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Home – Child Mental Health Blog

Vermont Center for Children, Youth and Families

Posted: January 12th, 2017 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.




Long Term Stimulant Treatment Associated with 1 inch Reduction in Height

Posted: April 5th, 2017 by David Rettew

When considering stimulant treatment for ADHD, one concern that is often voiced by parents is about height loss associated with long-term use.  Answering this question has been difficult, in part because the available literature has been inconsistent.  Some long term studies have shown no differences while other show reductions in over an inch. To help provide some more definitive data, a study was recently published that reports on the long term follow-up into adulthood of subjects who took part in the well-known Multimodal Treatment Study of Children with ADHD or MTA.   As a reminder, this government funded trials was one of the most comprehensive treatment studies ever done.  Back in 1994, over 500 children with ADHD were randomized to receive short term treatment with stimulants, behavioral therapy, combined treatment or treatment as usual in the community.  After 14 months, however, patients and families were free to choose the best treatment for them and the study was naturalistic in design from that point forward.

During the follow-up period, investigators performed multiple assessments at regular intervals until subjects were on average about 25 years of age.  Based on their recorded patterns of medication use, subjects were divided up into groups of those who consistently took medications into adulthood, those who inconsistently took medications, and those who took negligible amount of medications.  A community sample was also recruited for comparison.

In terms of results, one somewhat surprising finding was that only a minority of subjects (14.3%) took medications regularly across the study period.  While there was evidence that symptoms of ADHD persisted into adulthood compared to the comparison group, no significant differences in severity were found among ADHD patients between the three groups with regard to overall medication usage (consistent, inconsistent, and negligible).  Differences were found, however, with regard to height.  Specifically, the consistent and inconsistent groups were approximately 2.55 cm or about 1 inch shorter than the negligible group.

The authors concluded that symptom benefits of medication may dissipate over time but that the impact on growth may persist into adulthood.

While some would love to interpret the lack of significant differences in ADHD symptoms between the three medications groups as evidence that stimulants don’t work over the long term, it is crucial to point out, perhaps over and over again, that the naturalistic design of the follow-up period drastically impairs the ability to make that conclusion.  Yes if stimulants were a miracle cure for everyone then we would see differences, but in the real world case of a condition that varies in severity and treatment responsivity, what tends to happen of course is that more refractory cases continue taking medications while less severe cases often stop their medication successfully.

Then there is what to make of the fairly robust height differences which are larger than what most other studies have reported.  Do we just add it to the heap of studies showing different things and tell patients that we still don’t know the definitive answer, or do we give this study a little more weight?  In my view, it’s the latter.  The MTA study is arguably the most rigorous study ever done on ADHD treatment and, while no study is perfect, needs to be considered carefully.  The 1 inch differences will now be part of my standard spiel in doing informed consent with stimulant medications.


Swason JM, et al.  Young adult outcomes in the follow-up of the multimodal treatment study of attention-deficit/
hyperactivity disorder: symptom persistence, source discrepancy, and height suppression.  J Child Psychiatry Psychology 2017; epub ahead of print.

Vermont Legislature Busy with Mental Health Bills

Posted: February 24th, 2017 by David Rettew

Vermont’s 2017 legislation session is in full swing and this year there seems to be an unusually large number of bills that have direct impact on mental health.  What follows is a short list and update of the legislation as well as a few personal thoughts.

Improvements to the state mental health system (S90).  The current crisis that has many Vermonters with emotional/behavioral struggles stuck for long periods of time in emergency departments and hospitals has not gone unnoticed.  While there continues to be discussion about short-term interventions, people are also looking at the big picture.  S90 requires the Deputy Secretary of Human Services to coordinate a prevention and treatment program for victims of child trauma and adverse events.  It includes a statewide home visiting program and implementation of evidence based parenting and wellness programs.  Our Vermont Family Based approach is listed by name.  As you might expect, those of us in child psychiatry are strongly in support of this legislation.

