Birth control prescription blamed for stroke

A 29-YEAR-OLD WOMAN SUFFERED A BLOOD CLOT in her leg. Her family physician advised her to start taking aspirin, which she did, and counseled her to use birth control that didn’t contain estrogen. She was taking norgestimate/ ethinyl estradiol at the time of the clot.

The woman subsequently went to an obstetrician-gynecologist (ob-gyn), whom she said she told about her family physician’s advice to avoid estrogen-containing birth control medication. The ob-gyn prescribed and inserted an etonogestrel/ethinyl estradiol vaginal ring.

A few months later the patient was hospitalized with severe headaches. She had blood clots in her brain and had suffered a stroke, which affected her speech and executive functions.

PLAINTIFF’S CLAIM The ob-gyn was negligent in prescribing the vaginal ring.

THE DEFENSE The cause of the first clot was an injury; the vaginal ring didn’t cause the second clot and stroke.

VERDICT $523,000 Georgia verdict.

COMMENT A comprehensive history, and clear documentation of communicating the potential risks of therapy, might have prevented this judgment.

Elevated PSA without referral delays diagnosis

ROUTINE BLOOD WORK before orthopedic surgery revealed an elevated prostate-specific antigen (PSA) of 7.4 in a 53-year-old man. A medical assistant who was directed to refer the patient to a urologist didn’t do so. Widespread metastatic prostate cancer was diagnosed 18 months later.

PLAINTIFF’S CLAIM Diagnosing the cancer 18 months earlier would have given the patient a >50% chance of 5-year survival. Because of the delay, he was terminal. The clinic was negligent in having no written procedure or system for tracking adverse lab test results.

THE DEFENSE The patient already had metastatic disease when the PSA level was discovered and would have required the same treatment.

VERDICT $1 million Washington settlement.

COMMENT A clear system for tracking test results is imperative in today’s litigious society.

Removal of mole without follow-up leads to death

A MOLE ON THE UPPER BACK prompted a 26-year-old man to visit a dermatologist, who performed a complete excision. The pathologist who examined the excised tissue suggested that the patient return for follow-up. During the next 6 months, the patient saw the dermatologist twice but didn’t receive proper follow-up.

Two years later, the patient noticed a suspicious area on his back near the scar from the excision. A hospital biopsy resulted in a diagnosis of metastatic melanoma. A review of the slides from the original biopsy found “melanoma, superficial spreading type, invasive to a depth of a minimum of 1.0 mm anatomic level IV, extending to inked deep resection margin.”

The patient underwent a wide local excision and was given a diagnosis of stage III melanoma. The patient underwent neck and back radiation and high-dose treatment with alpha interferon, followed by high-dose interleukin-2 and chemotherapy. Nevertheless, the patient died.

PLAINTIFF’S CLAIM The dermatologist’s office had no system to contact the patient when he didn’t return. The chances for cure would have been between 73% and 94% if the melanoma had been diagnosed at the time of the original excision.

THE DEFENSE No information about the defense is available.

VERDICT $1.7 million Massachusetts settlement.

COMMENT Failure to follow up on abnormal results is a potentially preventable cause of malpractice. Do you have a mechanism to track such testing?

Suggestive symptoms, but no Dx until it was too late

A 42-YEAR-OLD WOMAN went to the hospital in February for chest pain, dizziness, and shortness of breath. The emergency room physician diagnosed sinusitis and bronchitis and discharged the patient in stable condition. In April, the woman visited her primary care physician complaining of fatigue and shortness of breath. She claimed that her physician knew about the February emergency room visit. Later in April, she again went to her physician with shortness of breath; in July, she reported an irregular heart rhythm.

In October, the patient was found unresponsive after suffering cardiorespiratory arrest, hypoxic ischemic brain injury, and static encephalopathy. She has since been in a vegetative state.

PLAINTIFF’S CLAIM The patient had gone to her primary care physician many times during the 2 years before her emergency room visit with complaints suggesting an underlying cardiac condition, including shortness of breath, dizziness, light-headedness, vertigo, chest tightness, fatigue, and an irregular heart rhythm. The defendants were negligent in failing to diagnose the patient’s condition and provide proper treatment, failing to order proper diagnostic testing, and failing to perform a cardiac workup.

THE DEFENSE No negligence occurred.

VERDICT $6.3 million Florida verdict.

COMMENT Comprehensive documentation, including your medical decision making, can help prevent multimillion dollar judgments.

A serendipitous finding—to no avail

A FALL ON THE ICE sent a 74-year-old woman to the hospital with a fractured ankle. A preoperative chest radiograph taken before open reduction and internal fixation to repair the fracture showed a 2-cm nodular opacity in the right upper hemithorax. The radiologist recommended a computed tomography scan to rule out lung cancer, but the treating internists didn’t order a scan or refer the patient for biopsy.

The nodule appeared again on a second radiograph taken 2 days later. The patient wasn’t informed, and the attending internist at the time didn’t order follow-up testing or refer the patient to a specialist. The attending physicians continued to treat the patient without further testing or referral for the nodule.

Two years after the fracture, the patient was admitted to the hospital with complaints of sweating and shortness of breath. A chest radiograph showed pneumonia and the previously noted nodule. The patient was diagnosed with metastatic, inoperable small-cell lung cancer. She died after receiving extensive chemotherapy and radiation.

PLAINTIFF’S CLAIM The doctors were negligent in failing to diagnose and treat the lung cancer in a timely manner.

THE DEFENSE No information about the defense is available.

VERDICT $325,000 Michigan settlement.

COMMENT Could this happen to you? How many times have you serendipitously noted an abnormal result that was not followed up adequately?

Birth control prescription blamed for stroke

A 29-YEAR-OLD WOMAN SUFFERED A BLOOD CLOT in her leg. Her family physician advised her to start taking aspirin, which she did, and counseled her to use birth control that didn’t contain estrogen. She was taking norgestimate/ ethinyl estradiol at the time of the clot.

The woman subsequently went to an obstetrician-gynecologist (ob-gyn), whom she said she told about her family physician’s advice to avoid estrogen-containing birth control medication. The ob-gyn prescribed and inserted an etonogestrel/ethinyl estradiol vaginal ring.

A few months later the patient was hospitalized with severe headaches. She had blood clots in her brain and had suffered a stroke, which affected her speech and executive functions.

PLAINTIFF’S CLAIM The ob-gyn was negligent in prescribing the vaginal ring.

THE DEFENSE The cause of the first clot was an injury; the vaginal ring didn’t cause the second clot and stroke.

VERDICT $523,000 Georgia verdict.

COMMENT A comprehensive history, and clear documentation of communicating the potential risks of therapy, might have prevented this judgment.

Elevated PSA without referral delays diagnosis

ROUTINE BLOOD WORK before orthopedic surgery revealed an elevated prostate-specific antigen (PSA) of 7.4 in a 53-year-old man. A medical assistant who was directed to refer the patient to a urologist didn’t do so. Widespread metastatic prostate cancer was diagnosed 18 months later.

PLAINTIFF’S CLAIM Diagnosing the cancer 18 months earlier would have given the patient a >50% chance of 5-year survival. Because of the delay, he was terminal. The clinic was negligent in having no written procedure or system for tracking adverse lab test results.

THE DEFENSE The patient already had metastatic disease when the PSA level was discovered and would have required the same treatment.

VERDICT $1 million Washington settlement.

COMMENT A clear system for tracking test results is imperative in today’s litigious society.

Removal of mole without follow-up leads to death

A MOLE ON THE UPPER BACK prompted a 26-year-old man to visit a dermatologist, who performed a complete excision. The pathologist who examined the excised tissue suggested that the patient return for follow-up. During the next 6 months, the patient saw the dermatologist twice but didn’t receive proper follow-up.

Two years later, the patient noticed a suspicious area on his back near the scar from the excision. A hospital biopsy resulted in a diagnosis of metastatic melanoma. A review of the slides from the original biopsy found “melanoma, superficial spreading type, invasive to a depth of a minimum of 1.0 mm anatomic level IV, extending to inked deep resection margin.”

The patient underwent a wide local excision and was given a diagnosis of stage III melanoma. The patient underwent neck and back radiation and high-dose treatment with alpha interferon, followed by high-dose interleukin-2 and chemotherapy. Nevertheless, the patient died.

PLAINTIFF’S CLAIM The dermatologist’s office had no system to contact the patient when he didn’t return. The chances for cure would have been between 73% and 94% if the melanoma had been diagnosed at the time of the original excision.

THE DEFENSE No information about the defense is available.

VERDICT $1.7 million Massachusetts settlement.

COMMENT Failure to follow up on abnormal results is a potentially preventable cause of malpractice. Do you have a mechanism to track such testing?

Suggestive symptoms, but no Dx until it was too late

A 42-YEAR-OLD WOMAN went to the hospital in February for chest pain, dizziness, and shortness of breath. The emergency room physician diagnosed sinusitis and bronchitis and discharged the patient in stable condition. In April, the woman visited her primary care physician complaining of fatigue and shortness of breath. She claimed that her physician knew about the February emergency room visit. Later in April, she again went to her physician with shortness of breath; in July, she reported an irregular heart rhythm.

In October, the patient was found unresponsive after suffering cardiorespiratory arrest, hypoxic ischemic brain injury, and static encephalopathy. She has since been in a vegetative state.

PLAINTIFF’S CLAIM The patient had gone to her primary care physician many times during the 2 years before her emergency room visit with complaints suggesting an underlying cardiac condition, including shortness of breath, dizziness, light-headedness, vertigo, chest tightness, fatigue, and an irregular heart rhythm. The defendants were negligent in failing to diagnose the patient’s condition and provide proper treatment, failing to order proper diagnostic testing, and failing to perform a cardiac workup.

THE DEFENSE No negligence occurred.

VERDICT $6.3 million Florida verdict.

COMMENT Comprehensive documentation, including your medical decision making, can help prevent multimillion dollar judgments.

A serendipitous finding—to no avail

A FALL ON THE ICE sent a 74-year-old woman to the hospital with a fractured ankle. A preoperative chest radiograph taken before open reduction and internal fixation to repair the fracture showed a 2-cm nodular opacity in the right upper hemithorax. The radiologist recommended a computed tomography scan to rule out lung cancer, but the treating internists didn’t order a scan or refer the patient for biopsy.

The nodule appeared again on a second radiograph taken 2 days later. The patient wasn’t informed, and the attending internist at the time didn’t order follow-up testing or refer the patient to a specialist. The attending physicians continued to treat the patient without further testing or referral for the nodule.

Two years after the fracture, the patient was admitted to the hospital with complaints of sweating and shortness of breath. A chest radiograph showed pneumonia and the previously noted nodule. The patient was diagnosed with metastatic, inoperable small-cell lung cancer. She died after receiving extensive chemotherapy and radiation.

PLAINTIFF’S CLAIM The doctors were negligent in failing to diagnose and treat the lung cancer in a timely manner.

THE DEFENSE No information about the defense is available.

VERDICT $325,000 Michigan settlement.

COMMENT Could this happen to you? How many times have you serendipitously noted an abnormal result that was not followed up adequately?

Birth control prescription blamed for stroke

A 29-YEAR-OLD WOMAN SUFFERED A BLOOD CLOT in her leg. Her family physician advised her to start taking aspirin, which she did, and counseled her to use birth control that didn’t contain estrogen. She was taking norgestimate/ ethinyl estradiol at the time of the clot.

The woman subsequently went to an obstetrician-gynecologist (ob-gyn), whom she said she told about her family physician’s advice to avoid estrogen-containing birth control medication. The ob-gyn prescribed and inserted an etonogestrel/ethinyl estradiol vaginal ring.

A few months later the patient was hospitalized with severe headaches. She had blood clots in her brain and had suffered a stroke, which affected her speech and executive functions.

PLAINTIFF’S CLAIM The ob-gyn was negligent in prescribing the vaginal ring.

THE DEFENSE The cause of the first clot was an injury; the vaginal ring didn’t cause the second clot and stroke.

VERDICT $523,000 Georgia verdict.

COMMENT A comprehensive history, and clear documentation of communicating the potential risks of therapy, might have prevented this judgment.

Elevated PSA without referral delays diagnosis

ROUTINE BLOOD WORK before orthopedic surgery revealed an elevated prostate-specific antigen (PSA) of 7.4 in a 53-year-old man. A medical assistant who was directed to refer the patient to a urologist didn’t do so. Widespread metastatic prostate cancer was diagnosed 18 months later.

PLAINTIFF’S CLAIM Diagnosing the cancer 18 months earlier would have given the patient a >50% chance of 5-year survival. Because of the delay, he was terminal. The clinic was negligent in having no written procedure or system for tracking adverse lab test results.

THE DEFENSE The patient already had metastatic disease when the PSA level was discovered and would have required the same treatment.

VERDICT $1 million Washington settlement.

COMMENT A clear system for tracking test results is imperative in today’s litigious society.

Removal of mole without follow-up leads to death

A MOLE ON THE UPPER BACK prompted a 26-year-old man to visit a dermatologist, who performed a complete excision. The pathologist who examined the excised tissue suggested that the patient return for follow-up. During the next 6 months, the patient saw the dermatologist twice but didn’t receive proper follow-up.

