Are Kids Dying With COVID-19?

How many children have died with COVID-19?

You have likely heard that COVID-19 is not supposed to make children sick, so what’s with the reports that kids are dying with COVID-19?

“Whereas most COVID-19 cases in children are not severe, serious COVID-19 illness resulting in hospitalization still occurs in this age group.”

Coronavirus Disease 2019 in Children — United States, February 12–April 2, 2020

So far, while only about 5% of cases in the United States have occurred in children and teens who are less than 18 years old, some of those “pediatric COVID-19 cases were hospitalized.”

The American Academy of Pediatrics reports at least 266 child deaths from COVID-19.
The American Academy of Pediatrics reports at least 266 child deaths from COVID-19.

Some were even admitted to the ICU and tragically, some have died.

Are Kids Dying With COVID-19?

How many kids?

So far, as of late-March, there have been over 2,703,000 COVID-19 deaths worldwide (all ages), including over 539,000 deaths in the United States (all ages).

“In China, the novel coronavirus has claimed the lives of a 10-month-old and a 14-year-old, at least.”

The coronavirus pandemic has claimed the lives of an infant and a teenager

And some of those deaths have been in children.

“Three deaths were reported among the pediatric cases included in this analysis; however, review of these cases is ongoing to confirm COVID-19 as the likely cause of death.”

Coronavirus Disease 2019 in Children — United States, February 12–April 2, 2020

It’s important to note that some these recent COVID-19 deaths in children are still being investigated, but according to reports they include:

The latest reports of COVID-19 deaths include:

Experts have still not confirmed that COVID-19 caused all of these deaths.

Kids are dying with COVID-19.
Kids are dying with COVID-19.

Still, the AAP reports that there have been at least 266 COVID-19 deaths in children in the United States and cases are on the rise in many areas.

“During February 12–July 31, 2020, a total of 391,814 cases of COVID-19 and MIS-C (representing approximately 8% of all reported cases) and 121 deaths (approximately 0.08% of all deaths) were identified among persons aged <21 years in the United States.”

SARS-CoV-2–Associated Deaths Among Persons Aged <21 Years — United States, February 12–July 31, 2020

While there are far fewer COVID-19 deaths in children than in adults, since fewer kids are reportedly getting infected, the number of deaths is concerning.

“Among the 121 decedents, 30 (25%) were previously healthy (no reported underlying medical condition), 91 (75%) had at least one underlying medical condition, and 54 (45%) had two or more underlying medical conditions.”

SARS-CoV-2–Associated Deaths Among Persons Aged <21 Years — United States, February 12–July 31, 2020

And that’s why it is important to continue to encourage your kids to follow all social distancing recommendations.

The latest report from the CDC lists at least 313 pediatric COVID-19 deaths, but is likely an undercount, as there have been over 539,000 deaths.
The latest report from the CDC lists at least 313 pediatric COVID-19 deaths, but is likely an undercount, as there have been over 539,000 deaths.

Keep in mind that there have been an additional 33 deaths in children from multisystem inflammatory syndrome in children (MIS-C), which is associated with COVID-19.

How Many Kids Have Died With Covid-19?

So just how many kids have died with COVID-19?

We still don’t have exact numbers, but it is easy to see that well over 200 nearly 300 children have died with COVID-19.

More on COVID-19 Deaths

How Many People Have Really Died With COVID-19?

There were at least 322,306 more deaths in 2020 than in 2019, which is about the number of deaths attributed to COVID-19.

Why do some people still not understand just how many people have died with COVID-19?

Why do some folks continue to push the idea that people aren't really dying with COVID-19?
Why do some folks continue to push the idea that people aren’t really dying with COVID-19? It makes it easier to convince you that you don’t need to wear a mask or get a COVID-19 vaccine…

The usual suspects…

How Many People Have Really Died With COVID-19?

If you are confused or doubt just how deadly COVID-19 has been, one easy way to estimate how many people have died with COVID-19 is to compare year-to-year total deaths.

Just over 2.8 million people died in 2018 and 2019.

For example, just over 2.8 million people died in 2018 and 2019.

In 2019, a total of 2,854,838 resident deaths were registered in the United States—15,633 more deaths than in 2018.

How does that compare to 2020?