Psychologist Prescribing Privileges (H280).  This bill would allow psychologists the ability to prescribe psychiatric medications after some additional training.  While on the surface this might appear to be a way to improve access to mental health care, there are concerns about the level of training needed to prescribe medications safely and specifically the need not only for pharmacological knowledge but true medical training as well.  This bill is now at the House Committee on Health Care.

Kuligoski clarification and possible reversal (S3).  As many people know, a VT Supreme Court decision known as the Kuligoski ruling drastically increased the circumstances for which confidential patient information would need to be breached for people who might even be at chronic risk for harming others (the previous standard was for imminent risk to identifiable people).  This judgment has left mental health professionals confused about what their responsibilities now are.  Some officials from the state believe that the ruling is partially responsible for the increased back-up of patients in emergency departments and hospitals.  This bill aims to bring the “duty to warn” closer to the original standard. While this bill is quite welcome by many patients and mental health professionals alike, some new language in the bill about the need to disclose “all necessary information” to caretakers at discharge has led some people to wonder how much of an improvement the bill actually would be in its present form. This bill is out of the Senate Judiciary Committee and going to the floor.

Medical and recreational marijuana (H170, H207, S16).  Despite recreational cannabis being voted down last year, it is back again just a year later in many different forms.  While the main legalization bill no longer opens up a broad commercial market, it does allow Vermonters to grow quite a bit of their own marijuana legally.  Many health professionals continue to voice concerns about the public health effects of legal cannabis, particularly when our state’s substance abuse resources are so limited. This bill is currently in the House Judiciary Committee and sponsors are trying to fast track it so that it is not reviewed by any health care committee.  A separate bill regarding marijuana expands the allowable indications, including PTSD.  Not only is there a lack of research evidence that cannabis helps PTSD but there are studies demonstrating that over the long-term cannabis worsens things like aggression, anxiety, and other types of substance use. S16 is now at the House Committee on Human Services. H207 would also allow psychologists to sign the medical verification form.

This list doesn’t even include other legislation regarding nutritional requirements for children’s meals (S70) or raising the tobacco smoking age to 21 (S88), and many other healthcare related bills.

These potential actions could have major impacts on the health of Vermonters and our elective officials are eager to learn from the medical community and hear our views.  Especially in a small state like Vermont, voicing your views to your legislators and letting the relevant committees know your science-based opinions can make a big difference so please speak up.  You can find more information about the specific bills here.

Autism Severity Criteria Has Dropped

Posted: February 3rd, 2017 by David Rettew

The increased prevalence of autism over the last several decades has been widely reported with rates now peaking at around 1 in 68 children, according to the CDC.  This rise has triggered alarm in many circles as well as mass speculation over its potential causes, including the widely discredited hypothesis regarding vaccines.  Tempering this concern, however, is the commonly held view that what appears to be a new epidemic probably isn’t, and that the increase in number of cases is mainly due to three main factors, namely 1) increased awareness and screening of autism, 2) a shifting from other developmental diagnosis to autism over the years, and 3) a reduction in the severity threshold for what qualifies for an autism diagnosis.  Regarding #3, this means that the diagnosis used to be mainly reserved for children who manifested very apparent and severe symptoms but more recently has been increasingly invoked for individuals with much milder, although still impairing, challenges.  Yet despite the broad consensus about this hypothesis, direct evidence to support it has been lacking….until now.

Researchers recently published data from an Australian registry that contained information on new autism cases between the years 200 and 2006: a time during which the rate of autism rose sharply.  The official diagnoses in these cases came from a standardized procedure and included an experienced clinician’s rating of the severity of individual symptoms as mild/moderate or extreme.  For a portion of the sample, the Vineland Adaptive Behavior Scale was also performed.

A total of 1252 cases were analyzed, all under 18 years of age.  The main finding was that the number of individuals who were rated as having extreme levels of many diagnostic criteria, or who had extreme levels of any symptom, dropped significantly over the study period.  The percentage of individuals who had an extreme rating on any symptom, for example, dropped from 38% to 15% over the study period.  Scores on the Vineland scale also dropped with time.