Two years later, the patient noticed a suspicious area on his back near the scar from the excision. A hospital biopsy resulted in a diagnosis of metastatic melanoma. A review of the slides from the original biopsy found “melanoma, superficial spreading type, invasive to a depth of a minimum of 1.0 mm anatomic level IV, extending to inked deep resection margin.”

The patient underwent a wide local excision and was given a diagnosis of stage III melanoma. The patient underwent neck and back radiation and high-dose treatment with alpha interferon, followed by high-dose interleukin-2 and chemotherapy. Nevertheless, the patient died.

PLAINTIFF’S CLAIM The dermatologist’s office had no system to contact the patient when he didn’t return. The chances for cure would have been between 73% and 94% if the melanoma had been diagnosed at the time of the original excision.

THE DEFENSE No information about the defense is available.

VERDICT $1.7 million Massachusetts settlement.

COMMENT Failure to follow up on abnormal results is a potentially preventable cause of malpractice. Do you have a mechanism to track such testing?

Suggestive symptoms, but no Dx until it was too late

A 42-YEAR-OLD WOMAN went to the hospital in February for chest pain, dizziness, and shortness of breath. The emergency room physician diagnosed sinusitis and bronchitis and discharged the patient in stable condition. In April, the woman visited her primary care physician complaining of fatigue and shortness of breath. She claimed that her physician knew about the February emergency room visit. Later in April, she again went to her physician with shortness of breath; in July, she reported an irregular heart rhythm.

In October, the patient was found unresponsive after suffering cardiorespiratory arrest, hypoxic ischemic brain injury, and static encephalopathy. She has since been in a vegetative state.

PLAINTIFF’S CLAIM The patient had gone to her primary care physician many times during the 2 years before her emergency room visit with complaints suggesting an underlying cardiac condition, including shortness of breath, dizziness, light-headedness, vertigo, chest tightness, fatigue, and an irregular heart rhythm. The defendants were negligent in failing to diagnose the patient’s condition and provide proper treatment, failing to order proper diagnostic testing, and failing to perform a cardiac workup.

THE DEFENSE No negligence occurred.

VERDICT $6.3 million Florida verdict.

COMMENT Comprehensive documentation, including your medical decision making, can help prevent multimillion dollar judgments.

A serendipitous finding—to no avail

A FALL ON THE ICE sent a 74-year-old woman to the hospital with a fractured ankle. A preoperative chest radiograph taken before open reduction and internal fixation to repair the fracture showed a 2-cm nodular opacity in the right upper hemithorax. The radiologist recommended a computed tomography scan to rule out lung cancer, but the treating internists didn’t order a scan or refer the patient for biopsy.

The nodule appeared again on a second radiograph taken 2 days later. The patient wasn’t informed, and the attending internist at the time didn’t order follow-up testing or refer the patient to a specialist. The attending physicians continued to treat the patient without further testing or referral for the nodule.

Two years after the fracture, the patient was admitted to the hospital with complaints of sweating and shortness of breath. A chest radiograph showed pneumonia and the previously noted nodule. The patient was diagnosed with metastatic, inoperable small-cell lung cancer. She died after receiving extensive chemotherapy and radiation.

PLAINTIFF’S CLAIM The doctors were negligent in failing to diagnose and treat the lung cancer in a timely manner.

THE DEFENSE No information about the defense is available.

VERDICT $325,000 Michigan settlement.

COMMENT Could this happen to you? How many times have you serendipitously noted an abnormal result that was not followed up adequately?

This year, ObGyn-related additions and revisions to the International Classification of Diseases, Clinical Modification (ICD-9-CM), involve tinkering with existing codes and adding some new code categories. The latter development means that more information will be required of you to code to the highest level of specificity.

On the obstetrics side, there are now specific codes for placental status for multiple gestations and some revised terminology.

In gynecology, changes include new codes for congenital anomalies of the cervix, vagina, and uterus; reporting an expanded list of a history of dysplasia; and reporting the insertion and removal of an intrauterine device for contraception.

In addition, new codes have been established for fecal incontinence and for reporting a body mass index >40.

Last, changes to the alphabetical index of codes have been put in place that will help you select the most appropriate code.

The new and revised ICD-9-CM codes were added to the national code set on October 1, 2010. As in previous years, there is no grace period for failing to use the new code set!

Changes to obstetric codes

PLACENTAL/AMNIOTIC SAC SPECIFICATION FOR MULTIPLE-GESTATION PREGNANCY

Multiple-gestation pregnancies are classified as monochorionic/monoamniotic, monochorionic/diamniotic, and dichorionic/diamniotic. Until now, however, you’ve had no way to report this additional information to a payer.

For fiscal year 2011, you are able to be more specific, which can increase your ability to report medical support care for a higher-risk pregnancy or an expanded treatment plan.

Because the current category of multiple-gestation codes (651) did not allow for expansion to include this information, a new code category, V91 (multiple gestation placenta status), was created for that purpose. The V91 category has distinct codes for twin gestation, triplet gestation, quadruplet gestation, and other “unspecified” gestations to denote placental/amniotic sac status.

Be aware that use of the V91 codes is optional, and that they can be reported only as a secondary diagnosis, with a category 651.xx (multiple gestation, etc.) code as primary. As I noted, however, the new codes may provide better information to the payer—and that might result in additional reimbursement for your care of such pregnancies.

The new codes for a twin pregnancy are:

V91.00 Twin gestation, unspecified number of placentae, unspecified number of amniotic sacs

V91.01 Twin gestation, monochorionic/monoamniotic (one placenta, one amniotic sac)

V91.02 Twin gestation, monochorionic/diamniotic (one placenta, two amniotic sacs)

V91.03 Twin gestation, dichorionic/diamniotic (two placentae, two amniotic sacs)

V91.09 Twin gestation, unable to determine number of placentae and number of amniotic sacs

There are similar V codes for triplet gestations (V91.10–V91.19), quadruplet gestations (V91.20–V91.29), and other unspecified multiple gestations (V91.91– V91.99).

RECURRENT PREGNANCY LOSS

The term “habitual aborter” has been replaced for 2011 with the more clinically accurate term “recurrent pregnancy loss.” This change is noted in both the ICD-9 alphabetical index and in the code definitions in the tabular section. The codes affected by this terminology change are:

629.81 Recurrent pregnancy loss without current pregnancy

646.3x Recurrent pregnancy loss (affecting the current pregnancy)

INDEX AND INSTRUCTIONAL CHANGES

These OB changes took effect on October 1, 2010:

• Periurethral trauma should be reported using 664.8x (other specified trauma to perineum and vulva), not 665.5x (other injury to pelvic organs).
• If you report puerperal sepsis (670.2x), you must report an additional code to identify severe sepsis (995.92) and any associated acute organ dysfunction, if applicable.
• If your diagnosis is superficial thrombosis (671.2x), an additional code—either 453.6, 453.71, or 453.81—should be reported to further explain the type of thrombophlebitis.
• If your patient has either asymptomatic, inactive, or a history of genital herpes that is complicating her current pregnancy, report 647.6x (other viral diseases).
• If you report pneumonia as complicating pregnancy, assign code 648.9x (other current conditions classifiable elsewhere).

Changes to gyn codes

CONGENITAL ANOMALIES OF THE UTERUS, CERVIX, AND VAGINA

Before October 1, 2010, of the seven distinct types of uterine anomalies, only a didelphus uterus (752.2, doubling of the uterus) and a diethylstilbestrol-related anomaly (760.76 [noxious influences affecting fetus or newborn via placenta or breast milk; diethylstilbestrol (DES)]) had specific codes. All other uterine anomalies were coded to “other” or “unspecified” codes that could include many different conditions.

Although vaginal and cervical anomalies may be less common, the only codes available before October 1, 2010, were ones that described an unspecified anomaly (753.40), imperforate hymen (752.42), or an embryonic cyst (752.41).

A higher level of specificity in coding, however, can make all the difference in receiving adequate reimbursement and preventing denials. For example, if you perform a Pap smear on a patient who has two cervices, a code that specifies a duplicate cervix can clearly tell the payer that billing for both is not a duplicate service or billing error.

Changes to codes in this area of care take the form of expanding existing codes. Code 752.3 (other anomalies of uterus) has been expanded to seven distinct five-digit codes to capture the seven anomalies of the uterus:

752.31 Agenesis of uterus

752.32 Hypoplasia of uterus

752.33 Unicornuate uterus (This code would be reported if the unicornuate uterus did or did not have a separate uterine horn, or if the uterus had only one functioning horn.)

752.34 Bicornuate uterus

752.35 Septate uterus (This code would be reported whether the septate was complete or partial.)

752.36 Arcuate uterus

752.39 Other anomalies of uterus (This code category includes aplasia or any other Müllerian anomaly of the uterus that is not otherwise or elsewhere classified.)

New codes have been added to the 752.4 code category (anomalies of cervix, vagina, and external female genitalia) to expand the options. Before October 1, 2010, any of these conditions would have been coded as 752.49, an “other” category.

752.43 Cervical agenesis

752.44 Cervical duplication

752.45 Vaginal agenesis (This code can also be reported for vaginal hypoplasia.)

752.46 Transverse vaginal septum

752.47 Longitudinal vaginal septum

For a patient who has a history of one of these anomalies, you would report new code V13.62, (personal history of other [corrected] congenital malformations of genitourinary system) if this history was a factor in her current care.

IUD INSERTION AND REMOVAL

Inserting and removing an IUD are integral services that most ObGyn practices provide, so it is imperative that your encounter forms reflect two new codes, to avoid denials for an invalid diagnosis code. A reminder: Code V45.51 (intrauterine contraceptive device) is a status code. It indicates that a patient has an IUD in place but you should never use it as a diagnosis code when the purpose of the visit is for you to check on the device and assess how it is working.

Changes in this area are:

Before October 1, 2010:

V25.1 Insertion

V25.42 Checking, reinsertion and/or removal After October 1, 2010:

V25.11 Encounter for insertion of intrauterine contraceptive device

V25.12 Encounter for removal of intrauterine contraceptive device

V25.13 Encounter for removal and reinsertion of intrauterine contraceptive device

V25.42 Encounter for routine checking of intrauterine contraceptive device

BODY MASS INDEX

Regrettably, the number of patients who have a very high body mass index (BMI) is increasing. When surgery is planned, reporting this information in your coding can help establish 1) the medical need for significant additional work during the procedure or 2) health risks in support of therapy.

Code V85.4 (Body mass index 40 and over, adult) has been expanded to five new codes. They should be reported secondary to the type of obesity (i.e., codes 278.0x [overweight and obesity]).

V85.41 Body Mass Index 40.0–44.9, adult

V85.42 Body Mass Index 45.0–49.9, adult

V85.43 Body Mass Index 50.0–59.9, adult

V85.44 Body Mass Index 60.0–69.9, adult

V85.45 Body Mass Index 70 and over, adult

FECAL INCONTINENCE

Fecal incontinence can present as problematic symptoms—fecal smearing, fecal urgency, incomplete defecation—but, until now, you only had one code to report any of these problems.

For that reason, 787.6 (incontinence of feces) has been expanded into four new five-digit codes. In addition, a new code has been added to report fecal impaction, which, in the past, was reported as 560.39, an “other” category code that was not specific to this problem.

New codes are:

560.32 Fecal impaction

787.60 Full incontinence of feces

787.61 Incomplete defecation

787.62 Fecal smearing

787.63 Fecal urgency

PERSONAL HISTORY OF DYSPLASIA

New codes have been added to complete the personal history codes for dysplasia. In addition to the existing code for cervical dysplasia history (V13.22), you can now report:

V13.23 Personal history of vaginal dysplasia

V13.34 Personal history of vulvar dysplasia

INDEX AND INSTRUCTIONAL CHANGES

These changes take effect October 1, 2010:

• Clarification that an abnormal Pap result indicated non-atypical endometrial cells should be reported using 795.09.
• Clearly indicate whether a fistula between the uterus and another organ is congenital (752.39) or noncongenital (619.0-619.9).
• Precocious menstruation should be coded as 259.1, not as a menstrual disorder.
• The terminology in the index and tabular sections has been revised to more clearly differentiate long-term from prophylactic use of medications. This change affects only code category titles and lookup terms, not existing code numbers.

We want to hear from you! Tell us what you think.

This year, ObGyn-related additions and revisions to the International Classification of Diseases, Clinical Modification (ICD-9-CM), involve tinkering with existing codes and adding some new code categories. The latter development means that more information will be required of you to code to the highest level of specificity.

On the obstetrics side, there are now specific codes for placental status for multiple gestations and some revised terminology.

In gynecology, changes include new codes for congenital anomalies of the cervix, vagina, and uterus; reporting an expanded list of a history of dysplasia; and reporting the insertion and removal of an intrauterine device for contraception.

In addition, new codes have been established for fecal incontinence and for reporting a body mass index >40.

Last, changes to the alphabetical index of codes have been put in place that will help you select the most appropriate code.

The new and revised ICD-9-CM codes were added to the national code set on October 1, 2010. As in previous years, there is no grace period for failing to use the new code set!

