In medicine, knowing where to draw the line is everything. For clinicians, it speaks to the tension between doing too little and doing too much. Do we subject a patient to unnecessary and/or expensive testing and possibly harmful treatment?
I once recall a lecturer saying good pediatricians over-treat ear infections by a factor of four; bad pediatricians by a factor of 10. What does that mean? It suggests that merely one out of four patients treated with antibiotics actually needed that medication, and the other three would have done just as well without it. Why can’t that be one out of two, or better? Because there is no way to know for sure whose ear infection requires antibiotics.
In the last decade, we’ve learned that many older toddlers and children will heal ear infections on their own, without antibiotic help. But, somewhere there will be a child for whom these medicines will make a serious difference. Clinical research combined with personal experience helps to better identify the children who will likely need treatment. Factors like age, appearance of the ear, presence of fever or listlessness, history of prior infections: Together, these allow clinicians to pencil in a line. Good clinicians draw that line, so that they rarely over-treat.
Alternatively, let’s look at urinary tract infections (UTIs) in children. Here, we have an opportunity to link treatment to diagnosis; we’ve just got to decide which children to test. If every patient you check for a UTI has one, you’re missing some. If that number is one in 100, you are checking too many. Where to draw the line? Is one out of four acceptable?
Decisions reached on the basis of careful analysis and solid clinical research are said to be evidence-based. Although evidence narrows the location, it still doesn’t tell us exactly where the line should be drawn.
In The New York Times, Stephen Hinshaw and Richard Scheffler, researchers from UC Berkeley, wrote an op-ed ("Expand Pre-K, Not ADHD") that made me think about drawing lines. They worried that one consequence of expanding preschool opportunities to more children (a very good thing) would be risking the over- diagnosis of ADHD. They presented evidence suggesting that poor children in preschool are given this diagnosis far more frequently than are children from middle- and high-income families. They believe a parallel exists “between our…push for increased school accountability and skyrocketing ADHD diagnoses.”
Inattentive, impulsive and hyperkinetic may describe many normal kids in pre-K. “Stop acting like a 4-year-old,” may be legitimate to say to your teenager but not to a child who’s four. Where do we draw that line, and what can evidence-based medicine tell us?
It would say that poverty, hunger, family dysfunction, lack of sleep, anemia, learning disabilities, anxiety and the behavior of normal 4- and 5-year-olds can all make drawing the line a great challenge. The diagnosis of ADHD in preschoolers, for example, requires understanding and addressing all matter of concerns—social, environmental, medical and psychological, before considering what might be appropriate treatment.
The American Academy of Pediatrics is clear that treatment begins with behavioral therapy, which can further clarify diagnosis. Before a clinician considers reaching for a prescription pad to treat a four-year-old for ADHD, she should know how to draw the line, where to draw it, why it’s being drawn and maybe whether or not it should be drawn at all.