What’s the best peanut policy to prevent severe allergic reactions in schools?

The Pediatric Insider

© 2017 Roy Benaroch, MD

Peanut-free schools, peanut-free rooms, peanut-free tables – they’re all an effort to protect children who have severe peanut allergies from accidental exposures. We’d all like to make sure our school are as safe as possible for everyone. So what’s the best policy on peanuts and tree nuts?

A study in press at the Journal of Allergy and Clinical Immunology adds some science to the debate.  Researchers looked back at peanut allergy experiences at Massachusetts public schools from 2006-2011. They polled every public school from K through 12 to determine their “peanut policy”. Though the response rate was only about 55%, the policies varied a lot – from completely no-serve, no-bring peanut schools (about 2-3%), to no peanuts allowed from home (about 10%), no peanuts served by the school (60%), to keeping some classrooms peanut free (70%), to having designated “peanut free tables” in the cafeteria (this was the most common policy in place, accounting for about 90% of the schools). (Some schools had multiple policies, so the numbers are > 100%). The peanut policies remained about the same for the 5 years of the study, and didn’t vary too much from elementary to high schools.

Data was also collected on every episode at school where epinephrine was administered. Epinephrine is the drug given to treat a serious allergic reaction (that’s the medicine in those weirdly expensive Epi-pens.) It turns out that Massachusetts schools must file a form when epi is given, so those were easy to track. Over the 5 years, epinephrine was given to children having an allergic reaction to peanuts in Massachusetts public schools about 20-40 times per year, with a modest increase from year-to-year during the study. We’re not talking huge numbers, here. Epinephrine administration was used as a “proxy”, or substitute number, for the actual number of peanut reactions in the schools – though it’s possible that epi was sometimes given when it wasn’t indicated, or sometimes was withheld when it should have been given.

The results are interesting. Of the peanut policies in place, the only one associated with a significantly decreased number of epinephrine uses was the presence of peanut-free tables in eating areas. Other policies, including having an entirely peanut-free school, did not result in fewer instances of epinephrine use. In other words, a school with a policy to be completely free of peanuts didn’t seem safer for peanut-allergic kids than a school that allowed peanuts to be brought from home.

These results aren’t super-strong. The number of serious reactions was small, and the number of absolutely peanut-free schools was small, too. There were only two nut reactions in the peanut-free schools (and one of them was in a boy that brought his own walnut cookie from home, despite being known to be walnut allergic.) When you crunch the numbers, the per capita chance of reactions in nut-free schools was actually higher than in schools with less-restrictive numbers, but with numbers so small I don’t think you can hang your hat on that conclusion.

A few lessons can be learned from this study. Even among schools that claimed to be “peanut free”, many allowed peanuts to be brought from home. Schools should have clear policies that make sense to parents. It’s also clear that even truly peanut-free schools aren’t a guarantee that no peanut exposures will occur—schools shouldn’t just declare no nuts, and leave it at that.

I wonder if the relative superiority of peanut-free tables is because that policy is easier to enforce. When an entire school is meant to be “peanut free”, you might be more likely to have some families break the rules. Also, “peanut free” policies might lead to a false sense of security among children who are nut allergic. They still have to watch what they eat. This study didn’t look into these factors, or how well peanut policies were enforced, or exactly how children were exposed in every instance.

Allergic reactions to peanuts are not common in schools, but when they do occur they can rapidly become life-threatening. Avoidance of exposures is the main way to treat peanut allergies; and when a serious reaction does occur, epinephrine should be given immediately. Beyond that, we just don’t know what the most-effective school policy should be. This study gives us some insight, but we’ve still got more to learn.

 

edit: Here’s a tangentially-related, sickening story about the apparent hazing of a peanut-allergic college student. What the hell is wrong with people? Accidents happen, but this is just…. just… I have no words.