Changes to obstetric codes

PLACENTAL/AMNIOTIC SAC SPECIFICATION FOR MULTIPLE-GESTATION PREGNANCY

Multiple-gestation pregnancies are classified as monochorionic/monoamniotic, monochorionic/diamniotic, and dichorionic/diamniotic. Until now, however, you’ve had no way to report this additional information to a payer.

For fiscal year 2011, you are able to be more specific, which can increase your ability to report medical support care for a higher-risk pregnancy or an expanded treatment plan.

Because the current category of multiple-gestation codes (651) did not allow for expansion to include this information, a new code category, V91 (multiple gestation placenta status), was created for that purpose. The V91 category has distinct codes for twin gestation, triplet gestation, quadruplet gestation, and other “unspecified” gestations to denote placental/amniotic sac status.

Be aware that use of the V91 codes is optional, and that they can be reported only as a secondary diagnosis, with a category 651.xx (multiple gestation, etc.) code as primary. As I noted, however, the new codes may provide better information to the payer—and that might result in additional reimbursement for your care of such pregnancies.

The new codes for a twin pregnancy are:

V91.00 Twin gestation, unspecified number of placentae, unspecified number of amniotic sacs

V91.01 Twin gestation, monochorionic/monoamniotic (one placenta, one amniotic sac)

V91.02 Twin gestation, monochorionic/diamniotic (one placenta, two amniotic sacs)

V91.03 Twin gestation, dichorionic/diamniotic (two placentae, two amniotic sacs)

V91.09 Twin gestation, unable to determine number of placentae and number of amniotic sacs

There are similar V codes for triplet gestations (V91.10–V91.19), quadruplet gestations (V91.20–V91.29), and other unspecified multiple gestations (V91.91– V91.99).

RECURRENT PREGNANCY LOSS

The term “habitual aborter” has been replaced for 2011 with the more clinically accurate term “recurrent pregnancy loss.” This change is noted in both the ICD-9 alphabetical index and in the code definitions in the tabular section. The codes affected by this terminology change are:

629.81 Recurrent pregnancy loss without current pregnancy

646.3x Recurrent pregnancy loss (affecting the current pregnancy)

INDEX AND INSTRUCTIONAL CHANGES

These OB changes took effect on October 1, 2010:

• Periurethral trauma should be reported using 664.8x (other specified trauma to perineum and vulva), not 665.5x (other injury to pelvic organs).
• If you report puerperal sepsis (670.2x), you must report an additional code to identify severe sepsis (995.92) and any associated acute organ dysfunction, if applicable.
• If your diagnosis is superficial thrombosis (671.2x), an additional code—either 453.6, 453.71, or 453.81—should be reported to further explain the type of thrombophlebitis.
• If your patient has either asymptomatic, inactive, or a history of genital herpes that is complicating her current pregnancy, report 647.6x (other viral diseases).
• If you report pneumonia as complicating pregnancy, assign code 648.9x (other current conditions classifiable elsewhere).

Changes to gyn codes

CONGENITAL ANOMALIES OF THE UTERUS, CERVIX, AND VAGINA

Before October 1, 2010, of the seven distinct types of uterine anomalies, only a didelphus uterus (752.2, doubling of the uterus) and a diethylstilbestrol-related anomaly (760.76 [noxious influences affecting fetus or newborn via placenta or breast milk; diethylstilbestrol (DES)]) had specific codes. All other uterine anomalies were coded to “other” or “unspecified” codes that could include many different conditions.

Although vaginal and cervical anomalies may be less common, the only codes available before October 1, 2010, were ones that described an unspecified anomaly (753.40), imperforate hymen (752.42), or an embryonic cyst (752.41).

A higher level of specificity in coding, however, can make all the difference in receiving adequate reimbursement and preventing denials. For example, if you perform a Pap smear on a patient who has two cervices, a code that specifies a duplicate cervix can clearly tell the payer that billing for both is not a duplicate service or billing error.

Changes to codes in this area of care take the form of expanding existing codes. Code 752.3 (other anomalies of uterus) has been expanded to seven distinct five-digit codes to capture the seven anomalies of the uterus:

752.31 Agenesis of uterus

752.32 Hypoplasia of uterus

752.33 Unicornuate uterus (This code would be reported if the unicornuate uterus did or did not have a separate uterine horn, or if the uterus had only one functioning horn.)

752.34 Bicornuate uterus

752.35 Septate uterus (This code would be reported whether the septate was complete or partial.)

752.36 Arcuate uterus

752.39 Other anomalies of uterus (This code category includes aplasia or any other Müllerian anomaly of the uterus that is not otherwise or elsewhere classified.)

New codes have been added to the 752.4 code category (anomalies of cervix, vagina, and external female genitalia) to expand the options. Before October 1, 2010, any of these conditions would have been coded as 752.49, an “other” category.

752.43 Cervical agenesis

752.44 Cervical duplication

752.45 Vaginal agenesis (This code can also be reported for vaginal hypoplasia.)

752.46 Transverse vaginal septum

752.47 Longitudinal vaginal septum

For a patient who has a history of one of these anomalies, you would report new code V13.62, (personal history of other [corrected] congenital malformations of genitourinary system) if this history was a factor in her current care.

IUD INSERTION AND REMOVAL

Inserting and removing an IUD are integral services that most ObGyn practices provide, so it is imperative that your encounter forms reflect two new codes, to avoid denials for an invalid diagnosis code. A reminder: Code V45.51 (intrauterine contraceptive device) is a status code. It indicates that a patient has an IUD in place but you should never use it as a diagnosis code when the purpose of the visit is for you to check on the device and assess how it is working.

Changes in this area are:

Before October 1, 2010:

V25.1 Insertion

V25.42 Checking, reinsertion and/or removal After October 1, 2010:

V25.11 Encounter for insertion of intrauterine contraceptive device

V25.12 Encounter for removal of intrauterine contraceptive device

V25.13 Encounter for removal and reinsertion of intrauterine contraceptive device

V25.42 Encounter for routine checking of intrauterine contraceptive device

BODY MASS INDEX

Regrettably, the number of patients who have a very high body mass index (BMI) is increasing. When surgery is planned, reporting this information in your coding can help establish 1) the medical need for significant additional work during the procedure or 2) health risks in support of therapy.

Code V85.4 (Body mass index 40 and over, adult) has been expanded to five new codes. They should be reported secondary to the type of obesity (i.e., codes 278.0x [overweight and obesity]).

V85.41 Body Mass Index 40.0–44.9, adult

V85.42 Body Mass Index 45.0–49.9, adult

V85.43 Body Mass Index 50.0–59.9, adult

V85.44 Body Mass Index 60.0–69.9, adult

V85.45 Body Mass Index 70 and over, adult

FECAL INCONTINENCE

Fecal incontinence can present as problematic symptoms—fecal smearing, fecal urgency, incomplete defecation—but, until now, you only had one code to report any of these problems.

For that reason, 787.6 (incontinence of feces) has been expanded into four new five-digit codes. In addition, a new code has been added to report fecal impaction, which, in the past, was reported as 560.39, an “other” category code that was not specific to this problem.

New codes are:

560.32 Fecal impaction

787.60 Full incontinence of feces

787.61 Incomplete defecation

787.62 Fecal smearing

787.63 Fecal urgency

PERSONAL HISTORY OF DYSPLASIA

New codes have been added to complete the personal history codes for dysplasia. In addition to the existing code for cervical dysplasia history (V13.22), you can now report:

V13.23 Personal history of vaginal dysplasia

V13.34 Personal history of vulvar dysplasia

INDEX AND INSTRUCTIONAL CHANGES

These changes take effect October 1, 2010:

• Clarification that an abnormal Pap result indicated non-atypical endometrial cells should be reported using 795.09.
• Clearly indicate whether a fistula between the uterus and another organ is congenital (752.39) or noncongenital (619.0-619.9).
• Precocious menstruation should be coded as 259.1, not as a menstrual disorder.
• The terminology in the index and tabular sections has been revised to more clearly differentiate long-term from prophylactic use of medications. This change affects only code category titles and lookup terms, not existing code numbers.

We want to hear from you! Tell us what you think.

This year, ObGyn-related additions and revisions to the International Classification of Diseases, Clinical Modification (ICD-9-CM), involve tinkering with existing codes and adding some new code categories. The latter development means that more information will be required of you to code to the highest level of specificity.

On the obstetrics side, there are now specific codes for placental status for multiple gestations and some revised terminology.

In gynecology, changes include new codes for congenital anomalies of the cervix, vagina, and uterus; reporting an expanded list of a history of dysplasia; and reporting the insertion and removal of an intrauterine device for contraception.

In addition, new codes have been established for fecal incontinence and for reporting a body mass index >40.

Last, changes to the alphabetical index of codes have been put in place that will help you select the most appropriate code.

The new and revised ICD-9-CM codes were added to the national code set on October 1, 2010. As in previous years, there is no grace period for failing to use the new code set!

Changes to obstetric codes

PLACENTAL/AMNIOTIC SAC SPECIFICATION FOR MULTIPLE-GESTATION PREGNANCY

Multiple-gestation pregnancies are classified as monochorionic/monoamniotic, monochorionic/diamniotic, and dichorionic/diamniotic. Until now, however, you’ve had no way to report this additional information to a payer.

For fiscal year 2011, you are able to be more specific, which can increase your ability to report medical support care for a higher-risk pregnancy or an expanded treatment plan.

Because the current category of multiple-gestation codes (651) did not allow for expansion to include this information, a new code category, V91 (multiple gestation placenta status), was created for that purpose. The V91 category has distinct codes for twin gestation, triplet gestation, quadruplet gestation, and other “unspecified” gestations to denote placental/amniotic sac status.

Be aware that use of the V91 codes is optional, and that they can be reported only as a secondary diagnosis, with a category 651.xx (multiple gestation, etc.) code as primary. As I noted, however, the new codes may provide better information to the payer—and that might result in additional reimbursement for your care of such pregnancies.

The new codes for a twin pregnancy are:

V91.00 Twin gestation, unspecified number of placentae, unspecified number of amniotic sacs

V91.01 Twin gestation, monochorionic/monoamniotic (one placenta, one amniotic sac)

V91.02 Twin gestation, monochorionic/diamniotic (one placenta, two amniotic sacs)

V91.03 Twin gestation, dichorionic/diamniotic (two placentae, two amniotic sacs)

V91.09 Twin gestation, unable to determine number of placentae and number of amniotic sacs

There are similar V codes for triplet gestations (V91.10–V91.19), quadruplet gestations (V91.20–V91.29), and other unspecified multiple gestations (V91.91– V91.99).

RECURRENT PREGNANCY LOSS

The term “habitual aborter” has been replaced for 2011 with the more clinically accurate term “recurrent pregnancy loss.” This change is noted in both the ICD-9 alphabetical index and in the code definitions in the tabular section. The codes affected by this terminology change are:

629.81 Recurrent pregnancy loss without current pregnancy

646.3x Recurrent pregnancy loss (affecting the current pregnancy)

INDEX AND INSTRUCTIONAL CHANGES

These OB changes took effect on October 1, 2010:

• Periurethral trauma should be reported using 664.8x (other specified trauma to perineum and vulva), not 665.5x (other injury to pelvic organs).
• If you report puerperal sepsis (670.2x), you must report an additional code to identify severe sepsis (995.92) and any associated acute organ dysfunction, if applicable.
• If your diagnosis is superficial thrombosis (671.2x), an additional code—either 453.6, 453.71, or 453.81—should be reported to further explain the type of thrombophlebitis.
• If your patient has either asymptomatic, inactive, or a history of genital herpes that is complicating her current pregnancy, report 647.6x (other viral diseases).
• If you report pneumonia as complicating pregnancy, assign code 648.9x (other current conditions classifiable elsewhere).

Changes to gyn codes

CONGENITAL ANOMALIES OF THE UTERUS, CERVIX, AND VAGINA

Before October 1, 2010, of the seven distinct types of uterine anomalies, only a didelphus uterus (752.2, doubling of the uterus) and a diethylstilbestrol-related anomaly (760.76 [noxious influences affecting fetus or newborn via placenta or breast milk; diethylstilbestrol (DES)]) had specific codes. All other uterine anomalies were coded to “other” or “unspecified” codes that could include many different conditions.

Although vaginal and cervical anomalies may be less common, the only codes available before October 1, 2010, were ones that described an unspecified anomaly (753.40), imperforate hymen (752.42), or an embryonic cyst (752.41).

A higher level of specificity in coding, however, can make all the difference in receiving adequate reimbursement and preventing denials. For example, if you perform a Pap smear on a patient who has two cervices, a code that specifies a duplicate cervix can clearly tell the payer that billing for both is not a duplicate service or billing error.

Changes to codes in this area of care take the form of expanding existing codes. Code 752.3 (other anomalies of uterus) has been expanded to seven distinct five-digit codes to capture the seven anomalies of the uterus:

752.31 Agenesis of uterus

752.32 Hypoplasia of uterus

752.33 Unicornuate uterus (This code would be reported if the unicornuate uterus did or did not have a separate uterine horn, or if the uterus had only one functioning horn.)

