March 2012 : The Role of a Pediatrician —gathering still more information
The Big Picture III
"My pediatrician told me that my son's problems with attention would go away with time. Jimmy is now in the second grade and I'm getting calls from his teacher. I remember Jimmy's kindergarten teacher also expressed some concerns. I just don't know. What should I do now? What would YOU do?"
"I'm so glad that Dr. Jordan steered me in the right direction. My daughter, Sara, now has a team of professionals to work with and she is getting the help she needs. Our pediatrician helped me understand that my child needed to get help as soon as possible. I was told Sara's problems with reading and language would worsen without intervention because she was getting older. I'm glad I moved on. Dr. Jordan was very helpful. Sara is doing great now!"
"My son had problems with focusing. It turned out Jonathan had a problem with his eyes. Our pediatrician advised us to see an ophthalmologist and my husband and I found out Jonathan needed glasses. I was relieved. It was so simple. This problem was easily solved. I'm so grateful!"
These situations may be familiar to you. Many parents have wondered whether they should talk to their pediatrician if their child is struggling in school. Other parents are very curious whether they ought to discuss their child's difficulties with social skills with their pediatrician as well.
Your pediatrician is the "key" in helping your child. I asked pediatrician, Peter Antall, M.D., from Thousand Oaks, California, to help us understand what a pediatrician is all about. The questions that I asked Dr. Antall are frequent questions that are asked in my private practice.
Karen L. Schiltz, Ph.D.: "Thank you, Dr. Antall, for joining this blog. Last month, Robin Burkholz, M.A. CCC-SLP from Westlake Village, California educated us about what a speech and language evaluation entailed. I know that Lynn, the mother of Ella, has been investigating what a professional "team" is all about. Most of the parents who come to see me wonder if their child should receive a physical examination every year. What do you recommend?"
Peter Antall, M.D.: "Hello Karen and thanks for inviting me to join you. It is my view that the pediatric well child exam is central to a child's physical, developmental, and emotional health. I recommend following the guidelines of the American Academy of Pediatrics, which call for yearly well child examinations starting at age three. Of course, prior to age 3 well-child exams are due even more frequently.
The pediatric well-child exam is the one chance each year to assess the whole child, as well as the parent-child dynamic. The pediatrician performs many tasks simultaneously at this evaluation including assessing the child's physical health, answering questions and offering parenting advice, watching carefully for any signs of emotional, behavioral, developmental or educational concern, and making diagnoses and treatment plans.
At each physical examination a full history should be elicited, which should include such things as current concerns, and general review of diet, exercise/activities, sleep, behavior and development. Past medical concerns should also be reviewed, as well as the use of any medications or supplements. Developmental screening questions should be asked or a developmental screening tool should be used. In a school age child, developmental screening revolves around a discussion of school performance. In teens the history should also address high-risk behaviors such as alcohol or drug use and sexual activity.
A full physical exam is then performed. Importantly, a physical examination means more than just listening with the stethoscope and looking in the mouth and ears. This ‘physical assessment' should, of course, be performed, but a full physical examination should also include much more. This assessment ought to include evaluation and charting of growth, observation of behavior, speech and affect, developmental assessment (including specific screening for autism spectrum disorders), vital signs, and assessment of hearing and vision at every visit. Other procedures include laboratory screening for anemia, cholesterol, lead, urinalysis, and a TB (tuberculosis) screening.
After all of this is accomplished, the pediatrician will make general conclusions regarding the child's health and make recommendations for further evaluation or treatment if needed. These recommendations may be standard for age, such as vaccines, lab or radiographic testing, or verbal anticipatory guidance, or they may be in response to conditions found during the well-child examination, including physical conditions as well as developmental, emotional or behavioral conditions. This is the point where referrals may be made for further evaluation."
Dr. Antall: "A vision evaluation is an essential part of a well child exam. Vision should be screened, if possible, at all well-child exams.
Mild vision impairment is prevalent and can be difficult to uncover unless it is screened. Importantly, children are often asymptomatic when their vision is abnormal.
The Journal of the American Public Health Association estimates that 10% of preschoolers have vision deficiencies. This figure increases in grades kindergarten through six to 25%, or one-in-four children. Vision disorders are the fourth most common disability and the most prevalent handicapping condition in children.
Having good vision, both for distance and for reading, is an essential prerequisite for learning. Imagine having to participate in school if you can't see the board. Or imagine trying to read if you can't see the letters on the page.
Vision impairment is treatable and early diagnosis and treatment in children is associated with improved long term vision and learning outcomes.
