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June 16, 2020

By Sam Marzouk, Ph.D., L.P.

Pediatric attention-deficit/hyperactivity disorder (ADHD) is one of the most heterogeneous behavioral health diagnoses. In the current iteration of the diagnostic and statistical manual of mental disorders (DSM-5), ADHD is conceptualized by two broad dimensions of inattention and hyperactivity/impulsivity, each comprising an array of symptoms. Given the numerous possible symptom combinations and diagnostic profiles, individualizing the treatment approach of ADHD is a clinically necessary yet challenging task. Emerging signs and symptoms of pediatric ADHD are often first identified in a primary care setting. This makes pediatric primary care providers well-positioned to make important treatment planning decisions. It is therefore helpful for pediatric providers to not only identify core symptomatology but also key associated features of pediatric ADHD that correlate with a higher risk of associated functional impairment and more longitudinally adverse outcomes. 

One such feature that appears to uniquely contribute to heightened functional impairment in children with ADHD is emotional impulsivity (EI). Emotional impulsivity (also referred to as “emotional lability” or “emotional dysregulation” throughout the literature) refers to a diminished ability to modulate an emotional state precipitated by an environmental stressor. Not surprisingly, EI typically leads to subsequent maladaptive behavioral choices (e.g., fights, destruction of property, verbal aggression, etc.). While impulsivity in and of itself is typically understood in behavioral terms, the preceding emotional impulsivity is often overlooked. As a general clinical feature, EI cuts across numerous behavioral health diagnoses and is by no means specific to pediatric ADHD. What is important, however, is the relationship between EI and pediatric ADHD. Epidemiological research suggests that between 24 and 50 percent of children with ADHD also have clinically significant EI. What’s more, research has shown that children with ADHD and co-occurring EI often have greater core symptom severity, a higher risk for comorbid psychopathology, and poorer long-term outcomes. As a more specific empirical example, Russel Barkley (2010), one of the more prolific pediatric ADHD researchers, longitudinally followed a group of children with ADHD into early adulthood. Barkley found that those with comorbid EI at childhood evidenced greater functional impairment in adulthood across multiple domains (e.g., occupational, social, financial, etc.). Taken together, EI may represent the proverbial “tipping point” of pediatric ADHD in terms of functional impairment and adverse long-term outcomes.    

Emotional impulsivity appears to be a particularly important yet overlooked associated feature of ADHD. Given that EI is not identified as a core symptom of ADHD in the DSM-5, providers are more prone to underestimate its importance to the overall clinical picture and may, therefore, fail to assess for its presence. Pediatric providers play an important role in formulating and often coordinating an ADHD treatment plan. The evidence-base surrounding best practices for treating pediatric ADHD suggests that pharmacological and/or psychosocial treatment modalities have the highest efficacy. When EI enters the clinical picture, a more integrated approach inclusive of psychopharmacological interventions, psychotherapeutic interventions, and even occupational therapy may be indicated. 

The Child Friendly Cities Initiative (CFCI) was launched by UNICEF nearly 25 years ago to respond to the challenges of realizing the rights of children at a municipal level. The CFCI framework assists cities to become more child focused in all aspects of governance and services through the implementation of systematic procedures and the meaningful involvement from children. By 2018, more than 3,000 Child Friendly Cities existed around the globe. However, there were none in the United States.

MNAAP Member Charles Oberg, MD, MPH, FAAP, along with Dr. Jeff Goldhagen and Nicholas Spencer, from the International Society of Social Pediatrics and Child Health (ISSOP), met with UNICEF in Geneva in the fall of 2018 to change this situation. Following a workshop in Jacksonville, FL in the spring of 2019, a few selected cities, including Minneapolis, began the effort to make CFCI a reality in the United States.

In collaboration with and under the leadership of the Minneapolis Commissioner of Health, Gretchen Musicant, a strategic planning effort began. On Feb. 14, 2020, the Minneapolis City Council passed and Mayor Jacob Frey signed a Memorandum of Understanding (MOU) with UNICEF to launch the first Child Friendly City Initiative in the United States.

Pictured: Child Rights Advocate Rachel Peterson, UNICEF USA Representative Adriana Alejandro Osorio, Minneapolis Mayor Jacob Frey, Minneapolis Commissioner of Health Gretchen Musicant, and Dr. Charles Oberg at the MOU signing.

What drew you to pediatrics?

I knew early on that I was interested in primary care because I really enjoyed getting to know patients in the clinic as a medical student, but I was torn between wanting to work with children and the elderly. When I look back, I see that I kept choosing projects that focused on children, which I think subconsciously kept bringing me back to pediatrics. Then there was that gut feeling doing peds as my final third-year rotation that cemented my passion for working with and for children.

