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Home – Child Mental Health Blog

Vermont Center for Children, Youth and Families

Posted: November 12th, 2014 by David Rettew

Welcome to a new format to assist Vermont primary care clinicians and the general community to access new and quality information to help improve child mental health assessment and treatment.  We know the problem all too well:  emotional and behavioral problems are extremely common, affecting at least 1 in 5 children.  Vermont like every other state has a critical shortage of child psychiatrists, and primary care clinicians are often needed to deliver this important care.   Unfortunately, most pediatricians and family medicine physicians have had little formal training in mental health, and consequently are uncomfortable addressing emotional behavioral problems in their patients.

David Rettew, MD

This blog developed by the Vermont Center for Children, Youth and Families and supported by the Vermont Child Improvement Program (VCHIP) is designed to offer practical and easily assessable information related to child psychiatry.  The regularly updated information will offer the following.

  • Regular postings from VCCYF staff about the assessment and treatment of common child emotional behavioral challenges
  • Links to important local and national resources
  • An ability to send clinical questions to VCCYF faculty that will be responded to in a timely manner

The central model that will be used is the Vermont Family Based Approach – a strategy developed by Dr Jim Hudziak that expands the focus of assessment and treatment beyond the individual symptoms of the child and towards the entire family environment.

Waitlist

Musical Training Linked to Enhanced Brain Maturation

Posted: December 2nd, 2014 by David Rettew

Patients who come to see child psychiatrists like Dr. Jim Hudziak at the Vermont Center for Children, Youth, and Families may leave with a prescription, but it often is not for a medication.  As part of a model he developed called The Vermont Family Based Approach (VFBA), there is increased emphasis on incorporating wellness and health promotion strategies into the overall treatment plan.  As Hudziak explains in a podcast related to the study, “One of my life goals is to see if there is a chance to move medicine away from its preoccupation with negative events and negative outcomes to argue that the opposite is also true, and that when positive things happen, positive outcomes will follow.”  Thus, the Violingoal of this model for children and families is to help them take steps not only to overcome whatever symptoms they have but to propel them towards true mental health and wellness.  To get there requires attention to domains such as nutrition, parental mental health, sleep, mindfulness, and physical activity, often given short shrift in traditional approaches.   Music and the arts are also highly encouraged within the VFBA.  According to the Department of Education, approximately 75% of American high school students rarely or never participate in music or art training outside of the school.

While participation in music and the arts is widely viewed as positive for child development, how it affects the brain remains only partially understood.  To investigate this question further and to bolster the scientific evidence behind the push for more involvement in music, Dr. Hudziak and his postdoctural associate Matt Albaugh, along with a team comprised of scientists from the University of Vermont, Montreal Neurological Institute, Harvard, and Washington University, examined brain scan data from the National Institutes of Health MRI Study of Normal Brain Behavior.   Their study was published as the lead article in the November edition of the Journal of the American Academy of Child & Adolescent Psychiatry.

The subjects for the study were 232 typically developing children without psychiatric illness between the ages of 6 and 18, all of whom received structural MRI scans at up to three different time points.   With these serial MRI scans the examiners were able to see how the thickness of the brain cortex changed with age.  Prior studies have indicated that the cortex generally thins across adolescence as the brain undergoes a normal “pruning” process that may be related to more efficient brain functioning.  A delay in this cortical thinning process, particularly in regions such as the prefrontal and orbitofrontal cortex, which are thought to be important for “executive control” functions such as inhibiting impulses and regulating attention, has recently been shown among those with clinical attention problems and ADHD.

The amount of musical training a child had was also measured to see if this variable interacted with age in its association to cortical thickness.  The average time playing an instrument was about two years.

Dr. Jim Hudziak

Dr. Jim Hudziak

The main result of the study was that years of musical training were indeed related to age-related cortical thinning. Specifically, more musical training was associated with accelerated thinning, not only in the expected motor cortices but also in some of the very same regions implicated in those with more pronounced attention problems. “What was surprising was to see regions that play key roles in emotional regulation also modified by the amount of musical training one did.”

The authors concluded that musical training was associated with more rapid cortical maturation across many brain areas, and they hypothesized that musical training may have beneficial effects on brain development for children whether or not they suffered from attention or executive function difficulties.