752.34 Bicornuate uterus

752.35 Septate uterus (This code would be reported whether the septate was complete or partial.)

752.36 Arcuate uterus

752.39 Other anomalies of uterus (This code category includes aplasia or any other Müllerian anomaly of the uterus that is not otherwise or elsewhere classified.)

New codes have been added to the 752.4 code category (anomalies of cervix, vagina, and external female genitalia) to expand the options. Before October 1, 2010, any of these conditions would have been coded as 752.49, an “other” category.

752.43 Cervical agenesis

752.44 Cervical duplication

752.45 Vaginal agenesis (This code can also be reported for vaginal hypoplasia.)

752.46 Transverse vaginal septum

752.47 Longitudinal vaginal septum

For a patient who has a history of one of these anomalies, you would report new code V13.62, (personal history of other [corrected] congenital malformations of genitourinary system) if this history was a factor in her current care.

IUD INSERTION AND REMOVAL

Inserting and removing an IUD are integral services that most ObGyn practices provide, so it is imperative that your encounter forms reflect two new codes, to avoid denials for an invalid diagnosis code. A reminder: Code V45.51 (intrauterine contraceptive device) is a status code. It indicates that a patient has an IUD in place but you should never use it as a diagnosis code when the purpose of the visit is for you to check on the device and assess how it is working.

Changes in this area are:

Before October 1, 2010:

V25.1 Insertion

V25.42 Checking, reinsertion and/or removal After October 1, 2010:

V25.11 Encounter for insertion of intrauterine contraceptive device

V25.12 Encounter for removal of intrauterine contraceptive device

V25.13 Encounter for removal and reinsertion of intrauterine contraceptive device

V25.42 Encounter for routine checking of intrauterine contraceptive device

BODY MASS INDEX

Regrettably, the number of patients who have a very high body mass index (BMI) is increasing. When surgery is planned, reporting this information in your coding can help establish 1) the medical need for significant additional work during the procedure or 2) health risks in support of therapy.

Code V85.4 (Body mass index 40 and over, adult) has been expanded to five new codes. They should be reported secondary to the type of obesity (i.e., codes 278.0x [overweight and obesity]).

V85.41 Body Mass Index 40.0–44.9, adult

V85.42 Body Mass Index 45.0–49.9, adult

V85.43 Body Mass Index 50.0–59.9, adult

V85.44 Body Mass Index 60.0–69.9, adult

V85.45 Body Mass Index 70 and over, adult

FECAL INCONTINENCE

Fecal incontinence can present as problematic symptoms—fecal smearing, fecal urgency, incomplete defecation—but, until now, you only had one code to report any of these problems.

For that reason, 787.6 (incontinence of feces) has been expanded into four new five-digit codes. In addition, a new code has been added to report fecal impaction, which, in the past, was reported as 560.39, an “other” category code that was not specific to this problem.

New codes are:

560.32 Fecal impaction

787.60 Full incontinence of feces

787.61 Incomplete defecation

787.62 Fecal smearing

787.63 Fecal urgency

PERSONAL HISTORY OF DYSPLASIA

New codes have been added to complete the personal history codes for dysplasia. In addition to the existing code for cervical dysplasia history (V13.22), you can now report:

V13.23 Personal history of vaginal dysplasia

V13.34 Personal history of vulvar dysplasia

INDEX AND INSTRUCTIONAL CHANGES

These changes take effect October 1, 2010:

• Clarification that an abnormal Pap result indicated non-atypical endometrial cells should be reported using 795.09.
• Clearly indicate whether a fistula between the uterus and another organ is congenital (752.39) or noncongenital (619.0-619.9).
• Precocious menstruation should be coded as 259.1, not as a menstrual disorder.
• The terminology in the index and tabular sections has been revised to more clearly differentiate long-term from prophylactic use of medications. This change affects only code category titles and lookup terms, not existing code numbers.

We want to hear from you! Tell us what you think.

CASE 1 Marilyn H, a 54-year-old woman with multiple chronic conditions, visits a “new” primary care physician to establish care following the retirement of her previous physician. She has poorly controlled diabetes, hypertension, and a lung nodule recently noted on a chest radiograph. Marilyn requests prescriptions for hydrocodone and alprazolam, stating that she has taken both drugs for years for chronic back pain and anxiety.

CASE 2 Don F, 38, has been on oxycodone/acetaminophen (Percocet) for 3 years for back pain resulting from a car accident. He has a remote history of amphetamine abuse, but reports that he has been clean for 10 years. Since the initiation of his pain medication, there have been no problems, and no “lost” prescriptions or requests for early refills.

If you were Marilyn and Don’s physician, would you order urine drug testing (UDT)?

Management of opioid therapy is a challenge for many family physicians, particularly when treating noncancer pain. Seemingly contradictory messages from various medical associations are part of the problem. Organizations such as the Joint Commission on Accreditation of Healthcare Organizations and the American Medical Association emphasize the importance of appropriate pain management, while regulatory bodies like the US Drug Enforcement Agency and many state medical boards warn of inappropriate prescribing and diversion of controlled substances.^1-4

In the realm of opioid management guidelines, however, patient monitoring is a common theme. It’s not hard to understand why. The Centers for Disease Control and Prevention reports that, between 1999 and 2005, the incidence of unintentional drug overdose more than doubled—a consequence of increasing abuse of prescription opioid analgesics.⁵ Prescription medications are now the second most commonly abused drug category (marijuana is first⁶), accounting for more cases of abuse than heroin, cocaine, and hallucinogens combined.⁷ In primary care and pain management settings, estimates are that more than 1 in 4 chronic pain patients misuse opioids or illicit drugs.⁸

Thus, physicians who prescribe controlled substances face increasing pressure to prevent opioid diversion. That pressure is reflected in the US Federation of State Medical Boards (FSMB)’s Model Policy for the Use of Controlled Substances for the Treatment of Pain, which was updated in 2004.⁴ This policy underscores physicians’ responsibility to closely monitor patients being treated with opioids for chronic pain.

Inexpensive and noninvasive. To this end, UDT can be a valuable tool. It is the most widely used and acceptable form of drug testing, because it is inexpensive and noninvasive, and because most drugs can be detected in urine for 1 to 3 days.^9,10 But many primary care physicians are unfamiliar with the complexities of UDT, and often fail to use it.¹¹ One study found that only 8% of family physicians employed UDT for patients on chronic opioid therapy.¹²

When introduced and used appropriately, UDT can not only help detect misuse of controlled substances, but may strengthen the doctor-patient relationship, as well. For that to happen, however, the physician who orders urine testing must know which patients to test, when to test, and what urine testing can (and cannot) reveal.

Consider testing all patients treated for chronic pain

The FSMB urges physicians to consider a written agreement with any patient receiving chronic opioid therapy who has a history of, or is at high risk for, substance abuse.⁴ (Red flags are listed in TABLE 1.^13-15) The document should state that the patient is responsible for providing urine and serum specimens for drug monitoring upon request. The 2009 guidelines from the American Pain Society and the American Academy of Pain Medicine also address the role of drug monitoring, strongly recommending periodic urine screens for high-risk patients on chronic opioid therapy.¹⁶

Evidence suggests that predictors of aberrant behavior are not completely reliable, however, and that a substantial number of individuals using illicit substances will be missed if clinicians restrict urine testing to those they deem to be at high risk.¹⁷ Thus, UDT may be a valuable tool for low-risk patients on chronic opioid therapy, as well. Written agreements governing opioid therapy may also be useful for low-risk patients.

TABLE 1
Aberrant drug-related behavior: Red flags^13-15

When to test, what to test for
No guidelines specify when to test, but testing upon initiation of chronic opioid treatment, followed by random testing, is the most widely used strategy. Unobserved specimen collection is generally acceptable,¹³ provided the specimens are requested at random rather than routinely at every visit.

Initial testing is done using an immuno-assay drug panel.^13,18 TABLE 2 lists the drugs most commonly included in a standard urine test. However, the drug panel can vary from 1 laboratory to another, as can the lower limits of drug detection. No-threshold testing is mentioned in pain management literature, but is not often available in clinical practice.

Before initiating UDT, it is important to know which drugs the laboratory you use routinely tests for and what its lower limits are. The simplest way to find out is to ask lab personnel.

CASE 1 At her first visit, Marilyn H’s new physician focuses on controlling her blood sugar and blood pressure, ordering follow-up testing of the lung nodule, and refilling her hydrocodone and alprazolam prescriptions. The physician requests the patient’s medical records and orders a urine drug screen per clinic protocol, testing for benzodiazepines as well as for opioids. He gives his patient prescriptions for a 1-month supply of both drugs while the UDT results are pending.

The lab report comes in the following day, and indicates that Marilyn tested positive for cocaine but negative for other substances, including narcotics and benzodiazepines. The clinic immediately notifies the pharmacy to confiscate the patient’s new prescriptions when she presents them and calls Marilyn, advising her that she will not be given any further prescriptions for controlled substances.

The physician refers the patient to a pain clinic, gives her the number of a substance abuse treatment center, and encourages her to follow up at the clinic for other medical issues. Marilyn fails to keep her appointment at the pain clinic and does not respond to a subsequent call.

TABLE 2
A standard urine drug test panel^13,18

Talking to patients about drug testing
Physicians are often concerned about patients’ feelings about drug testing—worrying that patients may not feel trusted or respected by a doctor who asks them to submit to UDT. Others may fear that the mere mention of urine testing will encourage patients to misuse prescription opioids, that patients will view UDT as a punitive measure, or that those being tested will believe that the physician is more concerned with self-protection than with providing optimal care to the patient.

Making UDT routine. One way to circumvent such possibilities is to implement a systematic approach to drug testing. We recommend that physicians discuss the role of UDT in the initial education session with patients being started on a course of opiates. Describing UDT as simply another routine monitoring parameter—akin to the measure of microalbuminuria for patients with diabetes—can decrease or eliminate the stigma associated with drug testing.

CASE 2 A new policy encouraging UDT for all patients on chronic controlled substances has just been implemented at the clinic where Don F is being treated. His physician tells him about the policy, and a urine test is ordered at his next visit. The test comes back negative for all substances, including opioids.

When presented with the results over the phone, Don insists that he regularly takes his prescription medication, and makes a same-day appointment to discuss the results with his physician.

Interpreting test results— what UDT can (and can’t) reveal

To avoid eroding trust by falsely accusing a patient of diversion or use of an illicit substance, it’s important to familiarize yourself with testing limitations. Factors that can affect the results, and may interfere with the ability of UDT to provide a definitive picture, include:

Lab variability and technical limitations. Some urine drug panels may not have a lower limit sufficient to detect small quantities of opioids. Others may not detect certain substances, notably the semisynthetic and synthetic opioids (TABLE 3).¹⁹ Oxycodone is a prime example of a commonly prescribed semisynthetic opioid that does not appear on many urine test panels.⁸

In addition, individual drugs within a class may not be identified on UDT panels. When confirmation of a specific drug or metabolite is needed, serum testing must be performed.⁸

TABLE 3
Classifying opioids¹⁹

Differences in metabolism. Genetic differences in metabolism can also skew the results of UDT. Codeine, which relies on hepatic metabolism via cytochrome P450 2D6 for conversion to morphine, is the classic example; cytochrome P450 2D6 is a polymorphic enzyme, meaning that it manifests with different activity levels in different people. Patients who are poor metabolizers (an estimated 5%-10% of Caucasians, 1%-5% of Asians, 2%-7% of African Americans, and 2%-6% of Hispanics²⁰) will convert very little codeine to morphine; conversely, those who are rapid metabolizers will convert extensive amounts. A rapid metabolizer taking codeine as prescribed may therefore have a negative UDT; in an average metabolizer taking the same dose, both codeine and morphine will be detected.²⁰

Drugs’ half-lives. Opioids with a short half-life (TABLE 4)^9,21 may not appear in the urine if the test is done several hours after the last dose. On the other hand, some opioids may have an extended half-life in patients with liver or kidney disease, and may appear in the urine longer than would be expected.⁹

False-positive results. Substances that may cause false positives for opioids on a urine test include dextromethorphan, papaverine, poppy seeds and oil, quinine, quinolones, rifampin, and verapamil.¹⁰

False-negative results. Many of the problems already discussed can lead to false-negative results, including the panel’s failure to detect semisynthetic and synthetic opioids, rapid metabolism (most notably, of codeine), the timing of the test relative to the dose, and adulteration of the specimen. Thus, a negative test result in a patient on opioid therapy does not necessarily mean that he or she is noncompliant—and certainly is not proof of diversion.

Because of the variables that affect UDT outcomes, unanticipated results should be reviewed with the patient and possibly, with the lab, and viewed within the therapeutic context. When more definitive information is needed, serum testing may be performed as follow-up. While serum testing can detect drugs and their metabolites ingested within hours, it is not widely used on initial screening because it is a more invasive procedure with higher associated costs.¹³

CASE 2 Upon further discussion with Don F, the physician orders a serum oxycodone test, which shows a level of 10 ng/mL. The physician notes that serum testing is more appropriate than UDT for Don because of the inconsistent detection of oxycodone in urine.