What is a typical day like for you?

I work exclusively in outpatient primary care pediatrics within a large academic institution, so most days I am doing some combination of seeing patients and teaching. Often that means having a medical student with me in the morning or supervising our resident pediatric clinic in the afternoon. I also serve as director of the resident continuity clinic which has given me the opportunity to create and implement a curriculum over the last several years. It has also taught me that the one constant I can count on in medical education is change!

You are involved with the AAP Council on Communications and Media (COCM) as the chairperson. Can you tell me about your work with the council?

I joined the council a little over a decade ago as the council itself had recently been formed as a combination of two committees, one that examined the effects of media on children and the other which served to prepare pediatricians to work with the media to accurately translate important science about children’s health to the public. I’ve been interested in children’s media exposure and its effects since residency. That interest hit me right in the face during my first year of practice when a four-year-old patient, after seeing a television commercial, told his dad that he was supposed to ask his doctor (me!) about Levitra.

Now, I feel that I have a foot in both worlds as we talk to parents about how to manage media when so many people are on lockdown due to the novel coronavirus, but I also use social media to inform, amplify, and advocate. As part of COCM’s Executive Board, I was the lead author and editor of Pedialink’s first-ever online CME media education module, which was also approved for MOC Part 2 credit. Before I became chair of COCM, I served as both Program and Education chairs, which involved creating programming for the AAP National Conference and Exhibition every year. I also chaired the 2016 Peds 21 pre-conference that focused on media. I’m also thrilled to be part of the 2020 Peds 21 program committee which will focus on racism, bias and health inequities for children of color.

What prompted you to go “back to school” to complete a Master’s in Public Administration through the Commonwealth Fund Fellowship in Minority Health Policy at Harvard University?

Becoming a grad student in my 40’s was not something I had planned on, but my long-standing professional and personal interest in working with immigrant communities coupled with the need to better understand the system outside the clinic prompted me to do a deep dive into policy. The last few years have been a crash course in how important it is to have informed leaders and elected officials who make laws that ultimately affect the kids I see in clinic. I can work hard to advocate on a one-to-one basis multiple times every day, but if the system is flawed, even this important work becomes Sisyphean. We need to do more work upstream to restructure broken systems that too often leave out some of our most vulnerable populations.

What is something your colleagues might be surprised to learn about you?

In sixth grade, I held the class record for upper body strength in the Presidential Physical Fitness Test and now I can barely do one pushup. I had my moment of triumph. It was awesome.

What’s the funniest thing a child has said to you recently?

We’ve been doing more telemedicine lately, which gave me a chance to pick a fun background and I’ve had a number of kids ask if that’s Baby Yoda behind me. It is!

By Heidi Hubbard, MD, FAAP

Many of us remember residency as the best, and most stressful, time on the path to becoming practicing physicians. It marks the period in training when a person is most likely to get derailed because very little margin exists to allow for balancing work and life. Trainees are especially vulnerable, considering their long hours, increasing responsibility, financial stress and limited time for personal health and wellness. A recent review of three years of national data about burnout in pediatric residency published in Pediatrics showed that a majority of residents met burnout criteria. But for anyone who has lived through residency, this information is not new.

In 2007, I established a fund at the University of Minnesota Medical School – where I completed my residency training – to provide an emotional and financial safety net for unforeseen life events as young doctors moved through residency. One of the most critical areas of need is financial stability. The Pediatric Resident Wellness Fund provides hardship grants for immediate support for residents who experience significant and unexpected financial burdens. Residents access the grants to relieve the stress associated with costs of travel for a family emergency or funeral, medical expenses, mental health resources, car repairs, child care and other critical needs. Ensuring residents can focus on their personal life demonstrates our commitment to their overall wellbeing.

Enhancements to the pediatric resident lounge at M Health Fairview University of Minnesota Masonic Children’s Hospital allowed for a dedicated space for residents to connect, socialize and relax with one another. The fund also created social and networking opportunities for residents, promoting community building, camaraderie and volunteerism. In 2017, the program sought to expand its mission by supporting an annual wellness retreat to connect residents with one another, reflect on their experiences and renew their purpose. Throughout the year, residents have opportunities to engage in wellness activities including meditation and yoga classes, participate in a wellness leadership series, enjoy healthy meals, and take part in other programs dedicated to promoting residents’ wellbeing during a demanding time.

Creating meaningful opportunities for residents to promote compassion and resilience has brought me great joy. I encourage you to consider ways you can support the next generation of pediatricians, whether through mentorship or programs like the Pediatric Resident Wellness Fund at the University of Minnesota. If you are interested in learning more, contact Jonna Schnettler, director of development with the University of Minnesota Foundation, at

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