Certainly, much more research is needed to support the notion of musical training as an effective treatment for diagnoses such as ADHD, but this study raises some thought-provoking possibilities.   In the article, Hudziak and colleagues  highlight Venezuela’s El Sistema program that has brought musical training and performance to millions of disadvantaged children both abroad and here in the U.S.. Studies have shown important improvements in drop-out rates, employment, and community involvement among participants of the program.  Such efforts are critical as many families are unable to access music lessons due to their cost.   Dr. Hudziak, who has done research on the genetic influence of various traits and abilities, notes that our culture seems to have it backwards in promoting certain activities only for children who seem born to excel at them.  He questions why “only the great athletes compete, only the great musicians play, and only the great singers sing,” especially as children age.  He and his team have worked to improve local access to musical training through research studies and mentorship programs. The need is still high, however, and is now underscored by the increasing data linking wellness activities to measurable changes in brain development.

Reference

Hudziak JJ, Albaugh MD, et al.  Cortical thickness maturation and duration of music training: Health-promoting activities shape brain development.  JAACAP. 2014;11:1153-1161.

ADHD as a Brain Maturation Delay

Posted: November 19th, 2014 by David Rettew

Despite a wealth of evidence, the diagnosis of ADHD remains controversial, particularly outside of the medical community.  Some research has suggested that ADHD might be better conceptualized as a delay in brain maturation rather than a “disease state” per se.   However, more research is needed to support this hypothesis.

The brain imaging literature has increasingly moved away from studies that look at the size or activity of a particular region in isolation and towards the examination of  regional networks of several areas that are intrinsically connected to

ADHD related maturational lags.   Red and blue indicate areas of stronger connectivity lag

ADHD related maturational lags. Red and blue indicate areas of stronger connectivity lag

each other when the brain is doing tasks or at rest.  Perhaps the most studied of these networks relates to brain activity when it is not engaged in a particular task.  This has been known best as the default mode network or DMN.  The present study published in PNAS examines the development of these networks over time between individuals with and without a diagnosis of ADHD.

The study utilized functional MRI scans from a group of 135 individuals with a diagnosis of ADHD and compared them to 188 typically developing controls from ages 7 to 21. To investigate their hypotheses, the authors employed complex analyses called whole-brain connectomic methods which reportedly represent an advance from older techniques that used a small number of “seeds.”  These techniques allowed the authors to examine more than 400,000 different brain connections.

With these analyses, the authors did find maturation lags in those with ADHD, particularly within the DMN and  between the DMN and two other task positive networks (networks involved in specific cognitive functions), namely the frontoparietal and ventral attention network (VAN). The VAN is involved in salience processing, i.e. detecting the relevant stimuli the external environment while the frontoparietal network is involved in adaptive cognitive control.  The implications of both of these networks seem to make sense clinically when considering those with struggle with ADHD. 

The authors concluded that their data lend additional support that ADHD is related to important lags in brain maturation in areas that underlie the regulatory control of attention and behavior.

This is an important study published in a highly respected journal.  It is also quite methodologically complex and difficult to evaluate on a technical level for those who are not neuroimaging experts.  Nevertheless, the study provides ever more increasing and specific evidence that the challenges related to ADHD reflect “real” alterations in brain function and structure.

Indeed, the hypothesis of ADHD as brain maturation delay could offer a compromise between those inclined to dismiss the very existence of ADHD and those who view it from a more traditional disease model.  Before jumping on this train, however, I personally would like to see more evidence regarding whether the brain function of those diagnosed with ADHD eventually catches up or whether these differences persist late in life.  As far as I can tell, this study does not address this important point.

Reference

Sripada CS, et al., Lag in maturation of the brain’s intrinsic functional architecture in attention-deficit/hyperactivity disorder.  PNAS 111(39):14259-64, 2014.

Prevention Study Shows Promise in Reducing Psychopathology and Crime

Posted: November 12th, 2014 by David Rettew

One of the “Holy Grails” of psychiatry is the ability not only to treat existing behavioral problems effectively but to prevent them.  This task has proven challenging but remains the focus of many given the extraordinary human and financial costs associated with chronic psychopathology and criminal behavior.  Some people have become somewhat pessimistic about this goal, especially among at-risk children who at young ages already show signs of early conduct problems and rule-breaking behavior.