The authors wrote that theirs was the first study to demonstrate directly that the severity level of symptoms among people newly diagnosed with autism has been decreasing.  They suspect that this phenomenon underlies what appears to be an increasing prevalence of the diagnosis.

In some ways, this is a study that proves something everyone already knew.  Nevertheless, it is important to have some solid data behind a claim that is hopefully reassuring to most people.  At the same time, the data underscore some new questions.  Is it good thing to use this diagnosis for less severely impacted children?  Does it open the door for needed services or cause unnecessary stigma while taking away resources from those who may need it most?  The study also cannot rule out the possibility that a “true” increase is autism is also occurring, albeit at less striking rates.


Whitehouse AJO, et al. Evidence of a Reduction over Time in the Behavioral Severity of Autistic Disorder Diagnoses.  Autism Research 2017; epub ahead of print.


Where Would We Be Without Research?

Posted: January 12th, 2017 by David Rettew

(Editor’s Note:  I am pleased to offer this guest blog by Hannah Frering who is the research coordinator at the Child Emotion Regulation Lab, Vermont Center for Children, Youth, and Families – DCR)

Medicine has come quite a long way since the medieval era where doctors would amputate at the first sign of infection, or would quickly diagnose patients’ terminal problems and send them away without intervention. The advancement of science and technology is the crucial step to how doctors are able to prescribe lifesaving drugs, and control robots that operate on patients. But, how do uncover the science and technology necessary for treatment of medical problems? hannahResearch.

The University of Vermont is a leader of education in the science and technology fields, with the College of Engineering and Mathematical Sciences, College of Agriculture and Life Sciences, Honors College, and the Rubenstein School of Environment and Natural Resources all performing ground breaking research. Furthermore, clinical and laboratory research being conducted at the University of Vermont Medical Center is central to the mission of the University. Spanning from clinical vaccine trials of a dengue fever vaccine, to neuroimaging assessing the relationship of drugs and the human brain, the UVM College of Medicine hosts 15 academic departments engaging in research.

At any time in the Vermont Center for Children, Youth, and Families, we have multiple studies recruiting for participants both from the pediatric psychiatry clinic and from the community. Principal investigator Dr. Robert Althoff is currently recruiting patients and families through collaboration with the Vermont Center on Behavior and Health. This major project investigates the epigenetic and psychophysiological mechanisms underlying severe forms of childhood psychiatric disorders. This work seeks to understand the long-term consequences of these disorders on psychiatric and non-psychiatric health in adulthood. In addition to this, there are two smaller projects recruiting through the Child Emotion Regulation Lab. One of the other studies is striving to examine the influence of television pacing and attentional symptoms, involving executive functioning. With funding from the University of Vermont Medical Group, Dr. James Hudziak is conducting a large clinical trial of the Vermont Family Based Approach in pediatrics clinics. This new way of treating whole families represents the culmination of years of research on the individual components of wellness, prevention, and family-based intervention. Dr. David Rettew is studying medication utilization at a state level, child temperament, and bullying.

So, why are we investigating these topics? Children diagnosed with psychiatric disorders need assistance to focus, self-regulate, and perform adequately in school. Research in child psychiatry has lagged far behind other medical fields and we are trying to catch up. Research in the Vermont Center for Children, Youth, and Families seeks to connect symptoms found in kids with attentional problems, or self-regulation problems to issues that may arise later in life, like metabolic problems or substance abuse. This research is essential not only for determining causes of psychiatric problems, but leading to solutions.

Interested in participating in research in the VCCYF? Check out our VCCYF and Child Emotion Regulation Lab webpages.