TABLE 4
Pharmacokinetics of common opioids: Time detectable in urine^9,21

CORRESPONDENCE Sarah McBane, PharmD, CDC, BCPS, University of California, San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences, 9500 Gilman Drive, La Jolla, CA 92023; [email protected]

CASE 1 Marilyn H, a 54-year-old woman with multiple chronic conditions, visits a “new” primary care physician to establish care following the retirement of her previous physician. She has poorly controlled diabetes, hypertension, and a lung nodule recently noted on a chest radiograph. Marilyn requests prescriptions for hydrocodone and alprazolam, stating that she has taken both drugs for years for chronic back pain and anxiety.

CASE 2 Don F, 38, has been on oxycodone/acetaminophen (Percocet) for 3 years for back pain resulting from a car accident. He has a remote history of amphetamine abuse, but reports that he has been clean for 10 years. Since the initiation of his pain medication, there have been no problems, and no “lost” prescriptions or requests for early refills.

If you were Marilyn and Don’s physician, would you order urine drug testing (UDT)?

Management of opioid therapy is a challenge for many family physicians, particularly when treating noncancer pain. Seemingly contradictory messages from various medical associations are part of the problem. Organizations such as the Joint Commission on Accreditation of Healthcare Organizations and the American Medical Association emphasize the importance of appropriate pain management, while regulatory bodies like the US Drug Enforcement Agency and many state medical boards warn of inappropriate prescribing and diversion of controlled substances.^1-4

In the realm of opioid management guidelines, however, patient monitoring is a common theme. It’s not hard to understand why. The Centers for Disease Control and Prevention reports that, between 1999 and 2005, the incidence of unintentional drug overdose more than doubled—a consequence of increasing abuse of prescription opioid analgesics.⁵ Prescription medications are now the second most commonly abused drug category (marijuana is first⁶), accounting for more cases of abuse than heroin, cocaine, and hallucinogens combined.⁷ In primary care and pain management settings, estimates are that more than 1 in 4 chronic pain patients misuse opioids or illicit drugs.⁸

Thus, physicians who prescribe controlled substances face increasing pressure to prevent opioid diversion. That pressure is reflected in the US Federation of State Medical Boards (FSMB)’s Model Policy for the Use of Controlled Substances for the Treatment of Pain, which was updated in 2004.⁴ This policy underscores physicians’ responsibility to closely monitor patients being treated with opioids for chronic pain.

Inexpensive and noninvasive. To this end, UDT can be a valuable tool. It is the most widely used and acceptable form of drug testing, because it is inexpensive and noninvasive, and because most drugs can be detected in urine for 1 to 3 days.^9,10 But many primary care physicians are unfamiliar with the complexities of UDT, and often fail to use it.¹¹ One study found that only 8% of family physicians employed UDT for patients on chronic opioid therapy.¹²

When introduced and used appropriately, UDT can not only help detect misuse of controlled substances, but may strengthen the doctor-patient relationship, as well. For that to happen, however, the physician who orders urine testing must know which patients to test, when to test, and what urine testing can (and cannot) reveal.

Consider testing all patients treated for chronic pain

The FSMB urges physicians to consider a written agreement with any patient receiving chronic opioid therapy who has a history of, or is at high risk for, substance abuse.⁴ (Red flags are listed in TABLE 1.^13-15) The document should state that the patient is responsible for providing urine and serum specimens for drug monitoring upon request. The 2009 guidelines from the American Pain Society and the American Academy of Pain Medicine also address the role of drug monitoring, strongly recommending periodic urine screens for high-risk patients on chronic opioid therapy.¹⁶

Evidence suggests that predictors of aberrant behavior are not completely reliable, however, and that a substantial number of individuals using illicit substances will be missed if clinicians restrict urine testing to those they deem to be at high risk.¹⁷ Thus, UDT may be a valuable tool for low-risk patients on chronic opioid therapy, as well. Written agreements governing opioid therapy may also be useful for low-risk patients.

TABLE 1
Aberrant drug-related behavior: Red flags^13-15

When to test, what to test for
No guidelines specify when to test, but testing upon initiation of chronic opioid treatment, followed by random testing, is the most widely used strategy. Unobserved specimen collection is generally acceptable,¹³ provided the specimens are requested at random rather than routinely at every visit.

Initial testing is done using an immuno-assay drug panel.^13,18 TABLE 2 lists the drugs most commonly included in a standard urine test. However, the drug panel can vary from 1 laboratory to another, as can the lower limits of drug detection. No-threshold testing is mentioned in pain management literature, but is not often available in clinical practice.

Before initiating UDT, it is important to know which drugs the laboratory you use routinely tests for and what its lower limits are. The simplest way to find out is to ask lab personnel.

CASE 1 At her first visit, Marilyn H’s new physician focuses on controlling her blood sugar and blood pressure, ordering follow-up testing of the lung nodule, and refilling her hydrocodone and alprazolam prescriptions. The physician requests the patient’s medical records and orders a urine drug screen per clinic protocol, testing for benzodiazepines as well as for opioids. He gives his patient prescriptions for a 1-month supply of both drugs while the UDT results are pending.

The lab report comes in the following day, and indicates that Marilyn tested positive for cocaine but negative for other substances, including narcotics and benzodiazepines. The clinic immediately notifies the pharmacy to confiscate the patient’s new prescriptions when she presents them and calls Marilyn, advising her that she will not be given any further prescriptions for controlled substances.

The physician refers the patient to a pain clinic, gives her the number of a substance abuse treatment center, and encourages her to follow up at the clinic for other medical issues. Marilyn fails to keep her appointment at the pain clinic and does not respond to a subsequent call.

TABLE 2
A standard urine drug test panel^13,18

Talking to patients about drug testing
Physicians are often concerned about patients’ feelings about drug testing—worrying that patients may not feel trusted or respected by a doctor who asks them to submit to UDT. Others may fear that the mere mention of urine testing will encourage patients to misuse prescription opioids, that patients will view UDT as a punitive measure, or that those being tested will believe that the physician is more concerned with self-protection than with providing optimal care to the patient.

Making UDT routine. One way to circumvent such possibilities is to implement a systematic approach to drug testing. We recommend that physicians discuss the role of UDT in the initial education session with patients being started on a course of opiates. Describing UDT as simply another routine monitoring parameter—akin to the measure of microalbuminuria for patients with diabetes—can decrease or eliminate the stigma associated with drug testing.

CASE 2 A new policy encouraging UDT for all patients on chronic controlled substances has just been implemented at the clinic where Don F is being treated. His physician tells him about the policy, and a urine test is ordered at his next visit. The test comes back negative for all substances, including opioids.

When presented with the results over the phone, Don insists that he regularly takes his prescription medication, and makes a same-day appointment to discuss the results with his physician.

Interpreting test results— what UDT can (and can’t) reveal

To avoid eroding trust by falsely accusing a patient of diversion or use of an illicit substance, it’s important to familiarize yourself with testing limitations. Factors that can affect the results, and may interfere with the ability of UDT to provide a definitive picture, include:

Lab variability and technical limitations. Some urine drug panels may not have a lower limit sufficient to detect small quantities of opioids. Others may not detect certain substances, notably the semisynthetic and synthetic opioids (TABLE 3).¹⁹ Oxycodone is a prime example of a commonly prescribed semisynthetic opioid that does not appear on many urine test panels.⁸

In addition, individual drugs within a class may not be identified on UDT panels. When confirmation of a specific drug or metabolite is needed, serum testing must be performed.⁸

TABLE 3
Classifying opioids¹⁹

Differences in metabolism. Genetic differences in metabolism can also skew the results of UDT. Codeine, which relies on hepatic metabolism via cytochrome P450 2D6 for conversion to morphine, is the classic example; cytochrome P450 2D6 is a polymorphic enzyme, meaning that it manifests with different activity levels in different people. Patients who are poor metabolizers (an estimated 5%-10% of Caucasians, 1%-5% of Asians, 2%-7% of African Americans, and 2%-6% of Hispanics²⁰) will convert very little codeine to morphine; conversely, those who are rapid metabolizers will convert extensive amounts. A rapid metabolizer taking codeine as prescribed may therefore have a negative UDT; in an average metabolizer taking the same dose, both codeine and morphine will be detected.²⁰

Drugs’ half-lives. Opioids with a short half-life (TABLE 4)^9,21 may not appear in the urine if the test is done several hours after the last dose. On the other hand, some opioids may have an extended half-life in patients with liver or kidney disease, and may appear in the urine longer than would be expected.⁹

False-positive results. Substances that may cause false positives for opioids on a urine test include dextromethorphan, papaverine, poppy seeds and oil, quinine, quinolones, rifampin, and verapamil.¹⁰

False-negative results. Many of the problems already discussed can lead to false-negative results, including the panel’s failure to detect semisynthetic and synthetic opioids, rapid metabolism (most notably, of codeine), the timing of the test relative to the dose, and adulteration of the specimen. Thus, a negative test result in a patient on opioid therapy does not necessarily mean that he or she is noncompliant—and certainly is not proof of diversion.

Because of the variables that affect UDT outcomes, unanticipated results should be reviewed with the patient and possibly, with the lab, and viewed within the therapeutic context. When more definitive information is needed, serum testing may be performed as follow-up. While serum testing can detect drugs and their metabolites ingested within hours, it is not widely used on initial screening because it is a more invasive procedure with higher associated costs.¹³

CASE 2 Upon further discussion with Don F, the physician orders a serum oxycodone test, which shows a level of 10 ng/mL. The physician notes that serum testing is more appropriate than UDT for Don because of the inconsistent detection of oxycodone in urine.

TABLE 4
Pharmacokinetics of common opioids: Time detectable in urine^9,21

CORRESPONDENCE Sarah McBane, PharmD, CDC, BCPS, University of California, San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences, 9500 Gilman Drive, La Jolla, CA 92023; [email protected]

CASE 1 Marilyn H, a 54-year-old woman with multiple chronic conditions, visits a “new” primary care physician to establish care following the retirement of her previous physician. She has poorly controlled diabetes, hypertension, and a lung nodule recently noted on a chest radiograph. Marilyn requests prescriptions for hydrocodone and alprazolam, stating that she has taken both drugs for years for chronic back pain and anxiety.

CASE 2 Don F, 38, has been on oxycodone/acetaminophen (Percocet) for 3 years for back pain resulting from a car accident. He has a remote history of amphetamine abuse, but reports that he has been clean for 10 years. Since the initiation of his pain medication, there have been no problems, and no “lost” prescriptions or requests for early refills.

If you were Marilyn and Don’s physician, would you order urine drug testing (UDT)?

Management of opioid therapy is a challenge for many family physicians, particularly when treating noncancer pain. Seemingly contradictory messages from various medical associations are part of the problem. Organizations such as the Joint Commission on Accreditation of Healthcare Organizations and the American Medical Association emphasize the importance of appropriate pain management, while regulatory bodies like the US Drug Enforcement Agency and many state medical boards warn of inappropriate prescribing and diversion of controlled substances.^1-4

In the realm of opioid management guidelines, however, patient monitoring is a common theme. It’s not hard to understand why. The Centers for Disease Control and Prevention reports that, between 1999 and 2005, the incidence of unintentional drug overdose more than doubled—a consequence of increasing abuse of prescription opioid analgesics.⁵ Prescription medications are now the second most commonly abused drug category (marijuana is first⁶), accounting for more cases of abuse than heroin, cocaine, and hallucinogens combined.⁷ In primary care and pain management settings, estimates are that more than 1 in 4 chronic pain patients misuse opioids or illicit drugs.⁸

Thus, physicians who prescribe controlled substances face increasing pressure to prevent opioid diversion. That pressure is reflected in the US Federation of State Medical Boards (FSMB)’s Model Policy for the Use of Controlled Substances for the Treatment of Pain, which was updated in 2004.⁴ This policy underscores physicians’ responsibility to closely monitor patients being treated with opioids for chronic pain.

Inexpensive and noninvasive. To this end, UDT can be a valuable tool. It is the most widely used and acceptable form of drug testing, because it is inexpensive and noninvasive, and because most drugs can be detected in urine for 1 to 3 days.^9,10 But many primary care physicians are unfamiliar with the complexities of UDT, and often fail to use it.¹¹ One study found that only 8% of family physicians employed UDT for patients on chronic opioid therapy.¹²

When introduced and used appropriately, UDT can not only help detect misuse of controlled substances, but may strengthen the doctor-patient relationship, as well. For that to happen, however, the physician who orders urine testing must know which patients to test, when to test, and what urine testing can (and cannot) reveal.

Consider testing all patients treated for chronic pain

The FSMB urges physicians to consider a written agreement with any patient receiving chronic opioid therapy who has a history of, or is at high risk for, substance abuse.⁴ (Red flags are listed in TABLE 1.^13-15) The document should state that the patient is responsible for providing urine and serum specimens for drug monitoring upon request. The 2009 guidelines from the American Pain Society and the American Academy of Pain Medicine also address the role of drug monitoring, strongly recommending periodic urine screens for high-risk patients on chronic opioid therapy.¹⁶

Evidence suggests that predictors of aberrant behavior are not completely reliable, however, and that a substantial number of individuals using illicit substances will be missed if clinicians restrict urine testing to those they deem to be at high risk.¹⁷ Thus, UDT may be a valuable tool for low-risk patients on chronic opioid therapy, as well. Written agreements governing opioid therapy may also be useful for low-risk patients.