One project that has tried to intervene is called the Fast Track prevention program.  It began in 1991 as a multi-site effort to test whether comprehensive early intervention could prevent later psychopathology and criminal behavior in a

Rates of Clinical Problems at Age 25 for Intervention and Control Participants

Rates of Clinical Problems at Age 25 for Intervention and Control Participants

group identified as at-risk. A total of 979 kindergarteners from 4 geographic areas were identified as showing early conduct problems, based on several rating scales. They were then randomized into a control group and an intervention group designed to increase social competence through skills training, parent behavior management training, peer coaching, and academic support over a period of 10 years. When the subjects were 25 year old, they were reassessed for their arrest records as well as for psychopathology, using standardized rating scales.

As young adults, the rate of a psychiatric or substance abuse diagnosis was 69% in the control group compared to 59% in the intervention group which was a significant difference. This result held for different demographic and severity groups. Significant group differences were also found related to crime, risky sexual behavior, and self-esteem.  One key metric was related to arrest and conviction.  The incarceration rate was 6.3% for the control group versus 5.0% for the intervention group.  While this difference was not statistically significant, there was a significant drop of severity-weighted violent and substance-related crime conviction of 31% and 35%, respectively. Significant effects were not found related to graduation rates or employment.  Disappointingly, there was also little effect on how these subjects parented their own offspring.

The study authors concluded that their intervention did result in a significant reduction in psychopathology and criminal behavior.  They advocate strongly that prevention efforts can succeed and should be encouraged.

Of note, this program was reported to cost approximately $58,000 per student and future cost analyses are planned.  In the discussion, they compare that amount to the estimate that the cost of chronic criminality is  5.3 million dollars per person.  The authors point out that one limitation of the study was that they were unable to determine which type of intervention was most protective among the many different types that were tried.

In looking at these data, I have to say that I was both inspired to see a program show clear results but also humbled by what I think many people will find as rather modest results from a fairly intensive and long intervention.   It takes an awful  lot of work to drop the rate of psychopathology from about 70% to 60% or to reduce the rate of certain types of crime by 30%.  This effort seems well worth doing in my view, despite an appreciation for how powerful the forces can be that conspire to keep at-risk children down.

Reference

Conduct Problems Prevention Research Group.  Impact of Early Intervention on Psychopathology, Crime, and Well-Being at Age 25.  Am J Psychiatry, 2014, epub ahead of print.

Omega-3s Founds to Improve Child Aggression

Posted: November 3rd, 2014 by David Rettew

 The benefits of Omega-3 supplementation has been touted for a wide range of therapeutic and health promotion uses.  While there is emerging data for problems such as ADHD, the literature has still suffered from issues such as small sample sizes, lack of randomization, short duration, and lingering questions about optimal dose.  This recent study sought to address some of these limitations using a randomized double-blind placebo controlled design and studying children for a total of 12 months, which included 6 months of study after the supplementation ended.  Another innovation for this study was the additional measurement of parent behavioral problems, under the notion that these could Omega-3mediate improvement in child behavior.

The nonclinical sample included 200 children from the ages of 8 and 16 from the island nation of Mauritius.  For those of you without a PhD in geography, this is a small island in the Indian Ocean off of Madagascar (yes I had to look it up too).  Half of the sample was radomized to receive 1 gram of Omega-3s (300 mg of DHA, 200 mg of EPA, 400 mg of alpha-linolenic acid, and 100 mg of DPA) delivered in a fruit drink while another 100 received a fruit drink without the Omega-3s. Behavior problems were measured by parent- and child-report at baseline, at the end of the six month study, and at 12 months, using our favorite instruments the Child Behavior Checklist (CBCL) and Youth Self-Report, supplemented with other measures of aggression.  As mentioned, an interesting aspect of this study was that rating scales were also given to parents to examine their own levels of psychiatric symptoms both at baseline and at follow-up.

The main finding was a significant effect for omega-3 supplementation across a wide range of parent-reported child behavior.  Improvements were found not only in the predicted areas of aggression and externalizing problems but also for internalizing problems such as anxiety and depressed mood.  The changes for child self-report behavior were less dramatic but present for things like both reaactive and proactive aggression.  Indeed, even the troubling and hard to treat callous-unemotional traits showed improvement by parent-report.  For many measures, significant differences were mainly apparent at the 12-month interval, six months after the trial ended, thus emphasizing the need to stay with treatment over a long period of time.  Overall, externalizing behavior decreased 41.6% six months after the trial ended compared to a drop of around 11% for placebo. The overall effect size was found to be moderate (d=-.59).