Psychiatric Medication Usage Among Vermont Medicaid-Insured Youth Drops by 42%

Posted: December 12th, 2016 by David Rettew

A new report prepared by Change Healthcare for the Department of Vermont Health Access documents a sharp drop in the number of Vermont Medicaid-insured youth who are prescribed psychiatric medications.  The report stems from a project called Improving the Use of Psychotropic Medications among Children and Youth in Foster Care. Vermont is one of six states involved in the project.

Some of the highlights include the following for Vermont Medicaid-insured youth not in foster care.

  • Between 2012 and 2016, the percentage of youth taking at least one psychiatric medication dropped by about 42% for both the 6-12 age group and the 13-17 age group.  In 2016, approximately 13% of Medicaid insured youth from the ages of 6-12 had taken a psychiatric medication in the past 6 months while for adolescents in 2016 the percentage was just under 20%.
  • For all age groups, ADHD medication usage dropped by about half.
  • Antipsychotics, a class of medications that many clinicians worry about most, had the biggest drop in prevalence, falling  74% in the 6-12 year old age group.  This class of medications continued to drop between 2014 and 2016 while for ADHD medications and antidepressants, the rate was relatively stable across the last 2 years after a more pronounced drop between 2012 and 2014.

While the usage of many types of medications across many age groups dropped, there were some exceptions.  For example, as ADHD medication usage among children under age 6 dropped between 2012 to 2016, the rate increased among those in foster care, although this was due to a very small number of children.    At the same time, antipsychotic usage among very young children in foster care dropped from 1.1% to 0.3%.  Overall, psychiatric medication usage among children in foster care continue to be much higher compared to kids not in foster care, although for many ages and medication classes there appeared to be a modest drop between 2012 and 2016.

The million dollar question, of course, and one that the report does not attempt to answer, is what might be behind these drops in usage. Most likely, the trends are due to a combination of factors some of which are more newsworthy than others. There were increases in the number of kids enrolled in Medicaid during this time and shifting demographics of the new enrollees could have been a factor.  There also, however, appears to be a change in culture with clinicians becoming more cautious about medications while trying to emphasize non-pharmacological treatments and wellness activities.

Another important question is whether or not all of these decreases are a good thing.  Most people, including myself, generally interpret these findings as positive, but the numbers alone can’t tell us the degree to which these usage decreases represent a more balanced approach to child emotional-behavioral problems versus the reduction of treatment among those who need it.  Further study is planned with these data to understand more fully what may be occurring and why.


ACOs and Psychiatric Care: New Threat or New Opportunity?

Posted: October 7th, 2016 by David Rettew

Like many physicians of all specialties, I’m not exactly sure what to make of the proposal for an all-payer ACO model of healthcare for Vermont.  For someone who has spent the vast majority of time doing clinical work, teaching, and research, the prospect of fully understanding the plan seems like a full-time job.  The Vermont Medical Society, among others, has nicely put a copy of the actual proposal as well as other resources on the website.  In looking at it, I note that it takes the first 3 pages of the 44 page proposal just to explain the terms found in the rest of the document.

photo by napong and freedigitalphotos.net

photo by napong and freedigitalphotos.net

As a psychiatrist, I am very interested in the degree to which the plan could affect our mental health care system for better or for worse.  To that end, I share some specific thoughts about how an all-payer plan might, or might not, fundamentally change the way mental health care is delivered to Vermonters.

First, it seems clear that mental health is front and center in the all-payer plan.  Indeed, 2 of the 4 “population-based health outcomes targets,” which will be one of the main metrics by which the success of the new plan is judged, are directly related to mental health.  One of the targets is to reduce the rate of completed suicides in Vermont to 16 per 100,000 or reduce our national ranking in terms of suicide rate from 7th to at least 20th.   Another target is to reduce the number of substance-abuse related deaths by 10% compared to 2015 levels.  One could even argue that the other two targets that involve 1) keeping flat the prevalence of COPD, diabetes, and hypertension in Vermont, and 2) getting at least 89% of Vermonters paired up with a primary care provider also are closely aligned with mental health, given the increasing research demonstrating that early mental health is not only one of the strongest risk factors for future psychiatric disorders but also for non-psychiatric chronic diseases.