TABLE 1
Aberrant drug-related behavior: Red flags^13-15

When to test, what to test for
No guidelines specify when to test, but testing upon initiation of chronic opioid treatment, followed by random testing, is the most widely used strategy. Unobserved specimen collection is generally acceptable,¹³ provided the specimens are requested at random rather than routinely at every visit.

Initial testing is done using an immuno-assay drug panel.^13,18 TABLE 2 lists the drugs most commonly included in a standard urine test. However, the drug panel can vary from 1 laboratory to another, as can the lower limits of drug detection. No-threshold testing is mentioned in pain management literature, but is not often available in clinical practice.

Before initiating UDT, it is important to know which drugs the laboratory you use routinely tests for and what its lower limits are. The simplest way to find out is to ask lab personnel.

CASE 1 At her first visit, Marilyn H’s new physician focuses on controlling her blood sugar and blood pressure, ordering follow-up testing of the lung nodule, and refilling her hydrocodone and alprazolam prescriptions. The physician requests the patient’s medical records and orders a urine drug screen per clinic protocol, testing for benzodiazepines as well as for opioids. He gives his patient prescriptions for a 1-month supply of both drugs while the UDT results are pending.

The lab report comes in the following day, and indicates that Marilyn tested positive for cocaine but negative for other substances, including narcotics and benzodiazepines. The clinic immediately notifies the pharmacy to confiscate the patient’s new prescriptions when she presents them and calls Marilyn, advising her that she will not be given any further prescriptions for controlled substances.

The physician refers the patient to a pain clinic, gives her the number of a substance abuse treatment center, and encourages her to follow up at the clinic for other medical issues. Marilyn fails to keep her appointment at the pain clinic and does not respond to a subsequent call.

TABLE 2
A standard urine drug test panel^13,18

Talking to patients about drug testing
Physicians are often concerned about patients’ feelings about drug testing—worrying that patients may not feel trusted or respected by a doctor who asks them to submit to UDT. Others may fear that the mere mention of urine testing will encourage patients to misuse prescription opioids, that patients will view UDT as a punitive measure, or that those being tested will believe that the physician is more concerned with self-protection than with providing optimal care to the patient.

Making UDT routine. One way to circumvent such possibilities is to implement a systematic approach to drug testing. We recommend that physicians discuss the role of UDT in the initial education session with patients being started on a course of opiates. Describing UDT as simply another routine monitoring parameter—akin to the measure of microalbuminuria for patients with diabetes—can decrease or eliminate the stigma associated with drug testing.

CASE 2 A new policy encouraging UDT for all patients on chronic controlled substances has just been implemented at the clinic where Don F is being treated. His physician tells him about the policy, and a urine test is ordered at his next visit. The test comes back negative for all substances, including opioids.

When presented with the results over the phone, Don insists that he regularly takes his prescription medication, and makes a same-day appointment to discuss the results with his physician.

Interpreting test results— what UDT can (and can’t) reveal

To avoid eroding trust by falsely accusing a patient of diversion or use of an illicit substance, it’s important to familiarize yourself with testing limitations. Factors that can affect the results, and may interfere with the ability of UDT to provide a definitive picture, include:

Lab variability and technical limitations. Some urine drug panels may not have a lower limit sufficient to detect small quantities of opioids. Others may not detect certain substances, notably the semisynthetic and synthetic opioids (TABLE 3).¹⁹ Oxycodone is a prime example of a commonly prescribed semisynthetic opioid that does not appear on many urine test panels.⁸

In addition, individual drugs within a class may not be identified on UDT panels. When confirmation of a specific drug or metabolite is needed, serum testing must be performed.⁸

TABLE 3
Classifying opioids¹⁹

Differences in metabolism. Genetic differences in metabolism can also skew the results of UDT. Codeine, which relies on hepatic metabolism via cytochrome P450 2D6 for conversion to morphine, is the classic example; cytochrome P450 2D6 is a polymorphic enzyme, meaning that it manifests with different activity levels in different people. Patients who are poor metabolizers (an estimated 5%-10% of Caucasians, 1%-5% of Asians, 2%-7% of African Americans, and 2%-6% of Hispanics²⁰) will convert very little codeine to morphine; conversely, those who are rapid metabolizers will convert extensive amounts. A rapid metabolizer taking codeine as prescribed may therefore have a negative UDT; in an average metabolizer taking the same dose, both codeine and morphine will be detected.²⁰

Drugs’ half-lives. Opioids with a short half-life (TABLE 4)^9,21 may not appear in the urine if the test is done several hours after the last dose. On the other hand, some opioids may have an extended half-life in patients with liver or kidney disease, and may appear in the urine longer than would be expected.⁹

False-positive results. Substances that may cause false positives for opioids on a urine test include dextromethorphan, papaverine, poppy seeds and oil, quinine, quinolones, rifampin, and verapamil.¹⁰

False-negative results. Many of the problems already discussed can lead to false-negative results, including the panel’s failure to detect semisynthetic and synthetic opioids, rapid metabolism (most notably, of codeine), the timing of the test relative to the dose, and adulteration of the specimen. Thus, a negative test result in a patient on opioid therapy does not necessarily mean that he or she is noncompliant—and certainly is not proof of diversion.

Because of the variables that affect UDT outcomes, unanticipated results should be reviewed with the patient and possibly, with the lab, and viewed within the therapeutic context. When more definitive information is needed, serum testing may be performed as follow-up. While serum testing can detect drugs and their metabolites ingested within hours, it is not widely used on initial screening because it is a more invasive procedure with higher associated costs.¹³

CASE 2 Upon further discussion with Don F, the physician orders a serum oxycodone test, which shows a level of 10 ng/mL. The physician notes that serum testing is more appropriate than UDT for Don because of the inconsistent detection of oxycodone in urine.

TABLE 4
Pharmacokinetics of common opioids: Time detectable in urine^9,21

CORRESPONDENCE Sarah McBane, PharmD, CDC, BCPS, University of California, San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences, 9500 Gilman Drive, La Jolla, CA 92023; [email protected]

Clinical experiences sometimes contradict the psychiatric literature. For example, some of my patients with panic disorder (PD) benefit from adding benzodiazepines to selective serotonin reuptake inhibitors (SSRIs). However, 2 double-blind studies show that adding benzodiazepines to SSRIs does not help PD patients.^1,2 Why are my patients different from those in the studies? Some of my patients may have been misusing benzodiazepines or were psychologically habituated to them, but I doubt that explains all of the improvement I observed.

A more relevant reason for the different responses seen in my patients and those in the 2 studies may be differences in the populations involved. For example, many of my PD patients had not responded to SSRIs alone. In contrast, none of the patients in the studies had been unresponsive to SSRIs.

Also, unlike patients in the studies, many of my patients with PD have severe psychiatric comorbidity—they also may have a diagnosis of schizophrenia, bipolar disorder, schizoaffective disorder, or depression. Comorbidity may affect the severity of PD and treatment response. For example, PD with recurrent comorbid depression has been shown to be more difficult to treat, suggesting the need for “combination treatment with SSRI and benzodiazepines or with pharmacotherapy and cognitive-behavior therapy.”³

I am not suggesting that benzodiazepines should be added to SSRIs for every patient with PD and severe comorbidity. Some of my patients with PD and comorbid psychiatric disorders do quite well with SSRIs alone. I suggest that patients who do not respond to SSRIs may benefit from adjunctive benzodiazepines. Severe comorbidity may suggest the need for adding benzodiazepines; the lack of response to high doses of SSRIs also may be a determining factor.

Disclosure: Dr Wilf reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Clinical experiences sometimes contradict the psychiatric literature. For example, some of my patients with panic disorder (PD) benefit from adding benzodiazepines to selective serotonin reuptake inhibitors (SSRIs). However, 2 double-blind studies show that adding benzodiazepines to SSRIs does not help PD patients.^1,2 Why are my patients different from those in the studies? Some of my patients may have been misusing benzodiazepines or were psychologically habituated to them, but I doubt that explains all of the improvement I observed.

A more relevant reason for the different responses seen in my patients and those in the 2 studies may be differences in the populations involved. For example, many of my PD patients had not responded to SSRIs alone. In contrast, none of the patients in the studies had been unresponsive to SSRIs.

Also, unlike patients in the studies, many of my patients with PD have severe psychiatric comorbidity—they also may have a diagnosis of schizophrenia, bipolar disorder, schizoaffective disorder, or depression. Comorbidity may affect the severity of PD and treatment response. For example, PD with recurrent comorbid depression has been shown to be more difficult to treat, suggesting the need for “combination treatment with SSRI and benzodiazepines or with pharmacotherapy and cognitive-behavior therapy.”³

I am not suggesting that benzodiazepines should be added to SSRIs for every patient with PD and severe comorbidity. Some of my patients with PD and comorbid psychiatric disorders do quite well with SSRIs alone. I suggest that patients who do not respond to SSRIs may benefit from adjunctive benzodiazepines. Severe comorbidity may suggest the need for adding benzodiazepines; the lack of response to high doses of SSRIs also may be a determining factor.

Disclosure: Dr Wilf reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Clinical experiences sometimes contradict the psychiatric literature. For example, some of my patients with panic disorder (PD) benefit from adding benzodiazepines to selective serotonin reuptake inhibitors (SSRIs). However, 2 double-blind studies show that adding benzodiazepines to SSRIs does not help PD patients.^1,2 Why are my patients different from those in the studies? Some of my patients may have been misusing benzodiazepines or were psychologically habituated to them, but I doubt that explains all of the improvement I observed.

A more relevant reason for the different responses seen in my patients and those in the 2 studies may be differences in the populations involved. For example, many of my PD patients had not responded to SSRIs alone. In contrast, none of the patients in the studies had been unresponsive to SSRIs.

Also, unlike patients in the studies, many of my patients with PD have severe psychiatric comorbidity—they also may have a diagnosis of schizophrenia, bipolar disorder, schizoaffective disorder, or depression. Comorbidity may affect the severity of PD and treatment response. For example, PD with recurrent comorbid depression has been shown to be more difficult to treat, suggesting the need for “combination treatment with SSRI and benzodiazepines or with pharmacotherapy and cognitive-behavior therapy.”³

I am not suggesting that benzodiazepines should be added to SSRIs for every patient with PD and severe comorbidity. Some of my patients with PD and comorbid psychiatric disorders do quite well with SSRIs alone. I suggest that patients who do not respond to SSRIs may benefit from adjunctive benzodiazepines. Severe comorbidity may suggest the need for adding benzodiazepines; the lack of response to high doses of SSRIs also may be a determining factor.

Disclosure: Dr Wilf reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

First recognize that a child with precocious puberty might actually have a serious underlying medical condition that triggers puberty. It is appropriate for you to distinguish true precocious puberty from precocious puberty secondary to a general underlying medical condition if this is within your comfort zone.

Begin with a complete history and physical examination. If you see physical signs of puberty that are not simply caused by “early puberty,” consider looking for underlying thyroid disorders, ovarian tumors, central nervous system tumors, or even tumors of the adrenal gland.

Importantly, perform a complete evaluation before initiation of any “treatment.” Occasionally, a patient with premature vaginal bleeding undergoes a very thorough hormone evaluation only to find the cause of her bleeding is a foreign body. Therefore, inspect the vaginal cavity as part of your physical examination or include this in your gynecologist referral when a girl presents with vaginal bleeding and no other evident signs of puberty. You might spare the patient a full hormone work-up. Also refer the child to a gynecologist if you suspect an abnormality of the reproductive tract because of pelvic pain, vaginal discharge, and/or abnormal vaginal bleeding.

The treatment for precocious puberty is controversial itself. Administration of an injection that blocks gonadotropin-releasing hormone (GnRH) secretion from the hypothalamus is the most commonly prescribed therapy (leuprolide acetate, Lupron Depot-PED). Consider referral of these patients because gynecologists and pediatric endocrinologists have the most experience with this medication.

Other medications and lifestyle modifications are not particularly effective at halting early puberty.

Optimally, I advocate a combined effort among the pediatrician, the pediatric endocrinologist, and the gynecologist with a special interest in children.

Consider ordering a bone age study during your initial evaluation. It is an easy-to-order test for early puberty. Determination of the bone age of the left wrist is particularly worthwhile and provides useful information should you decide to refer to a specialist. Referral is warranted if a child with precocious puberty has advanced bone age.

Although precocious puberty includes thelarche and adrenarche, some important differences exist. Breast development, the growth spurt, and menses are all under the control of one system, the hypothalamic-pituitary-ovarian axis. Adrenarche, or secondary sexual hair, is primarily under the control of the adrenal gland, although the ovary is a major contributor to circulating androgens. Clinically, evaluate adrenal pathology more aggressively in cases of precocious adrenarche than in cases of thelarche.