Also extremely interesting and providing further evidence for a family-based approach to child mental health is the finding that parents also showed reductions in measures of their own psychiatric symptoms (even though they weren’t taking the supplements).  Furthermore, improvement in parental symptoms was found to substantially mediate the improvement found in the child’s behavior.  An impressive 60.9% of the improvement in child antisocial behavior, for example, could be attributed to reductions in the parents’ reduction in psychopathology.

The authors concluded that their data provide support for the utility of using omega-3s to reduce both internalizing and externalizing behavior and suggest that one mechanism through which children get better is that their parents improve with regard to their own psychopathology. 

In my mind, this is an important study in many ways and I’m surprised it wasn’t covered more widely.  This may have been because it was published in a certainly reputable but not very prominent journal.  What is remarkable about this study is not only the fairly robust improvement noted with Omega-3 supplementation but also the demonstration of how important it can be to improve parental symptoms in the pathway of improving child behavior.

At the same time, some limitations are worth noting.  The sample was non-clinical and the authors did not examine whether or not more symptomatic children responded to the Omega-3s the same way that less symptomatic children did. Also, there obviously will be some questions about how generalizable this sample is coming from a fairly remote island.   Finally, it needs to be said that the commercial company that provided the Omega-3 drinks, a Norwegian company called Smartfish, supported this study financially, and it is important that we give that fact the same skeptical eye that we would apply if we were talking about a prescription medication study supported by a pharmaceutical company.

Nevertheless, these results are important and add to the growing body of research suggesting that Omega-3s should be on our radar screen as clinicians.  The specific dose is also helpful as a guide.

Reference

Raine A, et al. Reduction in behavior problems with omega-3 supplementation in children aged 8–16 years: a randomized, double-blind, placebo-controlled, stratified, parallel-group trial.  J Child Psychol Psychiatry. 2014, epub ahead of print.

Type 2 Diabetes Risk with Antipsychotic Medication Treatment Reported at 0.72%

Posted: October 15th, 2014 by David Rettew

While the  metabolic risks associated with antipsychotic medications use are now well known, finding some actual numbers about the risk have been slow to come.  A recent study by Nielsen and colleagues published in the Journal of the American Academy of Child and Adolescent Psychiatry offers some specific numbers that can be used when discussing the potential risk of developing Type 2 Diabetes in the course of treatment with antipsychotic medication.JAACAP logo

To arrive at these numbers, a case-control design was used that obtained information from a large Danish registry of psychiatric patients under 18 years of age seen from 1999 to 2010.  The indicator of having Type 2 Diabetes was the prescribing on an oral antidiabetic medication comparing between those who were and were not also prescribed an antipsychotic medication.  Antipsychotic use was counted as positive if one or more prescriptions were filled. Regression analyses were used, controlling for age, sex, and diagnosis in order to assess for the possibility that the diagnosis, rather than the treatment, might be behind any increase in diabetes. The records of nearly 50,000 psychiatrically ill youth were examined.

Overall, the rate of Type 2 Diabetes among youth treated with antipsychotics was 0.72% compared to a rate of 0.27% in psychiatrically ill youth not given antipsychotic medication. This difference, when controlling for potential confounds, resulted in a significantly elevated odds ratio of 1.60.  Being female and being older at the time of diagnosis was also related to diabetes. When metformin was excluded as an indicator of diabetes (because of the possibility that it was being used in many cases to treat wait gain and protect against the development of diabetes), the odds ratio related to antipsychotic use went up to 3.71; however, this odds ratio was no longer significant due to such a small number of cases.  (The authors state in the discussion that metformin is rarely used in Denmark for weight control).  Overall, the number needed to harm was calculated at 224.

The authors concluded that antipsychotic medication use does increase the risk of developing Type 2 Diabetes.  In the Discussion section, they recommend close adherence to indication and metabolic monitoring guidelines.

It is nice to have some specific numbers to talk about when having discussion of potential side effects that don’t rely on small and short-term clinical trials.  At the same time, however, these kinds of large registry databases can struggle with measuring other factors that may be important, such as compliance with treatment and overall duration. If milder diabetes was diagnosed but controlled through nonpharmacological means, for example, this study would have misclassified these children.