Before you say that there were 2,913,144 deaths in 2020, keep in mind that this data doesn't include January 2020...
Before you say that there were 2,913,144 deaths in 2020, keep in mind that this data doesn’t include January 2020…

Not surprisingly, there were far fewer deaths in 2018 and 2019…

We add these 264,000 deaths from January 2020 to the 2,913,144 deaths from February to December 2020 to get our total for the year.
We add these 264,000 deaths from January 2020 to the 2,913,144 deaths from February to December 2020 to get our total for the year.

Using complete year counts:

  • 2019 total deaths – 2,854,838
  • 2020 total deaths – 3,177,144

Leaving you with 322,306 more deaths in 2020 than in 2019.

Which is just about the count of COVID-19 deaths that experts have posted.

If you still aren’t convinced that these deaths have been caused by COVID-19, if not COVID-19, then what has caused all of these extra deaths?

“Excess deaths provide an estimate of the full COVID-19 burden and indicate that official tallies likely undercount deaths due to the virus.”

Estimation of Excess Deaths Associated With the COVID-19 Pandemic in the United States, March to May 2020

The count is even more startling if you understand that many experts think that we are under-counting COVID-19 deaths!

“Simon and colleagues suggest that it is critical to consider that for every death, an estimated 9 family members are affected, such as with prolonged grief or symptoms of posttraumatic stress disorder. In other words, approximately 3.5 million people could develop major mental health needs. This does not account for the thousands of health care workers in hospitals and nursing homes who have been witness to the unimaginable morbidity and mortality associated with COVID-19.”

Excess Deaths and the Great Pandemic of 2020

What else?

Many people are underestimating their risk of what could happen if they get COVID-19. Or if one of their family members get COVID-19.

Sure, COVID-19 is much more deadly if you have risk factors, but many people still underestimate their risks of getting and dying from COVID-19.

With a case-fatality rate between 1 and 3% in the United States, that means a lot of people with COVID-19 have been dying.
With a case-fatality rate between 1 and 3% in the United States, that means a lot of people with COVID-19 have been dying.

The bottom line is that COVID-19 is indeed deadly, with the possibility of serious long-term effects for many who survive.

“While most persons with COVID-19 recover and return to normal health, some patients can have symptoms that can last for weeks or even months after recovery from acute illness.”

Long-Term Effects of COVID-19

And since we now have safe and effective COVID-19 vaccines that can help end the pandemic, you know what to do.

Over 500,000 people have now died with COVID-19 in the United States.
Over 500,000 people have now died with COVID-19 in the United States.

It’s time to get vaccinated and protected.

More on COVID-19 Deaths

Are We Going to See a Summer Surge of RSV This Year?

Folks need to understand that RSV might still be coming. If not in the next few months, then maybe this summer. And if there is no summer surge of RSV, then it will likely be back even worse next year.

A summer surge of RSV?

I know, it sounds ridiculous, right?

After all, in a typical year, RSV season begins in September or October and peaks in December or January.

Of course, this hasn’t been a typical year…

Are We Going to See a Summer Surge of RSV This Year?

Except for COVID-19, rhinovirus, enterovirus, and some adenovirus, we haven’t seen most of the seasonal viral outbreaks that we typically see each year.

There hasn't been any RSV in Texas this year.
There hasn’t been any RSV in Texas this year.

There was no RSV, flu, or seasonal coronavirus, etc.

Not that anyone has been complaining…

It was one of the bright spots that came out of all of the social distancing, mask wearing, and travel restrictions to control the COVID-19 pandemic!

So why would anyone think that we might see a summer surge of RSV?!?

The news that folks in Australia started getting hit with RSV a few months ago, when it was still summertime!

Remember, Australia is in the Southern Hemisphere and their summer runs from December to February and their autumn from March to May.
Remember, Australia is in the Southern Hemisphere and their summer runs from December to February and their autumn from March to May.

What caused the summer surge of RSV in Australia?

An unexpected surge that is also being reported in South Africa

“Recent reports from Australia described an inter-seasonal RSV epidemic in Australian children following the reduction of COVID-19–related public health measures from September 2020 to January 2021.”

Delayed Start of the Respiratory Syncytial Virus Epidemic at the End of the 20/21 Northern Hemisphere Winter Season, Lyon, France

Is it because they got their COVID-19 cases under good control early and relaxed many of their COVID-19 related public health measures, including eliminating mandates to wear masks and most restrictions on public gathering, and allowed kids to go back to school?