It is also appropriate for a child without precocious puberty concerns to see a gynecologist in the early teenage years. This specialist can help you educate patients on reproductive health, including when Pap testing needs to be done and strategies to prevent pregnancy and sexually transmitted infection.

First recognize that a child with precocious puberty might actually have a serious underlying medical condition that triggers puberty. It is appropriate for you to distinguish true precocious puberty from precocious puberty secondary to a general underlying medical condition if this is within your comfort zone.

Begin with a complete history and physical examination. If you see physical signs of puberty that are not simply caused by “early puberty,” consider looking for underlying thyroid disorders, ovarian tumors, central nervous system tumors, or even tumors of the adrenal gland.

Importantly, perform a complete evaluation before initiation of any “treatment.” Occasionally, a patient with premature vaginal bleeding undergoes a very thorough hormone evaluation only to find the cause of her bleeding is a foreign body. Therefore, inspect the vaginal cavity as part of your physical examination or include this in your gynecologist referral when a girl presents with vaginal bleeding and no other evident signs of puberty. You might spare the patient a full hormone work-up. Also refer the child to a gynecologist if you suspect an abnormality of the reproductive tract because of pelvic pain, vaginal discharge, and/or abnormal vaginal bleeding.

The treatment for precocious puberty is controversial itself. Administration of an injection that blocks gonadotropin-releasing hormone (GnRH) secretion from the hypothalamus is the most commonly prescribed therapy (leuprolide acetate, Lupron Depot-PED). Consider referral of these patients because gynecologists and pediatric endocrinologists have the most experience with this medication.

Other medications and lifestyle modifications are not particularly effective at halting early puberty.

Optimally, I advocate a combined effort among the pediatrician, the pediatric endocrinologist, and the gynecologist with a special interest in children.

Consider ordering a bone age study during your initial evaluation. It is an easy-to-order test for early puberty. Determination of the bone age of the left wrist is particularly worthwhile and provides useful information should you decide to refer to a specialist. Referral is warranted if a child with precocious puberty has advanced bone age.

Although precocious puberty includes thelarche and adrenarche, some important differences exist. Breast development, the growth spurt, and menses are all under the control of one system, the hypothalamic-pituitary-ovarian axis. Adrenarche, or secondary sexual hair, is primarily under the control of the adrenal gland, although the ovary is a major contributor to circulating androgens. Clinically, evaluate adrenal pathology more aggressively in cases of precocious adrenarche than in cases of thelarche.

It is also appropriate for a child without precocious puberty concerns to see a gynecologist in the early teenage years. This specialist can help you educate patients on reproductive health, including when Pap testing needs to be done and strategies to prevent pregnancy and sexually transmitted infection.

First recognize that a child with precocious puberty might actually have a serious underlying medical condition that triggers puberty. It is appropriate for you to distinguish true precocious puberty from precocious puberty secondary to a general underlying medical condition if this is within your comfort zone.

Begin with a complete history and physical examination. If you see physical signs of puberty that are not simply caused by “early puberty,” consider looking for underlying thyroid disorders, ovarian tumors, central nervous system tumors, or even tumors of the adrenal gland.

Importantly, perform a complete evaluation before initiation of any “treatment.” Occasionally, a patient with premature vaginal bleeding undergoes a very thorough hormone evaluation only to find the cause of her bleeding is a foreign body. Therefore, inspect the vaginal cavity as part of your physical examination or include this in your gynecologist referral when a girl presents with vaginal bleeding and no other evident signs of puberty. You might spare the patient a full hormone work-up. Also refer the child to a gynecologist if you suspect an abnormality of the reproductive tract because of pelvic pain, vaginal discharge, and/or abnormal vaginal bleeding.

The treatment for precocious puberty is controversial itself. Administration of an injection that blocks gonadotropin-releasing hormone (GnRH) secretion from the hypothalamus is the most commonly prescribed therapy (leuprolide acetate, Lupron Depot-PED). Consider referral of these patients because gynecologists and pediatric endocrinologists have the most experience with this medication.

Other medications and lifestyle modifications are not particularly effective at halting early puberty.

Optimally, I advocate a combined effort among the pediatrician, the pediatric endocrinologist, and the gynecologist with a special interest in children.

Consider ordering a bone age study during your initial evaluation. It is an easy-to-order test for early puberty. Determination of the bone age of the left wrist is particularly worthwhile and provides useful information should you decide to refer to a specialist. Referral is warranted if a child with precocious puberty has advanced bone age.

Although precocious puberty includes thelarche and adrenarche, some important differences exist. Breast development, the growth spurt, and menses are all under the control of one system, the hypothalamic-pituitary-ovarian axis. Adrenarche, or secondary sexual hair, is primarily under the control of the adrenal gland, although the ovary is a major contributor to circulating androgens. Clinically, evaluate adrenal pathology more aggressively in cases of precocious adrenarche than in cases of thelarche.

It is also appropriate for a child without precocious puberty concerns to see a gynecologist in the early teenage years. This specialist can help you educate patients on reproductive health, including when Pap testing needs to be done and strategies to prevent pregnancy and sexually transmitted infection.

www.CHADIS.com[email protected]

“The preschool just called for the second time about Jason's behavior! What can I do?” This plea to you the pediatrician makes your stomach turn upside down. “What am I supposed to do about that?” you ask yourself. You're not there to see what is happening, and the parent isn't either.

This scenario is made even more difficult because the parents can be desperate for advice and quick solutions. It is incredibly inconvenient when a child is thrown out of child care or preschool for bad behavior, especially for parents who both work. Parents may even get hysterical because they immediately envision their darling failing to get into Harvard based on an inability to interact properly in preschool.

The differential diagnosis of this complaint takes some good sleuthing, but can make a big difference in the life of a young child.

Young children deal with social interaction issues that also confront grown-ups, but without the skills to navigate and manage them.

Learning social skills is a major benefit of preschool and kindergarten, particularly for children with few siblings or siblings of much different ages. The poem “All I Need to Know I Learned in Kindergarten” describes many of these social benefits, including learning to share, take turns, act kindly, and use manners. The poem does not mention some of the other less poetic skills developed at this age, however: learning how to tease successfully, pull your punches, stand tall when there is a bully, bounce back when people insult you or after you wet your pants, tell if someone is a real friend, and deal with a critical teacher who is screaming all the time.

Young children normally practice a social interaction known as “inclusion/exclusion,” where one day they say, “Oh, you're my best friend. Let's go have our secret club.” But the next day they say, “You're not my friend anymore. I've got a new best friend. You can't play with me.” In general, the best short- and long-term outcomes occur when children work out minor interaction problems on their own, with a little teacher support, but serious problems are handled privately by the adults.

Ask for specific information about one of the incidents from both the child and the parent. If a child comes home from school and says, “This kid called me names,” parents can ask, “What kind of names?” to distinguish normal teasing from a toxic environment that needs to be changed. Abnormal teasing is more vicious and adultlike, for example, a peer calling the child a “whore” or using a racial epithet.

Don't forget to suggest ways to pump up resilience such as getting sufficient sleep and proper nutrition.

Next, assess the child with problematic peer behavior for skill deficits. A child with a gap may act up to distract others from noticing, out of frustration or as result of discrimination the child experiences. Often children this age who are aggressive have shortcomings in language. They may speak a different language at home or still communicate only in two- or three-word phrases, and therefore are unable to keep up with others and feel – or actually are – left out. They don't have the repartee to negotiate social situations and can become the victim of taunting and teasing, a specialty of girls.

Children with gross motor skill deficits, particularly boys, also may experience difficulty keeping up with their peers. In some cases, they are rejected by the group for being unable to kick a soccer ball or to climb a jungle gym as well as others can, and they are angry as a result.

Check fine motor skills as well. A child with poor coordination may be slow to finish work and/or be ashamed of what they do produce. Children can be very self-critical at this age and even tear up their papers. If the teacher asks everyone to draw a truck, and another student pointedly says, 'That doesn't look like a truck,” the child might punch in return. The child is acting up in frustration.

While children at this age are just on the edge of acquiring “perspective taking” (considering another's point of view), in the most severe form, difficulty in doing this can be a sign of autism spectrum disorder. Peers quickly pick up on this and may tease them, call them names, and/or reject their awkward attempts to engage. Try telling them a joke or asking them to tell one, and you may see why.

You can help by addressing any detected skill deficits with language therapy or physical therapy. Importantly, suggest ways to build their skills while allowing them to bypass social humiliation. Let children who are not athletic skip recess, assigning them the task of getting out the snacks to avoid further humiliation. Then work on their motor skills through after-school karate instead.

Anxiety can spark aggression, too. If you are afraid, it seems better to strike first. If anxiety seems key, the parents and school will need to soften their handling of the child and help him or her put feelings into words to assist the child in not acting out.

Since some children will misbehave to get a teacher's attention, recommend that the parents drop in unannounced. Often the way a classroom appears (or is staffed) at 8 a.m. drop-off time is not the same way it operates at 10:30 a.m. Suggest a parent watch the part of the day their child complains about the most, which is frequently recess.

Even though there are bad situations and bad schools, most schools have great teachers and other professionals from whom parents can gain valuable information and advice.

Generally teachers can explain the timing of a child's troubles, for example, during circle time he cannot sit still or during craft time because his fine motor skills are not well developed. Having parents seek out these examples is the most efficient way to identify deficits in need of help.

Suggest parents speak to their child empathically instead of giving instructions. In this culture, boys especially are told to “keep a stiff upper lip” or “be a big soldier.” A better approach is to say, “Yes, it's tough when kids talk to you like that” or “I understand this really makes you sad and you feel like crying.”

It also helps when parents share a similar experience from their own childhood. For example, parents can say, “You know, when I was your age, I had an experience like this – I had a kid who was always on my case.”

Parents can promote social development as well. For example, role playing can clearly help a child develop appropriate socioemotional skills. Parents can use this strategy either before an incident – for example, to rehearse how a child might react to a bully in class – or afterward, to help the child determine what he or she might have said or done differently and prepare for the next time. Use of social stories can foster these skills (see www.socialstories.com

Parents who experienced a bad peer interaction as a preschooler or kindergartener may project their concerns on their child who may be doing just fine. The parents might be supersensitive to teasing, for example, and bring an otherwise minor incident to your attention and/or become overintrusive at school. Asking, “How was it for you when you were little? Did you ever run into anything like this?” may bring out past experiences as an important factor predisposing to overreaction. If they wet their pants in kindergarten and never got over it, realizing this connection makes it possible for them to back off and let the school and child handle the current problem.

Watch for red flags or warning signs that problematic behaviors are not within the range of normal stress. The child initially doing well at school who suddenly does not want to return is one example.

Sadly, you need to always consider whether there is abuse going on at school, including sexual abuse. Sudden adjustment problems at home, such as trouble sleeping, nightmares, or bed-wetting, also should raise your level of concern.

Also ask parents if their preschooler suddenly became more difficult to manage at home. Some children who experience negative peer interactions will cling to parents, but oppositional or defiant behavior is more common. Of course, 4-year-old children are notoriously brassy, so you cannot consider back talk a warning sign unless it is part of a sudden change in the normal flow of the child's behavior.

A child this stressed over school may need to be cared for at home or moved to a family day care situation

Unfortunately, the modern practice of grouping of kids of the same age together in a classroom increases the likelihood of interactions going badly. Ten 2-year-old children are not necessarily capable of peacefully spending hours together at a time. When a serious behavioral problem arises in this kind of setting, I frequently recommend family-based day care instead of center-based day care because children will be with others of different ages and different skill levels, and hopefully some of them will be more mature.

Support parents in deciding to pull the child out of a school if the situation is bad. If, for example, the school administration is unresponsive to or dismissive of a parent, removal of the child may be the best option. A new parent recently came to the parent group at our clinic. She reported that a teacher responded to her child's behavior problem by putting him in a closet, which would have been egregious enough, but the teacher also said that there were spiders and bugs in the closet that were going to get him before closing the door. I was flabbergasted. The school tried to defend the teacher for doing this, and my final advice was to “pull the kid.” Any school that ignorant of normal child development cannot be fixed.

www.CHADIS.com[email protected]

“The preschool just called for the second time about Jason's behavior! What can I do?” This plea to you the pediatrician makes your stomach turn upside down. “What am I supposed to do about that?” you ask yourself. You're not there to see what is happening, and the parent isn't either.

This scenario is made even more difficult because the parents can be desperate for advice and quick solutions. It is incredibly inconvenient when a child is thrown out of child care or preschool for bad behavior, especially for parents who both work. Parents may even get hysterical because they immediately envision their darling failing to get into Harvard based on an inability to interact properly in preschool.

The differential diagnosis of this complaint takes some good sleuthing, but can make a big difference in the life of a young child.

Young children deal with social interaction issues that also confront grown-ups, but without the skills to navigate and manage them.

Learning social skills is a major benefit of preschool and kindergarten, particularly for children with few siblings or siblings of much different ages. The poem “All I Need to Know I Learned in Kindergarten” describes many of these social benefits, including learning to share, take turns, act kindly, and use manners. The poem does not mention some of the other less poetic skills developed at this age, however: learning how to tease successfully, pull your punches, stand tall when there is a bully, bounce back when people insult you or after you wet your pants, tell if someone is a real friend, and deal with a critical teacher who is screaming all the time.