 

 

 

Vision therapy for dyslexia and reading disorders

The Pediatric Insider

© 2015 Roy Benaroch, MD

Dyslexia is a specific learning disorder—a problem not with intelligence or a lack or trying, but with the ability of children to learn to read. It affects 3-20% of children (depending on the exact definition used). Because reading is essential to school success in almost every subject, problems with reading need to be addressed as early as possible.

One kind of therapy for dyslexia is based on the premise that reading problems are caused by vision problems—though the scientific community isn’t convinced that this is the case. The large, national professional bodies representing pediatricians, ophthalmologists, and optometrists recommend only routine vision screening for children having reading difficulties. Nonetheless, there’s a cottage industry of so-called developmental or behavioral optometrists who offer a variety of services commonly called “vision therapy” to help with reading problems and other developmental challenges. There is very little objective evidence that any of these therapies offer more than short-term improvement. Besides, they’re very expensive, and often not covered by medical or vision insurance. Parents need to know whether this kind of therapy is worth pursuing.

Researchers in the UK published a study in May, 2015, looking at a large number of children in a birth cohort from the early 1990’s. These children had all had thorough serial health assessments as they grew. For this specific study, they found that 3% (172 kids) in the birth cohort of 5822 children met objective criteria for reading impairment. All of these children had a very through vision evaluation, and most of those were completely normal; the small number of reading-disabled kids who weren’t 100% normal on their vision assessment had subtle abnormalities. The authors concluded “We found no evidence that vision-based treatments would be useful to help children with severe reading impairment.”

A strength of the study was that it was population-based—it didn’t just include children referred to a clinic because of problems. And the findings were objective and validated. However, the authors only looked at the most severe level of reading impairment. It’s possible they may have missed vision issues in less-affected children (though one would think, if vision were the root of reading problems, that the worst readers would have the most egregious and easily-identified vision problems.)

This study adds to the weight of evidence that “vision therapy” is unlikely to be useful for reading problems, and may be a waste of time and money.

Back to school means back to backpack back pain

The Pediatric Insider

© 2014 Roy Benaroch, MD

(Yes, I know, I need an editor to help me write better headlines for these stories. Send in your application to our human resources department.)

From researchers in Spain, a simple, brief study confirms what you would have guessed: kids’ huge backpacks are hurting their backs.

A team collected data from about 1400 students in lovely Galicia, Spain (where I have decided I want to go on vacation, despite the hordes of back-injured children. I won’t tell them I’m a doc.) Those carrying the heaviest backpacks had a 50% increased incidence of back pain. The risk was higher among girls.

There are a lot of pressures on kids these days. You’d think a huge backpack wouldn’t have to be one of them. There are some things parents might be able to do to mitigate this problem:

• See if you can access textbooks online—and if so, encourage your child to just leave his books at school rather than lugging them back and forth.
• If you can’t get online access, consider getting a second set of books to keep at home. You can probably buy them used on Ebay or Amazon, or maybe convince the school to give you a second set with a doctor’s note documenting back problems.
• If allowed, try a rolling backpack. Many schools discourage these because they gum up the overcrowded hallways.
• Use a backpack that fits right, with the straps tight enough to hold the weight high on the back. A high-quality backpack has wide, padded straps and is designed to keep the weight close to the body, not hanging down the back.
• Discourage the slouchy, single-shoulder carry. A backpack with a significant amount of weight is best carried on straps across both shoulders—or even better yet, with a belt across the lower belly that supports some weight on the hips.

When can kids walk themselves to school?

The Pediatric Insider

© 2013 Roy Benaroch, MD

It’s back-to-school time! Now that your kids are a year older, is this the right time for them to walk themselves to school?

The highest risk group for pedestrian versus vehicle accidents is in the 5-9 year age group, with boys having far more accidents than girls. Most accidents occur in the late afternoon, probably because of reduced light and longer shadows, and the most common scenario is an accident occurring mid-block, when a child darts out from between parked cars.