Whatever the reason for the surge, what is most troubling is that we may not have to wait until this summer for our own surge!

“In 2020, the first RSV cases of the 20/21 season were detected in Lyon at week 46 and 47 (Figure 1) at the same time of the southern hemisphere outbreak. A sustained detection of cases was observed from week 51, which is the expected time of the epidemic peak, to week 5. On week 6, the RSV epidemic was declared in the first French region (Ile de France) while the number of RSV cases has continued to increase in the Lyon population.”

Delayed Start of the Respiratory Syncytial Virus Epidemic at the End of the 20/21 Northern Hemisphere Winter Season, Lyon, France

France is seeing RSV too – with a 4 month delay to the start of their season. And they haven’t relaxed their physical distancing recommendations as much as Australia, as they were still seeing cases of COVID-19.

And as if all of that wasn’t enough, the summer surge of RSV in Australia is at rates that are much higher than is seen in a typical RSV season!

Wasn’t that expected?

“Our results suggest that a buildup of susceptibility during these control periods may result in large outbreaks in the coming years.”

The impact of COVID-19 nonpharmaceutical interventions on the future dynamics of endemic infections

While larger future outbreaks have been expected, most people likely thought they would start with next year’s season.

“Our findings raise concerns for RSV control in the Northern Hemisphere, where a shortened season was experienced last winter. The eventual reduction of COVID-19–related public health measures may herald a significant rise in RSV. Depending on the timing, the accompanying morbidity and mortality, especially in older adults, may overburden already strained healthcare systems.”

The Interseasonal Resurgence of Respiratory Syncytial Virus in Australian Children Following the Reduction of Coronavirus Disease 2019–Related Public Health Measures

I’m not sure anyone is ready for RSV and COVID-19 at the same time. That’s not the Twindemic folks were warning us about!

But maybe we should get ready to start seeing some RSV.

March is typically close to the end of RSV season, not the beginning.
March is typically close to the end of RSV season, not the beginning.

After all, rates of RSV are starting to increase in Florida and the South Atlantic division of the United States.

While there is no way to know if we will see this trend in other states and we may just be delaying when RSV season starts anyway, parents should know that we can always protect those who are most at risk from severe RSV disease.

“Ideally, people with cold-like symptoms should not interact with children at high risk for severe RSV disease, including premature infants, children younger than 2 years of age with chronic lung or heart conditions, and children with weakened immune systems.”

RSV Prevention

At some point, we might even have to consider changing when Synagis, the monthly shot that can help prevent RSV, is given. Should we continue giving Synagis to high risk infants this Spring and Summer, for example, instead of stopping in March?

Mostly, folks need to understand that RSV might be coming. If not in the next few months, then maybe this summer. And if not this summer, then it will likely be back with an even worse next year.

More on RSV

What is the Rule of Two/Too?

The Rule of Too/Two is an easy way to discover possible risks of genetic conditions in your family medical history.

Have you ever heard of the Rule of Two?

No, this isn’t about Star Wars…

What is the Rule of Two/Too?

If you didn’t know about the Rule of Two/Too, you will likely be very surprised to know that there are more than one of these rules!

The Rules of Two is a quick and easy way to figure our if your child's asthma is under good control.

The Rules of Two is a quick and easy way to figure our if your child’s asthma is out of control.

Remember that one now?

What about this other one?

The rule of Two/Too.

Arthur Grix proposed the Rule of Too/Two to make things simple for primary care providers when looking for genetic conditions within a family.
Arthur Grix proposed the Rule of Too/Two to make things simple for primary care providers when looking for genetic conditions within a family.

The Rule of Too/Two can help you figure out if you might have a genetic condition in your family!

After all, filling out your family medical history is pretty easy for most people. Knowing what to do with all of that information, especially how it might translate into a risk for a genetic condition is the tricky part…

“Family health history questions that result in answers using the descriptors “too” or “two”may indicate a genetic condition.”

A Toolkit to Improve Care for Pediatric Patients with Genetic Conditions in Primary Care

And that’s where the Rule of Too/Two comes in!

It reviews many of the red flags for genetic conditions and can help you figure out if you or your kids should undergo any kind of genetic screening.