Young children normally practice a social interaction known as “inclusion/exclusion,” where one day they say, “Oh, you're my best friend. Let's go have our secret club.” But the next day they say, “You're not my friend anymore. I've got a new best friend. You can't play with me.” In general, the best short- and long-term outcomes occur when children work out minor interaction problems on their own, with a little teacher support, but serious problems are handled privately by the adults.

Ask for specific information about one of the incidents from both the child and the parent. If a child comes home from school and says, “This kid called me names,” parents can ask, “What kind of names?” to distinguish normal teasing from a toxic environment that needs to be changed. Abnormal teasing is more vicious and adultlike, for example, a peer calling the child a “whore” or using a racial epithet.

Don't forget to suggest ways to pump up resilience such as getting sufficient sleep and proper nutrition.

Next, assess the child with problematic peer behavior for skill deficits. A child with a gap may act up to distract others from noticing, out of frustration or as result of discrimination the child experiences. Often children this age who are aggressive have shortcomings in language. They may speak a different language at home or still communicate only in two- or three-word phrases, and therefore are unable to keep up with others and feel – or actually are – left out. They don't have the repartee to negotiate social situations and can become the victim of taunting and teasing, a specialty of girls.

Children with gross motor skill deficits, particularly boys, also may experience difficulty keeping up with their peers. In some cases, they are rejected by the group for being unable to kick a soccer ball or to climb a jungle gym as well as others can, and they are angry as a result.

Check fine motor skills as well. A child with poor coordination may be slow to finish work and/or be ashamed of what they do produce. Children can be very self-critical at this age and even tear up their papers. If the teacher asks everyone to draw a truck, and another student pointedly says, 'That doesn't look like a truck,” the child might punch in return. The child is acting up in frustration.

While children at this age are just on the edge of acquiring “perspective taking” (considering another's point of view), in the most severe form, difficulty in doing this can be a sign of autism spectrum disorder. Peers quickly pick up on this and may tease them, call them names, and/or reject their awkward attempts to engage. Try telling them a joke or asking them to tell one, and you may see why.

You can help by addressing any detected skill deficits with language therapy or physical therapy. Importantly, suggest ways to build their skills while allowing them to bypass social humiliation. Let children who are not athletic skip recess, assigning them the task of getting out the snacks to avoid further humiliation. Then work on their motor skills through after-school karate instead.

Anxiety can spark aggression, too. If you are afraid, it seems better to strike first. If anxiety seems key, the parents and school will need to soften their handling of the child and help him or her put feelings into words to assist the child in not acting out.

Since some children will misbehave to get a teacher's attention, recommend that the parents drop in unannounced. Often the way a classroom appears (or is staffed) at 8 a.m. drop-off time is not the same way it operates at 10:30 a.m. Suggest a parent watch the part of the day their child complains about the most, which is frequently recess.

Even though there are bad situations and bad schools, most schools have great teachers and other professionals from whom parents can gain valuable information and advice.

Generally teachers can explain the timing of a child's troubles, for example, during circle time he cannot sit still or during craft time because his fine motor skills are not well developed. Having parents seek out these examples is the most efficient way to identify deficits in need of help.

Suggest parents speak to their child empathically instead of giving instructions. In this culture, boys especially are told to “keep a stiff upper lip” or “be a big soldier.” A better approach is to say, “Yes, it's tough when kids talk to you like that” or “I understand this really makes you sad and you feel like crying.”

It also helps when parents share a similar experience from their own childhood. For example, parents can say, “You know, when I was your age, I had an experience like this – I had a kid who was always on my case.”

Parents can promote social development as well. For example, role playing can clearly help a child develop appropriate socioemotional skills. Parents can use this strategy either before an incident – for example, to rehearse how a child might react to a bully in class – or afterward, to help the child determine what he or she might have said or done differently and prepare for the next time. Use of social stories can foster these skills (see www.socialstories.com

Parents who experienced a bad peer interaction as a preschooler or kindergartener may project their concerns on their child who may be doing just fine. The parents might be supersensitive to teasing, for example, and bring an otherwise minor incident to your attention and/or become overintrusive at school. Asking, “How was it for you when you were little? Did you ever run into anything like this?” may bring out past experiences as an important factor predisposing to overreaction. If they wet their pants in kindergarten and never got over it, realizing this connection makes it possible for them to back off and let the school and child handle the current problem.

Watch for red flags or warning signs that problematic behaviors are not within the range of normal stress. The child initially doing well at school who suddenly does not want to return is one example.

Sadly, you need to always consider whether there is abuse going on at school, including sexual abuse. Sudden adjustment problems at home, such as trouble sleeping, nightmares, or bed-wetting, also should raise your level of concern.

Also ask parents if their preschooler suddenly became more difficult to manage at home. Some children who experience negative peer interactions will cling to parents, but oppositional or defiant behavior is more common. Of course, 4-year-old children are notoriously brassy, so you cannot consider back talk a warning sign unless it is part of a sudden change in the normal flow of the child's behavior.

A child this stressed over school may need to be cared for at home or moved to a family day care situation

Unfortunately, the modern practice of grouping of kids of the same age together in a classroom increases the likelihood of interactions going badly. Ten 2-year-old children are not necessarily capable of peacefully spending hours together at a time. When a serious behavioral problem arises in this kind of setting, I frequently recommend family-based day care instead of center-based day care because children will be with others of different ages and different skill levels, and hopefully some of them will be more mature.

Support parents in deciding to pull the child out of a school if the situation is bad. If, for example, the school administration is unresponsive to or dismissive of a parent, removal of the child may be the best option. A new parent recently came to the parent group at our clinic. She reported that a teacher responded to her child's behavior problem by putting him in a closet, which would have been egregious enough, but the teacher also said that there were spiders and bugs in the closet that were going to get him before closing the door. I was flabbergasted. The school tried to defend the teacher for doing this, and my final advice was to “pull the kid.” Any school that ignorant of normal child development cannot be fixed.

www.CHADIS.com[email protected]

“The preschool just called for the second time about Jason's behavior! What can I do?” This plea to you the pediatrician makes your stomach turn upside down. “What am I supposed to do about that?” you ask yourself. You're not there to see what is happening, and the parent isn't either.

This scenario is made even more difficult because the parents can be desperate for advice and quick solutions. It is incredibly inconvenient when a child is thrown out of child care or preschool for bad behavior, especially for parents who both work. Parents may even get hysterical because they immediately envision their darling failing to get into Harvard based on an inability to interact properly in preschool.

The differential diagnosis of this complaint takes some good sleuthing, but can make a big difference in the life of a young child.

Young children deal with social interaction issues that also confront grown-ups, but without the skills to navigate and manage them.

Learning social skills is a major benefit of preschool and kindergarten, particularly for children with few siblings or siblings of much different ages. The poem “All I Need to Know I Learned in Kindergarten” describes many of these social benefits, including learning to share, take turns, act kindly, and use manners. The poem does not mention some of the other less poetic skills developed at this age, however: learning how to tease successfully, pull your punches, stand tall when there is a bully, bounce back when people insult you or after you wet your pants, tell if someone is a real friend, and deal with a critical teacher who is screaming all the time.

Young children normally practice a social interaction known as “inclusion/exclusion,” where one day they say, “Oh, you're my best friend. Let's go have our secret club.” But the next day they say, “You're not my friend anymore. I've got a new best friend. You can't play with me.” In general, the best short- and long-term outcomes occur when children work out minor interaction problems on their own, with a little teacher support, but serious problems are handled privately by the adults.

Ask for specific information about one of the incidents from both the child and the parent. If a child comes home from school and says, “This kid called me names,” parents can ask, “What kind of names?” to distinguish normal teasing from a toxic environment that needs to be changed. Abnormal teasing is more vicious and adultlike, for example, a peer calling the child a “whore” or using a racial epithet.

Don't forget to suggest ways to pump up resilience such as getting sufficient sleep and proper nutrition.

Next, assess the child with problematic peer behavior for skill deficits. A child with a gap may act up to distract others from noticing, out of frustration or as result of discrimination the child experiences. Often children this age who are aggressive have shortcomings in language. They may speak a different language at home or still communicate only in two- or three-word phrases, and therefore are unable to keep up with others and feel – or actually are – left out. They don't have the repartee to negotiate social situations and can become the victim of taunting and teasing, a specialty of girls.

Children with gross motor skill deficits, particularly boys, also may experience difficulty keeping up with their peers. In some cases, they are rejected by the group for being unable to kick a soccer ball or to climb a jungle gym as well as others can, and they are angry as a result.

Check fine motor skills as well. A child with poor coordination may be slow to finish work and/or be ashamed of what they do produce. Children can be very self-critical at this age and even tear up their papers. If the teacher asks everyone to draw a truck, and another student pointedly says, 'That doesn't look like a truck,” the child might punch in return. The child is acting up in frustration.

While children at this age are just on the edge of acquiring “perspective taking” (considering another's point of view), in the most severe form, difficulty in doing this can be a sign of autism spectrum disorder. Peers quickly pick up on this and may tease them, call them names, and/or reject their awkward attempts to engage. Try telling them a joke or asking them to tell one, and you may see why.

You can help by addressing any detected skill deficits with language therapy or physical therapy. Importantly, suggest ways to build their skills while allowing them to bypass social humiliation. Let children who are not athletic skip recess, assigning them the task of getting out the snacks to avoid further humiliation. Then work on their motor skills through after-school karate instead.

Anxiety can spark aggression, too. If you are afraid, it seems better to strike first. If anxiety seems key, the parents and school will need to soften their handling of the child and help him or her put feelings into words to assist the child in not acting out.

Since some children will misbehave to get a teacher's attention, recommend that the parents drop in unannounced. Often the way a classroom appears (or is staffed) at 8 a.m. drop-off time is not the same way it operates at 10:30 a.m. Suggest a parent watch the part of the day their child complains about the most, which is frequently recess.

Even though there are bad situations and bad schools, most schools have great teachers and other professionals from whom parents can gain valuable information and advice.

Generally teachers can explain the timing of a child's troubles, for example, during circle time he cannot sit still or during craft time because his fine motor skills are not well developed. Having parents seek out these examples is the most efficient way to identify deficits in need of help.

Suggest parents speak to their child empathically instead of giving instructions. In this culture, boys especially are told to “keep a stiff upper lip” or “be a big soldier.” A better approach is to say, “Yes, it's tough when kids talk to you like that” or “I understand this really makes you sad and you feel like crying.”

It also helps when parents share a similar experience from their own childhood. For example, parents can say, “You know, when I was your age, I had an experience like this – I had a kid who was always on my case.”

Parents can promote social development as well. For example, role playing can clearly help a child develop appropriate socioemotional skills. Parents can use this strategy either before an incident – for example, to rehearse how a child might react to a bully in class – or afterward, to help the child determine what he or she might have said or done differently and prepare for the next time. Use of social stories can foster these skills (see www.socialstories.com

Parents who experienced a bad peer interaction as a preschooler or kindergartener may project their concerns on their child who may be doing just fine. The parents might be supersensitive to teasing, for example, and bring an otherwise minor incident to your attention and/or become overintrusive at school. Asking, “How was it for you when you were little? Did you ever run into anything like this?” may bring out past experiences as an important factor predisposing to overreaction. If they wet their pants in kindergarten and never got over it, realizing this connection makes it possible for them to back off and let the school and child handle the current problem.

Watch for red flags or warning signs that problematic behaviors are not within the range of normal stress. The child initially doing well at school who suddenly does not want to return is one example.

Sadly, you need to always consider whether there is abuse going on at school, including sexual abuse. Sudden adjustment problems at home, such as trouble sleeping, nightmares, or bed-wetting, also should raise your level of concern.

Also ask parents if their preschooler suddenly became more difficult to manage at home. Some children who experience negative peer interactions will cling to parents, but oppositional or defiant behavior is more common. Of course, 4-year-old children are notoriously brassy, so you cannot consider back talk a warning sign unless it is part of a sudden change in the normal flow of the child's behavior.

A child this stressed over school may need to be cared for at home or moved to a family day care situation

Unfortunately, the modern practice of grouping of kids of the same age together in a classroom increases the likelihood of interactions going badly. Ten 2-year-old children are not necessarily capable of peacefully spending hours together at a time. When a serious behavioral problem arises in this kind of setting, I frequently recommend family-based day care instead of center-based day care because children will be with others of different ages and different skill levels, and hopefully some of them will be more mature.

Support parents in deciding to pull the child out of a school if the situation is bad. If, for example, the school administration is unresponsive to or dismissive of a parent, removal of the child may be the best option. A new parent recently came to the parent group at our clinic. She reported that a teacher responded to her child's behavior problem by putting him in a closet, which would have been egregious enough, but the teacher also said that there were spiders and bugs in the closet that were going to get him before closing the door. I was flabbergasted. The school tried to defend the teacher for doing this, and my final advice was to “pull the kid.” Any school that ignorant of normal child development cannot be fixed.