Children themselves are at increased risk for several reasons:

• They’re small and not as easily seen.
• They’re not very good at judging the distance and speed of oncoming vehicles.
• They assume if they can see the car, the car can see them.

There’s no accepted, national recommendation for kids on the best age to allow independent walking—it depends on the setting, the kind of neighborhood, the length of the walk, obstacles and intersections on the way, and the skills, maturity, and reliability of the child.

Even though there may be increased risks, encouraging your child to walk once it’s safe can be a great opportunity to encourage independence and self-confidence.

There are good ways to improve your child’s pedestrian skills, whether or not you encourage completely independent walking. Always model good skills—don’t just say that you have to look both ways, do it. And speak out loud what you’re seeing. It’s not just turning your head and then walking—say “I see that red car on the next block, it’s moving very slow,” or “I see that big truck, those can’t stop quickly, so even though it’s far away let’s give it time to pass,” or “I see that guy in the car talking on his phone. Since he’s on his phone, he’s not paying any attention to us. We better let him pass.”

Another idea: there’s a trend towards using what are called “walking buses”, where groups of neighborhood kids led or followed by just a few parents travel in a pack. That increases safety by increasing visibility, and also allows kids to learn from each other—if they’re paying attention during the walk.

You know your kids best, and you’re in the best position to judge if your own child is ready for independent walking. Consider a few trial runs, maybe with you tagging behind a few blocks—or let your children lead you to school, rather than the other way around, checking on traffic themselves. They may prove to you that they’re ready to do it themselves. After all, that’s the entire purpose of parenting, right?

Idiotic attendance policies, part 2: The preschoolers

The Pediatric Insider

© 2012 Roy Benaroch, MD

I’ve written about stupid school policies before—schools that set up carrots and sticks to prevent even genuinely sick kids from staying home. Dumb, dumb, dumb. But it did give me the opportunity to write, “If absences are outlawed, only outlaws will have absences.” I’m not sure exactly what that means, but it seems wise. Someone ought to put it on a bumper sticker.

Now I’m noticing more and more little kids being sent home (and often sent to my office) for equally dumb reasons. I don’t know why, but while the high schools seem to want to keep genuinely sick kids in the classrooms, child care centers for little ones want to send them home for next-to-nothing illnesses. Both extremes aren’t helping keep kids healthy.

The AmericanAcademyof Pediatrics has tried to offer guidance about sensible, science-based pre-school policies to protect the health of children. They’re summarized in this book, also available at Amazon. Owners and operators of preschools and government bodies that make health policies really ought to read that book, and keep it under their pillows at night to help absorb its wisdom. Instead, they seem to be making things up.

School exclusion rules ought to be designed to protect the health of children and staff. Children, in general, ought to stay home if:

• They can’t comfortably participate
• Their presence poses a health risk to themselves or others
• Their presence requires more support than the staff can offer

The AAP has specific suggestions for certain health problems that may surprise you. They certainly run counter to what I’m seeing from day cares in my community. Some of their recommendations:

Kids with the common cold, even if there is green snot, don’t need to be excluded from school. This is because the period of highest infectivity is before symptoms become obvious. Once a child has obvious cold symptoms, they’re no longer very contagious anymore—no matter the color of their snot. As long as they’re comfortable, they can go to school.

Fever, itself, isn’t a reason to keep kids home. Now, most kids with fever are uncomfortable—those kids shouldn’t go to school, since they can’t participate. But some kids with fevers, especially those with viral infections, feel just fine after a dose of ibuprofen. Excluding these children is unlikely to reduce the spread of disease, since most viral infections are spread by children who have no symptoms at all.