The Rule of Too/Two includes:

  • being TOO tall as compared to their genetic potential for height
  • being TOO short as compared to their genetic potential for height
  • getting sick at TOO early/TOO young an age – extreme early onset cardiovascular disease, cancer, or renal failure, etc., and developing adult disorders in childhood can be a sign of a genetic cause
  • TOO many people in a family having the same condition
  • having an unusual or extreme presentation of a common condition that is TOO different than usual, like breast cancer in a male family member
  • a family member having TWO different types of tumors
  • a condition in TWO generations of family members
  • a condition that affects TWO people in the family
  • a family member with TWO or more birth defects or congenital anomalies

When you fill out your family health history, if you are using the terms ‘too’ and ‘two’ very often, then you might talk to your health care provider to take a closer look.

“Everyone is eligible for one tumor, one birth defect (ASD, cleft lip, birth mark, etc.).”

Arthur Grix, MD

The Rule of Too/Two is an easy way to discover possible risks of genetic conditions in your family medical history.

There are other genetic risk assessment methods besides the Rule of Too/Two.
There are other genetic risk assessment methods besides the Rule of Too/Two.

Which ever method you use, if you find genetic risks in your family tree, you might want to see a genetic counselor for further evaluation.

More on the Rule of Two/Too

Algorithms to Manage Common and Rare Pediatric Conditions

From an elevated ANA to a child with recurrent fractures, these evidence based clinical pathways, guidelines, and algorithms can help pediatricians figure out what’s the best next step for their patients.

What do you do when a baby has abnormal muscle tone, an elevated TSH, high blood pressure, or a high phenylalanine level ?

Do you refer them to a specialist for further management?

Or do you do a little research first, grabbing a few of your medical books?

There is an algorithm to help your pediatric provider figure out what to do if your kids have high blood pressure.
There is an algorithm to help your pediatric provider figure out what to do if your kids have high blood pressure.

Since these aren’t necessarily common things, you likely do need a little help to make sure you do the right thing, but on the other hand, you don’t have all day to research one problem…

So what do you do?

“Implementation of multiple evidence-based, standardized clinical pathways was associated with decreased resource utilization without negatively affecting patient physical functioning improvement. This approach could be widely implemented to improve the value of care provided.”

Standardized Clinical Pathways for Hospitalized Children and Outcomes

Having guidelines and algorithms to look to for some extra help would probably be nice…

Algorithms to Manage Common and Rare Pediatric Conditions

And here’s how you can quickly and easily find many of those guidelines and algorithms:

And of course, you can always look things up in a textbook, call your favorite expert, or refer your patient to a specialist if you need more help.

More on Managing Common and Rare Pediatric Conditions

Lab Tests That Are Often Misinterpreted

To get the most accurate results and avoid false positive and false negative results, you want to use the right test for the right patient, and then know how to interpret the results correctly.

There are a lot of good reasons that most doctors should do fewer lab tests.

For one thing, many are simply unnecessary.

And few tests are inexpensive.

Another reason, one that you likely haven’t thought of, is that sometimes lab tests are misinterpreted, leading to unnecessary treatments.

Lab Tests That Are Often Misinterpreted

In addition to false positive and false negative test results, which are an inherent risk with almost any test, you sometimes run the risk that your doctor doesn’t truly understand how to interpret the results of the test they ordered.

How is that possible?

Consider Lyme disease testing.

Unless you live in or visited an area with ticks that cause Lyme disease and you have symptoms of Lyme disease, then you don’t need to be tested for Lyme disease. If you do get tested, you doctor should use two-tiered testing – an EIA or IFA test first, and if positive, Western blot testing.

The CDC recommends two-tiered testing for Lyme disease.

How do you know if your Western Blot test is positive?

A positive IgM Western blot for Lyme disease requires at least two of the following bands of the test to be positive:

  1. 24 kDa (OspC)
  2. 39 kDa (BmpA)
  3. 41 kDa (Fla)

And a positive IgG Western blot for Lyme disease requires at least five of the following bands of the test to be positive:

  1. 18 kDa
  2. 21 kDa (OspC)
  3. 28 kDa
  4. 30 kDa
  5. 39 kDa (BmpA)
  6. 41 kDa (Fla)
  7. 45 kDa
  8. 58 kDa (not GroEL)
  9. 66 kDa
  10. 93 kDa (2)

What happens if someone only sees one of the IgM bands or four of the IgG bands? Are they going to know it is a negative test or are they going to wonder if they have Lyme disease?