It will also be interesting to see how this Diabetes risk will be interpreted.  An 60% increase sounds like a lot, yet the overall rate was 0.72% which is likely lower than many people were expecting.  Several of the authors have rather extensive ties to various pharmaceutical companies, which will likely cause some people to discount the results.  As far as I can see, the study has not received much press at all, perhaps because the results were not that dramatic in either direction.

Reference

Nielsen RE, et al.  Risk of Diabetes in Children and Adolescents Exposed to Antipsychotics: A Nationwide 12-Year Case-Control Study. JAACAP. 53(9):971–979, 2014.

 

The Link Between Adolescent Psychiatric Disorders and Crime

Posted: October 9th, 2014 by David Rettew

Are people with mental illness more likely to commit crimes?  This question has been studied and discussed for decades, fueled by movies of deranged serial killers.  For years, the conventional wisdom was that, despite the hype, individuals who suffer from psychiatric disorders are no more likely than anyone else to commit a crime. More recently, however, there’s been a shift in that stance as increasing evidence points to the conclusion that, while the vast majority of those with mental illness do not break the law, the presence of psychiatric disorders is linked with higher rates of crime.  Less is known, however, about children and adolescents, and a new report on adolescents provides Crimesome useful data for clinicians to know and pass along.

The study comes from National Comorbidity Survey – Adolescent Supplement which is one of our most important sources for epidemiological data on the community rates of adolescent psychopathology.  This survey covers a nationally representative sample of 10,123 adolescents between the ages of 13 and 17.  For this article, the key variables were the presence of a DSM-IV disorder as assessed using structured interviews with the adolescents directly as well as self-reported crime and arrest history. The average age was 15.

In terms of overall results, a total of 47% of the sample met criteria for at least one lifetime psychiatric disorder while 18.4% reported having committed some type of crime. Youth with psychiatric disorders were more likely to commit a crime, including violent crime, than those without psychiatric disorders. For crime resulting in an arrest, the largest elevations were, not surprisingly, related to conduct disorder (with an odds ratio of 57.5), as well as alcohol and drug disorders, but most other diagnoses were significant as well, including things such as anxiety disorders.  In terms of percentages, the rate of violent crime resulting in arrest, for example, was 20.4% for those with a diagnosis of conduct disorder versus 0.4% among those with no diagnosis.  The presence of multiple psychiatric disorders further increased the risk of crime. Excluding patients with conduct disorder weakened the link between psychopathology and arrested crime but less so for crime not associated with arrest. At the same time, over 88% of youth with at least one psychiatric disorder had no history of crime.

The authors concluded that the presence of mental illness raises the risk of crime. The authors advocate that these data should strengthen the case of good access to mental health care.  Stay tuned for a summary about a study that documents a decrease in crime among at-risk children who received a comprehensive mental health program.

The major take away point from this study is both that 1) crime rates are elevated among adolescents with psychiatric disorders, and 2) the vast majority of those who meet criteria for a disorder do not report being involved in crime.  Additionally, however, some side findings in this study were also interesting, like what’s up with the diagnosis of  intermittent explosive disorder (at 14.1%) being the second most common psychiatric disorder, while ADHD is a meager 4%.  One also wonders the degree to which the self-report nature of the criminal behavior affected the results and  the fact that many subjects were not yet through adolescence (both of which might have resulted in under-reporting).

Reference

Coker KL.  Crime and Psychiatric Disorders Among Youth in the US Population: An Analysis of the National Comorbidity Survey–Adolescent Supplement.  JAACAP 2014; 53:888-898.

 

Harvard Reserach Study on Early Psychosis Looking for Participants

Posted: October 7th, 2014 by David Rettew

Harvard

by Sarah Hope Lincoln

Schizophrenia is a disorder that causes significant impairments in independent functioning. While many may associate the disorder with its ‘positive’ symptoms like delusions and hallucinations, there are many ‘negative’ symptoms as well – social and emotional deficits, as well as a loss of pleasure and motivation. The expression and persistence of these negative symptoms may be stronger predictors of poor functioning and independence as the illness takes its course. Because of this, some researchers are beginning to focus on understanding and developing interventions for these negative impairments before individuals experience a first episode of psychosis.

Several studies (Jones et al., 1994; Neindam, 2003) have shown that individuals who develop schizophrenia show nonspecific precursors to the illness, such as social problems, misreading social cues, and difficulty with relationships. Some of these children can be considered to be at risk for schizophrenia and related disorders, although many will not develop the illness.