Pink eye? This seems to be the biggest boogeyman at preschool. Like the common cold, pink eye is contagious, but there is no evidence that treatment of pink eye reduces the spread of the bacteria or viruses that cause this common infection. The symptoms are quite mild, and will resolve in 5-6 days with or without treatment. The schools freak out, but kids do not go blind from garden-variety pink-eye, and most of them feel fine. As with other illnesses, if the child really feels bad she ought to stay home. Note that there are rare, more-serious occasional outbreaks of more-serious pink eye caused by adenovirus, so a classroom with multiple cases of severe pink eye needs to be reported to public health authorities. But the vast majority of pink eye that’s referred “emergently” to my office are very mild, nearly symptom-free infections.

Infections that really ought to stay home are those that include diarrhea that can’t be contained in a diaper or requires frequent changes, or vomiting. These symptoms really can’t be managed safely or comfortably in a group care setting.

Wrongheaded day care policies probably drive a lot of my business. Many centers seem to require a “note from a doctor” to return to school. Still, wrong is wrong. What we need is a more sensible approach to group care and school illnesses, rather than knee-jerk policies that keep children and parents home or send them to my office. Sick kids ought to stay home, but most kids with mild illnesses who feel pretty well can go to school safely.

Is he ready for kindergarten?

The Pediatric Insider

© 2011 Roy Benaroch, MD

Lydia wrote: “I live in a state with a December 1st cut-off and both of my kids have fall birthdays. We started the oldest when he was four and have never questioned our decision, but my younger son’s birthday is in late November, so he’d be four for the first 3 months of the school year. The kindergarten classes have over 25 kids and the district is starting full-day kindergarten for the first time next year. Are most four year olds ready for full-day kindergarten or for such large classes?”

I think most four year olds are ready for this kind of experience, if the classes are organized and supportive and well-run. With tight budgets, though, parents need to ensure that there are adequate resources for a strong kindergarten experience, no matter what the age of their children.

I’ve written kindergarten readiness on this blog before, and also recently on WebMD. My feeling has always been to allow most kids (boys and girls) to advance and proceed as recommended by the guidelines of the local school—that is, to follow “the usual track”—unless there’s a specific academic or emotional issue that’s holding your child back. Schools that indulge parents only for being “squeaky wheels” are not doing children or society any favors by allowing a handful of older children to stay back and mix with younger kids.

There is a downside to holding kids back. Some will get bored, and some will end up pushing around the smaller, younger kids. Children surrounded by same-age peers are more likely to pick up new, more mature skills than children who are with kids younger than they are. As held-back children age, they may feel especially awkward going through pubertal changes in fifth grade, long before most of their classmates will.

That being said, there certainly are some kids who should be held back. Some children, whenever their birthdays, may not be emotionally or academically ready to proceed forward. The best people to make this judgment are people from the local school, who know what the kids in their classes are like, and know what kinds of expectations there will be. Parents also need to keep in mind that not all kindergartens (or pre-Ks) are the same—a child may not quite be ready for “The Aristotle Scholars Academy,” but could do great in the “Learning Together Preschool” across the street. There isn’t one set of requirements that applies to all schools.

Parents know their kids best, and local teachers and administrators know their schools best. They should work together to help choose the best placement for children entering school.

Idiotic attendance policies

The Pediatric Insider

© 2010 Roy Benaroch, MD

The teenager started crying when I said, “Go home, get some sleep, you’ll probably be ready to make it back to school in a few days.”

She was sick, but not sick-sick. Fever 101, sore throat, achy, didn’t feel well. We’ve all been there.

The crying wasn’t because she felt bad. She was upset because she was missing school. She’d have to take her final exams.

The Federal “No Child Left Behind” act made school attendance crucial component of whether schools meet objective performance thresholds—and therefore, whether funding flows their way. Too many absences? There may not be enough cash to operate. As usual, legislation begets unintended consequences.