Still, that doesn’t mean that you should never test patients for Lyme disease. You just want to use the right test for the right patient, and then know how to interpret the results correctly.

What other tests are often misused or can be easily misinterpreted?

  • blood allergy tests – Ever been told you’re child is allergic to everything? That’s likely because instead of a simple positive or negative result, blood allergy tests are prone to false positive results
  • the PPD test – it is important to understand that interpreting the tuberculin skin test depends on the child’s risk factors and that a previous BCG vaccine can trigger a false positive
  • rapid strep tests – prone to false positive results, picking up strep carriers, especially if you test kids who do not have classic symptoms of strep throat
  • rapid flu tests – prone to false positive results if you test when flu activity is low
  • thyroid function tests
  • monospot test – this is a non-specific test, so is not just for mono and most experts recommend that it no longer be used
  • EBV titers – titers of Epstein-Barr virus (EBV) antigens, including viral capsid antigen (VCA), Early antigen (EA), and EBV nuclear antigen (EBNA) can all appear at different points in your infection, from early on to years after you have recovered. Many persist for the rest of your life after you have had mono, which some folks confuse as a new infection or a relapse.
  • vaccine titers
  • ANA – while your anti-nuclear antibody test should typically be negative and a positive ANA can be a sign of arthritis, it is also very common for kids without any problems to have a positive or elevated ANA
  • WBC
  • vitamin D levels
  • drug testing
  • tox screening
  • covid-19 tests
  • EEGs

Why are these tests so easily misinterpreted?

False Positive Test Results

For one thing, many people underestimate the risk of false positive test results.

That’s why it is important to remember that a positive test doesn’t necessarily mean 100% that you have any specific disease or condition. It just means that you have a positive test.

“EEG will be negative in a large portion of patients with epilepsy, and may be positive in patients without epilepsy. False positive EEG findings commonly lead to unnecessary use of antiepileptic drugs and may delay the syncope diagnosis and treatment. EEGs are most helpful in specific situations when there is high pre-test probability for epilepsy based on history and exam, and clinical presentation.”

Do not routinely order electroencephalogram (EEG) as part of initial syncope work-up.

The fact that you can actually have a false positive EEG test should help you understand this whole issue a little better.

So how do you reduce the chance that you will have a false positive test result – or a false negative for that matter?

“A given test will have a higher positive predictive value in those patients with a higher prior probability of disease.”

Sensitivity, Specificity, and Predictive Values of Diagnostic and Screening Tests

You have to understand the sensitivity, specificity, and predictive values of the tests you use. And the things that influence them.

“The positive and negative predictive values vary considerably depending upon the prevalence of influenza (level of influenza activity) in the patient population being tested.”

Rapid Diagnostic Testing for Influenza: Information for Clinical Laboratory Directors

For example, when no one has the flu and disease prevalence is low, you are more likely to have false-positive rapid antigen test results. So that positive flu test this year, when no one has the flu might not actually mean that you have the flu either. It is probably a false positive, which makes you wonder why the test was done in the first place…

And know that you can’t just test everyone for everything…

More on Lab Tests That Are Often Misinterpreted

Mental Health Treatment Tips for Teens

Things your teen can do to help them cope with anxiety, depression, insomnia, and other mental health issues.

What do we do when our kids are having mental health problems?

Counseling?

Medication?

There are many tools your teen can learn to help them manage anxiety, stress, and other mental health issues.
There are many tools your teen can learn to help them manage anxiety, stress, and other mental health issues.

Cognitive behavioral therapy?

Whatever we do, there are times when they might need a little more help

Mental Health Treatment Tips for Teens

Most importantly, teens with mental health issues, like depression and anxiety, should know what to do when these specific problems flare up (follow the links for detailed advice):

  1. extra anxiety – learn to manage anxiety when it attacks with different exercises, like deep breathing, focusing on their five senses, thinking positively for 12 seconds, or laughing at a video they typically find funny, etc.
  2. extra social anxiety – are there specific social situations that make your anxiety worse during which you will need extra help
  3. extra sadness – learn grounding and mindfullness skills
  4. not being able to sleep – teens who have trouble sleeping should learn about progressive muscle relaxation and guided imagery
  5. not being able to get out of bed – call your health care provider if this happens most days and have a plan in case it happens once in a while
  6. feeling lonely
  7. wanting to self medicate – see your health care professional if you are turning to drugs or alcohol as a coping mechanism to deal with stress. Overeating is another negative coping skill to avoid.
  8. getting more easily distracted – talk to your health care provider, as this can be a sign of worsening anxiety and depression
  9. getting angry
  10. coping with a breakup – how can they deal with the heartbreak after a breakup?
  11. getting bullied – you’re not alone.
  12. feeling like you want to hurt yourself – teens thinking of hurting themselves should know that they should seek immediate help

Whatever they are going through, it is especially important that your teen knows that things will get better!