By understanding what is going on in the social brain of children who are at clinical high risk, researchers hope to eventually develop targeted skills training that may improve a person’s long-term functioning and possibly prevent the disorder altogether.

One of these research groups is the Social Neuroscience and Psychopathology lab at Harvard University. They investigate the neural underpinnings of social functioning and deficits in different populations, and are currently exploring how the brain processes social situations, and how this relates to children’s relationships and their experiences of the world around them. They are currently seeking participants 8-13 years old who may have had any of the following experiences:

-          Feeling worried that people may be reading his or her mind

-          Worrying about being watched or feeling mistrustful of people

-          Hearing or seeing things that others do not hear

-          Isolating from peers, friends or family

-          Performing worse in school

-          Reporting unusual ideas that are hard to follow or understand.

*As these symptoms may be confusing for the child or parent, helpful referrals can be provided as needed.

This is a two-part study that involves a behavioral session that includes questionnaires and interviews with a researcher, as well as a one-hour long brain scan during which your child will be asked to do simple tasks. Throughout the study, the Social Neuroscience and Psychopathology lab makes every effort to ensure the child is safe and comfortable participating in the research. For many children, the experience can be both fun and interesting. All travel costs to and from Boston will be covered, and the child and family will be compensated for each part of the study, possibly up to $110 gift cards for the child and $110 for the family.

To learn more about participating, contact Sarah Hope Lincoln at 559-904-4431 or email childsocialstudy@gmail.com

Vermont Pediatrician, Dr. Joseph Hagan, Running for AAP President-Elect

Posted: September 29th, 2014 by David Rettew

(Note: parts of this posting have previously appeared in online posts for Psychology Today and for Pediatric News)

One of our own Vermont pediatricians, Dr. Joseph Hagan, is running to be President-elect of the national organization, the American Academy of Pediatrics (AAP). Many people around the state and elsewhere know Joe well and support his candidacy. Dr. Hagan has been involved in shaping pediatric mental health care policy for years as the former chair of the AAP’s  Committee on the Psychosocial Aspects of Child and Family Health and Hagan photo rotatedco-editor of the Bright Futures Guidelines.

To provide some more information about Dr. Hagan and elicit his thoughts especially related to child mental health, I sat down with him recently for an informal interview. The following are some excerpts from that meeting.

Q: How did you become interested in running for AAP President?

A: People have asked me and I’ve always said ‘no’ but in the past few years it’s occurred to me that it’s a job that I can do. I’m ready for it and have the skill set necessary, and I felt that I could contribute something. I’ve been asked to do a number of things with the Academy over the years and I’m really proud of the fact that my academy experience over the past ten years has put me in a room with a lot of smart people and let me chair the meetings. We’ll give you product.

 

Q: Where do you see child mental health on your list of priorities with all the other things you would have to do?

A: I think it has been front and center for the Academy for a long time. I don’t see that changing. I’m going to use every opportunity I get to continue to work at it. It’s sort of who I am as a practitioner. It’s fascinating how capitated managed care decapitated mental health. I don’t know why we decided that the head is any different. We don’t think the kidney is different.

 

Q: What do you see as some of the key issues affecting child mental health care?

A: One of the things I haven’t heard a lot about is that there are not enough therapists to see kids. The system has traditionally been based upon procedures and not on time and that’s a problem. Therapists get paid less than the shop rate of your local auto mechanic, and of course, anyone who sees kids has to talk to schools and parents outside of the session. That’s non-billable, and we wonder why nobody will see kids. Mental health is part of health and the earlier we invest, the bigger the return. Since our practice was certified as a Family Centered Medical Home and now has access to a Community Health Team, my life has changed because we now have services that we didn’t have before. The problem with screening in the past has been “What if you find something?” Now we have so much more to offer.

 

Q: How much should a pediatrician really be expected to know and do when it comes to child behavioral problems? Is there a floor of knowledge and skills when it comes to mental health that all pediatricians should attain?

A: I think there definitely is. Behavioral and mental health problems can be managed in our offices and everyone ought to be able to manage the majority of kids with not only with ADHD, but also with oppositional defiant disorder, anxiety and depression. I mean, there are certain mental health problems that are part of pediatrics. To refer a standard ADHD child is absurd because it really is a day to day problem that needs to be managed in your primary care medical home. Everybody needs to know how to do that and do it well. It is a chronic illness and you need to hang in there with these kids.