• Parents are routinely being dragged in front of child protective services, accused of raising truants, because their kids are missing too much school. I know—I’ve written the letters defending good parents whose kids are sick just a few too many days. The schools feel so much pressure to get the kids behind the desks that they’ve become far quicker to call in the police.
• Kids feel tremendous pressure not to miss school, even when they’re legitimately ill.
• Parents bring kids to see me even for trivial illnesses, just to get a documented school note. There are times when kids are too sick for school, but don’t really need to see a doctor. Parents know this, and I don’t suggest that parents bring kids to see me if they miss a day of school for a minor illness. It’s a waste of time for me, the parents, and the child, and it doesn’t help Junior get healthier any sooner.

My patient explained that at her school, if you miss less than two days per semester, you can skip your final exams. Miss two or more days, and you’re stuck. It doesn’t seem to matter why you missed, or what your grades are—the point is, drag your sick keister to school, and you can get into the HOV lane. You’ll get other people sick, but you’ll cruise past the suckers toiling through finals.

What? You thought final exams were to make sure you learned the material? Ha! They’re punishment for illness.

There are other rewards for perfect attendance. How about some McDonald’s gift certificates? Or a free bike? (I’m glad the givaway includes a helmet—but are they really just trying to prevent absences from cracked skulls?)  Cash is always a good option, too.

I understand, and agree with, the idea that kids ought to be in school. But sick kids, especially ones with contagious illnesses, need to stay home. There should be no punishment for becoming ill. As a community, it’s clear that if more sick kids attend school, more kids will catch more illnesses, and we’ll just end up with more sick kids—and more sick parents.

If absences are outlawed, only outlaws will have absences. I don’t know what that means, but I do know that creating incentives for sick children to go to school is shortsighted. And, frankly, idiotic.

Let kids play

The Pediatric Insider

© 2010 Roy Benaroch, MD

School has become far more intense since I was a kid. Kindergarteners are expected to read; first graders bubble in standardized tests; third graders are doing book reports, frantically re-reading The Old Man and the Sea by candlelight with a Vente Mocha. Are we working them too hard?

Researchers at the Albert Einstein College of Medicine examined data from about 12,000 children aged 8-9, collected across many different schools in  the USA in 2001. Their study correlated classroom behavior with the availability of routine recess time—time to get outside and play. No one ought to be surprised at the results: the children with no or little recess had far-worse classroom behavior than the kids who had time to run and play. In fact, more playtime equaled better behavior. If playtime were a medicine, higher doses (as expected) worked even better than low doses. The improved behavior was seen even after correcting for factors like overall classroom achievement, the income of the families, proportion of minority and disadvantaged students, and the proportion of boys in the class. Among all groups, more playtime led to better functioning in the classroom.

Is your child tough to handle, restless, jumpy, a noodge? Get him or her outside, playing. Playtime one “drug” that everyone needs. It helps kids focus and do well in school. And it’s cheaper than a trip to Starbucks!

Who has ADHD?

The Pediatric Insider

© 2009 Roy Benaroch, MD

Kristin would like to know, “How do you actually ‘diagnose’ a nine year old boy with ADHD? Descriptions of ADHD are so vague. Most of what is described as ADHD symptoms seem like normal boy behavior to us. Can a child be a straight A student and still have ADHD?”

It’s a fair question. There is no objective test for any psychiatric or mental health disorder, including ADD (Attention Deficit Disorder; one subtype is ADHD, or Attention Deficit-Hyperactivity Disorder), depression, anxiety disorders, autism—none of these can in any way be “tested for” or diagnosed with the kind of precision expected of ordinary medical diagnoses. I’m convinced that in 100 years, doctors will look back at my generation of physicians and chuckle knowingly, saying things like “¡ssǝ1ǝn1ɔ ʍoɥ ‘suɐıɹɐqɹɐq ǝsoɥʇ”. (Apparently, in the future, people speak upside down.)