Although that often doesn’t seem likely when you are in the middle of a crisis, it is true.

That can be easier to understand once you review these stories of hope and recovery!

What else can you do?

In general, things like keeping a journal, getting daily exercise, and talking to your friends and family members are positive coping skills that can be helpful.

Create healthy habits and avoid spending too much time online.

“We all need a little extra help sometimes. If you are feeling sad, afraid or overwhelmed, talk to someone you trust – whether it is a family member, close friend, therapist, or case manager. It is important to reach out for help if you need it.”

Hey Teens! Take Care of Your Mental Health

You can also always talk to your pediatrician or other health care provider.

More on Mental Health Tips for Teens

Other Treatments for ADHD

In addition to stimulant and non-stimulant medications, behavior management therapy can help your child with ADHD.

So most people know that stimulant and non-stimulant medications are available as treatment for ADHD.

But what else is available?

Other Treatments for ADHD

Wait, why would you need to consider other treatments?

Well, believe it or not, some kids can’t tolerate stimulants.

And others either can’t tolerate non-stimulants either, or neither work for them.

So what’s left?

There’s behavior management therapy.

In fact, although it is often overlooked, it is important to remember that behavior management therapy should be the first treatment for younger, preschool children with ADHD.

“There are many forms of behavior therapy, but all have a common goal—to change the child’s physical and social environments to help the child improve his behavior.”

Behavior Therapy for Children with ADHD

And even though older kids are often treated with medication, they too might benefit from behavior management therapy.

“Under this approach, parents, teachers, and other caregivers learn better ways to work with and relate to the child with ADHD. You will learn how to set and enforce rules, help your child understand what he needs to do, use discipline effectively, and encourage good behavior. Your child will learn better ways to control his behavior as a result. You will learn how to be more consistent.”

Behavior Therapy for Children with ADHD

Typical behavior management therapy techniques might include positive reinforcement and allowing your child to earn rewards for desired behaviors and withdrawing privileges to try and decrease other behaviors.

You also want to help your child:

Some children with ADHD may also need social skills training and behavioral therapy for help controlling impulsive behavior.

Once you find a therapist, you can expect it to take time for your child to master the behavioral therapy techniques and better control his ADHD symptoms.
Once you find a therapist, you can expect it to take time for your child to master the behavioral therapy techniques and better control his ADHD symptoms.

And of course, accommodations at school (504 Plan vs IEP) can also be helpful so that your child has extra time to take tests if needed, modified instructions and assignments, and extra break time, etc.

What About Alternative ADHD Treatments?

What about all of those “other” treatments for ADHD that you might have heard about?

At those homeopathic dilutions, it is unlikely that there is any real active ingredient left in the Brillia pills. Remember, homeopathy works by the law of the minimum dose and  although it doesn't say it on the label, homeopathic medications only contain a "memory" of an active ingredient.
At those homeopathic dilutions, it is unlikely that there is any real active ingredient left in the Brillia pills. Remember, homeopathy works by the law of the minimum dose and although it doesn’t say it on the label, homeopathic medications only contain a “memory” of an active ingredient.

Restrictive diets, vitamins, minerals, brain training, and homeopathic remedies that are basically diluted to nothing…

Nutritional lithium, probiotics, and digestive enzymes…

You are actually trying to help your child with ADHD, right?

If all you have tried are alternative therapies to try and help your child with ADHD, then it's time to talk to your pediatrician about some real treatments.
If all you have tried are alternative therapies to try and help your child with ADHD, then it’s time to talk to your pediatrician about some real treatments.

Then try something that at least has a chance of working…

And if nothing works, keep in mind that your child might not actually have ADHD. Maybe something else is causing their symptoms or problems, like obstructive sleep apnea, depression, anxiety, or a learning disability, etc.