Karen, if I could, I would also like to mention that it is our belief that a qualified pediatric ophthalmologist should evaluate any young child with a vision problem, if one is available locally. There are many vision clinicians who are not specifically trained in the intricacies of vision disorders of childhood. I would also caution against any recommendation for a child to receive ‘vision therapy.' The American Academy of Pediatrics has advised against such therapies, because they are generally ineffective, and often delay diagnosis of true learning disabilities or attentional problems."
Dr. S.: "How about a hearing examination?"
Dr. Antall: "A hearing evaluation is also an essential part of a well child exam. Hearing should also be screened, if possible, at all well-child examinations, especially in the young school age child.
Mild hearing impairment is also very prevalent and can be difficult to pick up without screening. Hearing loss may be congenital, or may be an acquired condition. Acquired hearing loss in young children is most commonly due to frequent or persistent ear infections and these children should be screened carefully.
According to Niskar, et al., in the United States as many as 14% of children have detectible low or high frequency hearing loss in one or both ears. (1)
Importantly, hearing loss often causes delays in speech development. In these cases, early identification of the hearing loss is essential in order to correct the speech delay.
Like vision, hearing properly is essential for learning, and hearing loss can cause significant learning problems. Importantly, all hearing loss can be treated, and early detection and treatment is generally associated with improved outcomes."
Dr. S. "Many parents are confused and need help in understanding what a pediatrician and a developmental pediatrician is all about. Can you please educate us about this?"
Dr. Antall: "A pediatrician is a primary care provider. All children should have a regular pediatrician (or comparable clinician such as a family physician or pediatric nurse practitioner). A pediatrician's role is to supervise and support all aspects of the physical and developmental health of a child, as described above.
A key role for the pediatrician is to make the proper referral. While there is a lot of overlap amongst the specialists involved in the care of educational or developmental health, a poor referral can cause delay in diagnosis or can even lead to improper diagnosis or treatment of the child. A pediatrician can narrow down the diagnosis, and can choose a specialist clinician that is most likely to help the child."
Dr. S.: "Why do parents need to keep the pediatrician "in the loop" when their child exhibits problems with thinking, academics, social, and attentional areas?"
Dr. Antall: "I believe the pediatrician should be centrally involved when a child is having social or academic difficulties. The pediatrician is essential in the process as the pediatrician should have a relationship with the child (and parents), can evaluate for physical conditions that impact learning, and as mentioned above, can direct the family to the appropriate clinician for full evaluation or treatment.
When asked to evaluate these patients, the role of the pediatrician is to help define the problem that is occurring and to evaluate for any physical disorders that may be causing or contributing to the problem. The pediatrician can play an important role here by clarifying the child's symptoms, educating the parent, explaining the process of assessment, and setting expectations. The pediatrician can then help direct the parent to local resources and specialists for the assessment.
Once the child has been evaluated, the pediatrician can partner with the specialist to care for the child. The pediatrician may be asked to prescribe medications, for further referrals, or to follow the child longitudinally to assess response to medications or other interventions."
Dr. Antall: "As a general rule a pediatrician should trust the instincts of the parent. A pediatrician should take all parental concerns seriously. The parent's subjective sense of something being ‘a little off' is very significant and important.
It is important, however, to take advantage of these moments because subtle learning, behavioral or developmental problems might be uncovered. As we know, early intervention is key in treating such disorders.
My approach in these cases is to refer the child for an objective assessment of development and learning.
The parent may need to consider switching to another pediatrician who values their questions if their concerns are not being adequately met by their pediatrician. The parent should also consider self-referral to seek out an objective assessment of their child from an appropriate specialist."
Dr. Antall: "Thanks, Karen, for inviting me to participate. And thank you for your work in helping parents and clinicians understand children with learning difficulties.
I am a practicing general pediatrician at Conejo Children's Medical Group in Thousand Oaks, California. We are a small office and we try to practice medicine the old fashioned way: with empathy, good listening, and professionalism. I am also President and Medical Director for Pediatric Hospitalist Services where we provide pediatric consultations to local Emergency Departments.
Dr. S.: I will be interviewing pediatric/young adult neuropsychologist, Claudia Kernan, Ph.D., next month. Dr. Kernan is an expert in the field of concussion/head injury from UCLA. As you recall in my December 2011 blog, Lynn's daughter, Ella, was a victim in a car accident and was disoriented and exhibited signs of headaches and fatigue for approximately one month after the accident. Ella's mother is still wondering whether her daughter's behaviors are related to the accident. I'm looking forward to my conversation with Dr. Kernan about the short-term symptoms of concussion and what we, as parents, need to know when our child has such an event.
1. JAMA. 1998; 279 (14):1071-1075. doi: 10.1001/jama.279.14.1071
Copyright Karen L. Schiltz 2001