In an effort to codify and standardize the language and diagnoses of psychiatry, the American Psychiatric Association first published the “Diagnostic and Statistical Manual of Mental Disorders” in 1952. The current version, last revised in 2000, is called the DSM-4-TR. It’s been criticized as “cookbooky”, relying on lists of symptoms to establish mental health diagnoses using checklists reminiscent of ordering a family meal at a Chinese Restaurant. Choose at least one from Column A (eg “inability to sit still”) and one from column B (“starting not older than seven years”), plus some qualifiers, and you’ve either got Mongolian Beef or Major Depression, maybe even both.

Though there are legitimate criticisms of the DSM, in fairness to psychiatry there are important caveats that are often overlooked. The book states explicitly that the diagnostic labels are mainly useful as “convenient shorthand for professionals,”  and that only well-trained professionals should interpret the standards and apply diagnostic criteria. So consider the DSM as a starting point for mental health diagnoses, not a straightjacket (sorry, poor time for a straightjacket joke).

DSM-IV Criteria for ADHD

I. Either A or B

A. Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level.

Inattention

• Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
• Often has trouble keeping attention on tasks or play activities.
• Often does not seem to listen when spoken to directly.
• Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
• Often has trouble organizing activities.
• Often avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).
• Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).
• Is often easily distracted.
• Is often forgetful in daily activities.

B. Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level.

Hyperactivity

• Often fidgets with hands or feet or squirms in seat.
• Often gets up from seat when remaining in seat is expected.
• Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).
• Often has trouble playing or enjoying leisure activities quietly.
• Is often “on the go” or often acts as if “driven by a motor.”
• Often talks excessively.

Impulsivity

• Often blurts out answers before questions have been finished.
• Often has trouble waiting one’s turn.
• Often interrupts or intrudes on others (e.g., butts into conversations or games).

II. Some symptoms that cause impairment were present before age 7 years.

III. Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).

IV. There must be clear evidence of significant impairment in social, school, or work functioning.

V. The symptoms do not happen only during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder. The symptoms are not better accounted for by another mental disorder (e.g. mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).

In summary: children with ADD have either inattention or impulsivity & hyperactivity, have these to a greater extent than expected for the developmental age, have these starting in early childhood, and have these as a more-or-less permanent part of their behavioral makeup. The symptoms must occur in multiple settings, and must occur to such an extent that they interfere with social, school, or occupational functioning. Part V is especially helpful—it says, essentially, that it’s ADD unless it is something else. Clearly, attorneys were involved in the preparation of this document.

To help “standardize” the diagnosis and hopefully make the assessment more objective, many clinicians rely on standardized testing instruments. Parents and teachers are asked a number of questions, like “How often does he fidget,” and answer something like always, sometimes, or never. The answers are decoded in a manner similar to the quizzes in Glamour Magazine (“What kind of guy is perfect for you?”), and the total score can be compared with thousands of other children who took the test. The “outliers”—the ones with the highest scores, above some set statistical set point—are said to have ADD.

Though these tests are helpful, it’s easy to see how parent or teacher preconceptions could color their answers. There are strong feelings about ADD and medication for ADD, and I’m not sure that making adults bubble in answers recalling a child’s behavior is likely to cut through their own feelings in a way that can reliably reveal what’s going on with a child. ADD “testing” has a role—in my mind, chiefly to rule out learning disorders and other problems that often go together with or appear very much like ADD—but a more reliable diagnosis I believe requires a thorough medical history and evaluation, as well as multiple observations over time by a skilled examiner. It’s not easy, and not quick, to do it right.

In answer to the final question, “Can a straight A student have ADHD?”—according to the DSM criteria, ADD characteristics like hyperactivity and inattention must occur to a degree to cause problems in school, home, or work. If your child is getting along well at home and with friends, and is getting straight As at school, he would not meet DSM criteria for ADD and should not be diagnosed as having ADD. Nonetheless, he may  benefit from behavioral interventions to encourage better sustained attention—but that’s a subject for a future post!