More on ADHD Treatments

Treating Hard to Control ADHD

Learn why ADHD can sometimes be hard to control and require more than just a quick prescription for Ritalin or Adderall, including adding behavior therapy, careful monitoring, and special accommodations at school.

ADHD is often much harder to treat than many people imagine.

It isn’t always just a matter of writing a script for Adderall or Ritalin and then have kids who had been failing suddenly jump to the ‘A’ Honor Roll.

ADHD Treatments

Whether your child’s ADHD symptoms include problems with inattention, hyperactivity and impulsivity, or both, the treatments are the same:

  • Stimulants – Adderall vs Ritalin based
  • Non-Stimulants – Intuniv (extended release guanfacine), Kapvay (extended release clonidine), Strattera
  • Behavior Management Therapy

Although often underused, it is recommended that behavior therapy be the first treatment for younger, preschool children with ADHD. Both medication and behavior therapy are typically recommended for older children with ADHD.

ADHD Medications

Surprisingly, there is really no one best ADHD medicine. Those that aren’t yet generic (in bold) are going to be much more expensive than the others.

  • Short Acting Stimulants – Adderall, Focalin, Methylin (chewable), ProCentra (liquid), Ritalin
  • Intermediate Acting Stimulants – Dexedrine, Ritalin SR, Methylin ER
  • Long Acting Stimulants – Adderall XR, Adzenys XR-ODT, Concerta (Methylphenidate ER), Daytrana (patch), Focalin XR, Metadate CD, Metadate ER, Quillichew ER (chewable), Quillivant XR (liquid), Ritalin LA, Vyvanse
  • Non-Stimulants – Intuniv, Kapvay, Strattera

In general, stimulants are thought to work better than non-stimulants, but again, there isn’t one stimulant that is consistently better than another.

Treating Hard to Control ADHD

What do you do when your child’s ADHD treatments aren’t working?

While it is important to “initiate an evaluation for ADHD for any child 4 through 18 years of age who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity,” it is important to remember that not all kids with academic or behavioral problems have ADHD.

So the first thing you should do is confirm that your child really does have ADHD. Is it possible that your child was misdiagnosed and doesn’t have ADHD at all? Or could your child have ADHD and another co-morbid condition, including “emotional or behavioral (eg, anxiety, depressive, oppositional defiant, and conduct disorders), developmental (eg, learning and language disorders or other neurodevelopmental disorders), and physical (eg, tics, sleep apnea) conditions.”

Next, ask yourself these questions and discuss the answers with your pediatrician:

  • Is your child taking his medicine?
  • Does your child need behavior management therapy?
  • Are you not getting your child’s ADHD medicine because of how expensive it is? Ask your pediatrician about a lower cost generic ADHD medicine.
  • Has there been a sudden worsening of previously well controlled ADHD, which might indicate a problem with bullying, social changes at home, abuse, or depression, etc.?
  • Are you relying on restrictive diets or other alternative treatments for ADHD that have been proven to not usually work?
  • Does your child need a different dosage of his current stimulant, either a higher or lower dose?
  • Is your child’s medication wearing off too soon?
  • Does your child’s medication take too long to work?
  • Does your child need to switch to a different stimulant or to a stimulant with a different delivery method?
  • Does your child need to switch from a long-acting stimulant to a short-acting stimulant?
  • Does your child need to switch to a non-stimulant, keeping in mind that these are often used in combination with a stimulant and not by themselves.
  • Do you need to adjust your expectations for what kind of control you can get from even maximal treatment?
  • Does your pre-teen or teen with ADHD not want to take his medication anymore?
  • Are side effects keeping your child from taking his ADHD medicine everyday?
  • Does your child need 504 plan accommodations at school and/or an IEP?

And perhaps most importantly, what is making your child’s ADHD hard to control? Is he just still having some ADHD symptoms or are those lingering ADHD symptoms causing an impairment? If they aren’t causing an impairment, such as poor grades, problems with friends, or getting in trouble at school, etc., then your child’s ADHD may be under better control than you think.

What To Know About Treating Hard to Control ADHD

ADHD can sometimes be hard to control and require more than just a quick prescription for Ritalin or Adderall, including adding behavior therapy, careful monitoring, and special accommodations at school.

More Information About Treating Hard to Control ADHD

Pediatric Referral Guidelines

These referral guidelines can help you figure out when to refer a sick child to a specialist, how quickly you should get the child seen, and what to do as part of your pre-referral workup.