 

Q: Psychiatric medications certainly have become even more controversial lately. What advice do you have for pediatricians when they prescribe them?

A: Tell families the expected effects and potential side effects. If you don’t, Dr. Google will. Start low and go slow, but titrate until desired effect of recovery. Remember if you are 100% anxious and miserable, you’ll look and feel great when your only 50% anxious, but you’re still only halfway better! It’s also important to discuss with your patient when you start meds how long you are going to continue them, lest they feel good and stop prematurely.

 

Q: There are a lot of efforts these days to extend the education of pediatricians and provide consulting back up while the patient remains directly in the care of pediatrician. Do you think those efforts are enough or should we be more focused on providing more psychiatrists and other mental health clinicians that pediatricians can refer to?

A: We need to be able to do this (mental health) work but part of being successful is having someone to consult with and someone to refer to. Just like with cardiac or GI problems, there are cases we can take care of all by ourselves, cases where we will need to reach out to a consultant for help, and cases that need referral. Yes we need more child psychiatrists. Co-located and collaborative care are best-case scenarios.

 

More information about mental health care from the American Academy of Pediatrics can be found here.  More information about Dr. Hagan can be found here .

Voting for members of the AAP will take place from October 10 through November 10. If you are not a member, you can’t vote, but you still can help spread the word to pediatricians who can. Turnout for elections like these can often be rather low so motivating a few people to vote can make a big difference.  Good luck Joe!

New Study Examines a “Suicide Gene”

Posted: September 10th, 2014 by David Rettew

To keep in mind National Suicide Prevention Suicide Week as well as to offer some hopeful news, this week’s post summarizes a recent study from the American Journal of Psychiatry that claims to have found a gene that is related to suicidal behavior.  It is somewhat of a complicated study with multiple samples (it’s hard to publish single gene studies anymore without an independent replication sample) and Suicide prevention logoassociations related both to the actual gene and its DNA code as well as epigenetic differences in the amount of methylation the gene has undergone: all of which in turn affects how much of the gene product is expressed.  The gene under scrutiny is involved in the regulation of the hypothalamic-pituitary-adrenal (HPA) axis function: a key factor in a body’s response to stress. Previous research in both animals and humans has suggested that genes involved in this process might be an important place to look.

This study used prefrontal cortex tissue from several brain banks that included many individuals with depression, some of whom died by suicide. Possible candidate genes that emerged were then validated in tissue from other individuals as well as gene expression analyses from three groups of living patients (coming from blood not brain, obviously), where levels of anxiety and stress were assessed as well as concentrations of salivary cortisol.

The signal for suicide and suicidal behavior was found to be related to the SKA2 gene on chromosome 17. As mentioned, a significant association was found both related to DNA, specifically a single nucleotide polymorphism (SNP) at location rs7208505, and more strongly to epigenetic changes of that gene.  Here, increased methylation was related to higher rates of suicide as well as higher rates of suicidal behavior. The accuracy of predicting suicidal behavior from these genetic and epigenetic variations in the living group was quite high at 80%, particularly the progression from suicidal ideation into attempt.  However, this number comes from complicated statistical models and does not lend itself to an easy yes/no prediction of suicidal behavior based on the result of simple blood test.

The authors concluded that the SKA2 gene and its level of epigenetic changes may be an important biomarker for suicidal behavior. In saying this, however, it is important to remember that the term “suicide gene,” just like an “ADHD gene” or a “depression gene” is really a misnomer, as genes don’t code for diseases per se but rather for products involved in some kind of brain activity.  In this case, the SKA2 gene is thought to help “chaperone” a glucocorticoid receptor (which may play an important step in regulating down the stress response) to the nucleus and can thus play a role in HPA axis function.  While certainly an important and thought provoking study, the authors cautioned that their sample size was small and results should be considered preliminary.  Lest people also start thinking that certain people are destined to be depressed and suicidal, it is also important to note that epigenetic changes to genes such as the ones found to be important in this study can be strongly related to the quality of one’s environment.

Reference

Guintivano J, et al.  Identification and Replication of a Combined Epigenetic and Genetic Biomarker Predicting Suicide and Suicidal Behaviors.  Am J Psychiatry 2014, epub ahead of print.

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