Special needs misadventures

Deb posted: “I’m wondering if you can guide me here. My 8 yr old son with mild-moderate special needs was having regular behavior problems at school and was up for a 3 yr reevaluation though the school. After a thorough private neuropsychiatric evaluation we were sent to another psychiatrist to rule out some of the neuropsych’s concerns. This Dr did rule out the concerns, asserting different ones in their place. Upon seeking another opinion because the two specialists’ assessments were so different, we received yet another ‘suggested’ diagnosis. The only point these specialists agreed on was that my child needed intensive therapy (4-5 days/week) and medication, although they could not agree on which kind and what for. Amazingly enough, during the period of time that we met and were evaluated by these specialists my son ‘remembered how he was supposed to behave’ and almost all of his problems at school disappeared. So my question is, at what point should a parent stop seeking out additional opinions in hope of finding some consensus in evaluating their child’s special needs? I want to give my child every support possible to be successful but frankly it’s often hard to remember why we went through all the testing in the first place. Can you offer some guidelines for how much is enough?”

This is a fair but tough question—I don’t really have enough information to speculate on what kind of problems Deb’s child is having, or what kinds of diagnoses or treatments would be appropriate. But it does raise the question of how to approach children with special needs and learning difficulties, and Deb’s post illustrates a frustration many parents have felt when trying to get help for their kids.

Part of the problem lies with the very nature of psychiatric diagnoses. In other realms of medicine, a diagnosis is made firmly on fairly objective data: take a history, ask about the symptoms, do an exam, maybe some tests—viola, you’ve got a diagnosis, or at least a very likely stab at a diagnosis, and treatment follows logically from there. The psychiatrists have tried to codify and objectify their diagnoses, too, in a huge book called the Diagnostic and Statistical Manual of Mental Disorders, or DSM, now in its fourth edition. To have “Attention Deficit Disorder,” for instance, you have to have 6 of 9 listed characteristics along with four required features. The DSM is an effort to make diagnoses in the realm of mental health standardized and objective, so practitioners are more clear and precise.

But in issues of mental health, especially in children, over-reliance on the DSM tends to oversimplify problems. It shoves kids into little boxes with clear labels on them: this one has ADD, that one has expressive language disorder, this other one has autism, this one has a processing disorder, etc. But in my experience many kids who need extra help in school have a combination of many features of each of these problems, and every one of these kids is unique. The labels themselves can become a distraction, forcing children into loops of expensive testing and diagnostic pigeonholing that doesn’t really help delineate exactly what kind of help would be best for the individual child.

Complicating matters further: children change and develop. A child who seems to mostly have problems with speech and language may later on have more problems with memory. And health and social circumstances can certainly have a big impact on a child’s success. If obstructive sleep apnea is preventing a good night sleep, a child might have symptoms identical to Attention Deficit Disorder; a child who’s being bullied may retaliate and be labeled with “Oppositional Defiant Disorder”; a child with a hearing deficit may seem autistic. Performance on testing to help determine a child’s diagnosis may depend on the rapport developed with the psychologist, and may be influenced by how well the child slept the night before and what was had for breakfast. A very good psychologist can work through these complications, at least most of the time. But it’s tricky.

So what’s a parent to do? Concentrate on what’s holding your child back, right now. Is it learning, or remembering? Conduct? Attention? Handwriting? Speaking? Getting along with others? All of these skills can be reinforced and tutored. As children grow, expect their strengths and weaknesses to change, and reassess how things are going and whether specific therapies are still leading to measurable, significant, and important improvements. If input from testing doesn’t make sense, don’t automatically accept suggestions. Even if you do follow a new course, reassess whether there really has been an improvement before continuing long-term. A certain amount of trial-and-error is unavoidable, but don’t feel locked into any sort of therapy that just isn’t working.

I like to think that a pediatrician can help get to know your child well, and hopefully provide guidance and a good objective viewpoint as parents try to digest these sorts of decisions. Our job is also to stay alert for medical conditions that can affect school performance and behavior.

I know some of our regulars have special needs kids—I’d love to hear from parents about their experiences with these problems, first hand.