As much as we like to create a medical home for our kids, there are times when we have to refer them to specialists to help diagnose or manage an issue.

It is sometimes hard to know when that time is though.

Or what you can do before you start the referral process.

Do you know what to do as part of pre-referral workup for a child with short stature?
Do you know what to do as part of pre-referral workup for a child with short stature?

Reviewing our collection of pediatric referral guidelines can help to make sure that you send the right patient to the right specialist at the right time. And can help avoid unnecessary referrals and testing!

Pediatric Referral Guidelines

This is especially important because it can sometimes take time to get a pediatric patient in to see a specialist, so you don’t want a sick child to wait months only to discover that you could have or should have done something else.

Most importantly, these types of guidelines can help you figure out when to refer a sick child to a specialist, how quickly you should get the child seen, and what to do as part of your pre-referral workup.

Do the specialists you routinely refer to have their own guidelines you can look to before referring a patient?

If not, consider reviewing these referral guidelines for:

  • adolescent medicine – abnormal uterine bleeding, eating disorders
  • pediatric allergy & immunology – allergic rhinoconjunctivitis, anaphylaxis, asthma, atopic dermatitis, drug allergy, eosinophilic esophagitis, food allergy, immunodeficiency, insect hypersensitivity, sinusitis, urticaria/angiodema
  • back pain
  • pediatric cardiology – heart murmur, palpitations, arrhythmia, abnormal ECG, chest pain, syncope, hypertension, Kawasaki, genetic disorders, premature and term infants, hyperlipidemia
  • concussions
  • developmental-behavioral pediatrics – speech/language delay, delayed milestones, ADHD, preschool behavior disorder, autism
  • eating disorders – anorexia nervosa, bulimia, avoidant/restrictive food intake disorder
  • pediatric endocrinology – hypothyroidism, hyperthyroidism, goiter, thyroid nodule, diabetes, obesity, acanthosis nigricans, short stature, failure to thrive, precocious puberty, premature thelarche, premature adrenarche, delayed puberty
  • pediatric gastroenterology – abdominal pain, celiac disease, chron’s disease, diarrhea, hematochezia, food allergy, peptic ulcer disease, GER, vomiting, constipation, failure to thrive, eosinophilic esophagitis
  • GI conditions – abdominal pain, constipation, reflux, failure to thrive, vomiting, diarrhea, celiac disease, Crohn’s Disease / Ulcerative Colitis, Suspected Eosinophilic Esophagitis (EoE)
  • pediatric headaches
  • pediatric hematology – anemia, thrombocytopenia, neutropenia, coagulation defects (bruising and bleeding)
  • infectious diseases – recurring fevers, recurrent sinusitis, FUO, recurrent abscesses
  • metabolic disorders – developmental regression, hypotonia, stroke like episodes, recurrent seizures, failure to thrive, hypoglycemia, abnormal labs, positive newborn screen
  • menstrual irregularity
  • pediatric nephrology – microhematuria, gross hematuria, proteinuria, acidosis, cystic kidneys, hypertension
  • pediatric neurology – recurrent seizures, febrile seizure, first seizure, developmental delay, tics, autism, concussion, headaches
  • pediatric ophthalmology – visual acuity, ptosis, dacryostenosis, glaucoma, nystagmus, strabismus,
  • pediatric orthopaedics – flat feet, intoeing, chronic knee pain, acute knee pain, scoliosis
  • physical or occupational therapy/hand therapy
  • pediatric pulmonology – apnea, asthma, BPD, chronic cough, cystic fibrosis, recurrent pneumonia
  • psychiatry
  • pediatric rheumatology – arthralgias, joint swelling, weakness, back pain, malar rash, extremitiy color changes, positive ANA
  • umbilical hernia
  • pediatric urology – balanitis, bladder stones, dysfunctional voider, dysuria, frequency, hematuria, hernia, hidden penis, hydrocele, hydronephrosis, incontinence, kidney stoney, labial adhesions, meatal stenosis, paraphimosis, penile adhesions, phimosis, testicular pain, varicocele, vesicoureteral reflux
  • urology – undescended testicle, phimosis, UTI, hydronephrosis

And if you’re lucky, you might learn enough in the referral guidelines to save your patient a referral!

More on Pediatric Referral Guidelines