are no useful lab or brain scanning techniques currently applicable which have any substantive diagnostic specificity.


At a research level, it is now known there are defects in development of microscopic portions of certain areas of the brain which evidently contribute to symptom generation.  This technology is now rapidly advancing, and the specific genetics of all these Neurobiological conditions is now becoming clear.  These are all almost always familial conditions.


Accurate diagnosis is almost always based upon these issues:


1)  Concern by one or more parent (usually the mother) about significant difficulty in management of the child's behavior;

2)  Recognition by grandparent that something is unusually troublesome in the child's behavior;

3)  Pre-school staff, and/or experienced Day Care staff, find the child significantly different from, and more difficult to manage, than same-age children;

4)  Recognition by one of the parents (usually the mother) that there are specific similarities between the child's symptoms and those of one of the parents or biological family members;

5)  Careful review of numerous Web Sites on the internet leads to enhanced concern about specific conditions.


I often suggest, not all in jest, HMO's and their tendency to sweep under the rug and ignore the significance of childhood conditions SHALL BE DEFEATED BY THE INTERNET.  HMO's were developed to prey upon patient/family ignorance.  A parent who carefully studies the scientific data now available on the internet is not going to buy into the denial of significance of symptoms of any of these conditions typically found at the "primary care" level, and will demand specialty consultation.


There are several further reasons for Resistance to Diagnosis:


1)  MOTHERS: while harboring a creeping fear that their child may have one (or more) of these conditions, are concerned about:

     What will the family think?

     Is it my fault?

     My husband is so resistant!

     Medication might have toxic side-effects!


2)  FATHERS: in most cases we see are resistant to any diagnosis or treatment for any reason, because:

     Nothing is wrong with my kid!

     A sense of failure as a parent.

     Whenever possible, blame the mother for any problems.

     This is total "crock;" these conditions are overdiagnosed.


Commentary


"OVERDIAGNOSIS" of any of these conditions may play well at the TV talk-show tabloid radio level, but it is scientifically absurd.  Careful surveys of incidence of these conditions compared to diagnosis has consistently revealed about 10-25% of all affected children are properly diagnosed, and even fewer  treated.


IGNORANCE of basic, current, scientific knowledge about any of these conditions is PERVASIVE in the "public" domain.  The genetics of ADHD and OCD are now very specific, yet a very small minority of the public has ever heard of these studies.  Our public media, of course, simply never finds these concepts sufficiently interesting to publish.  Boring! We all want to hear more about sensational stories.


DIETARY IDIOCY:  This is perhaps A new diagnosis: DID, Dietary Idiocy Disorder.  Individuals afflicted with this condition imagine their child's behavior might/may/must be affected by what he/she eats, and thus undertake all manner of manipulation of foods in the hope the child will respond accordingly.  Young parents are especially prone to development of this condition, which may occur in as many as 5-10% of families.


In many cases, some young mothers develop a conviction specific diets shall influence their child's behavior, often when under the influence of a grandparent who has read an article in a woman's magazine.  There never has been ANY scientific evidence this conviction is anything more than absurd, and it has been refuted by 20-30 careful studies over more than 20 years.


FEAR OF MEDICATION:  In 1955, this was quite realistic, and possibly also in the 1960's.  We live in 2012.  Medications specifically for treatment of ADHD, OCD, Anxiety Disorders, Asperger's Disorder, etc., are incredibly safe: far more so than any antibiotic any parent would administer to a child.  Medications used for these conditions have trivial immediate side-effects, and no known long-term adverse effects of any kind.


On the other hand, by the way, untreated children who have any of these conditions may have a disastrous future.  There are some non-medicated based interventions which may help a few, but unless these measures (coaching, parenting treatment, behavioral treatment) are employed vigorously long-term outcome studies show minimal success.  Oddly enough, many parents are more afraid of side-effects of treatment than adverse outcome when the child is not treated.  There is now ample scientific data indicating outcome in untreated children is dismal.  If it were my kid:  I would spare no efforts to obtain, and use, the most intensive and specialized treatment available.


Corydon G. Clark, M.D.