In many ways, it is extremely gratifying to see mental health being given the priority that many of us have felt for a long time it has always deserved.  Yet while the two goals of mortality reduction from suicide and substance abuse are critically important, I hope that we don’t go too far in “teaching to the test,” thereby de-emphasizing many other important mental health initiatives.

Another important point has to do with the implications of doing away with the traditional fee-for-service model of care.  The more that I think about it, the bigger the potential consequences of this change seem.  Psychiatrists will continue to be a scarce resource, and where their time is maximally allocated should be carefully considered.  It might be easy to simply have us continue to go on doing the same thing the same way, but in my view, not at least considering the possibilities for change would be a huge wasted opportunity.

To be sure, I cherish my one-on-one time with children and their families and would be very disappointed to see that time lost to other things.  But I also see the incredible potential of mental health professionals to impact positively on the health of families in creative ways, once the yoke of fee-for-service is lifted.  We may want to consult more closely with primary care providers in their day to day care of Vermonters before they get psychiatrically ill.  We may want to increase our use of technology such as tele-medicine.  We may want to ramp up our use of group treatment relative to individual work.  We may want to work more closely in teams with other types of mental health professionals.  Even things like writing this blog could make a difference.  All of these kids of initiatives were very difficult to enact in a fee-for-service world but, because they can improve both overall mental health and save money, would now be squarely on the table for consideration.

The train is starting to move with us or without us, and we need to invest the effort to figure out where it is going.   There’s no doubt that the system is complicated, that the devil is in the details, and that the landscape ahead is full of both hazards and opportunities.  Ever the optimist, I for one will be trying to hold back my cynicism and look for creative solutions to old problems.


AAP Publishes New Guidelines on Adolescent Suicide Prevention

Posted: September 2nd, 2016 by David Rettew

September marks National Suicide Prevention Month and a chance for all of us to think again about what we can do against this huge public health problem and the number two killer of Vermonters between the ages of 10 and 34.  While we’ve seen increased attention and resources devoted to suicide, there is still a long way to go.  Just imagine the response locally and nationally that would happen if the second leading cause of death was something like a new infectious agent or terrorism.   Indeed,we all Suicide Prevention Monthneed to work against a feeling of complacency that suicides are inevitable and cannot be prevented through the implementation of optimal assessment and intervention strategies.

Just in July 2016, the American Academy of Pediatrics released a new report on suicide from the Committee on Adolescence. The article provides a number of important updates with regard to suicide statistics, trends, and risk factors that incorporate today’s more modern and digital environment.  Some basic information useful to all primary care clinicians include the following.

  • Suicide rates rose 300% from 1950 to 1990 before declining.  Unfortunately, however, this period of decline seems to have stopped with the rate now being on the rise over the past 5-10 years.
  • Males have higher rates of suicide completion while females have more attempts.  The number of attempts to completions is about 1:50 to 1:100.
  • Surveys continue to show an alarming number of high school youth report strong feeling of depression and suicidality, with a startling 14% of high school students nationally reporting have made a plan to attempt suicide in the past year.
  • Suffocation and firearms are the two leading causes of suicide death.  While the presence of firearms in the homes, regardless of how securely stored they are, increases the risk of adolescent suicide, there is data suggesting that secure firearm storage does diminish this risk.
  • 90% of adolescent suicide victims met criteria for a psychiatric disorder, including but not confined to depression.
  • Bullying, both in person and online, is an important risk factor for suicidality.  Perhaps more surprisingly, those who bully others are also at increased risk.
  • An LGBQ orientation increases the risk of suicide.  Transgender youth are also at increased risk, although it is likely that at least some of this risk is related to bullying and nonacceptance.
  • Excessive use (more than 5 hours per day) of using the internet and/or video games increases suicide risk.
  • The way suicides are covered in the media can be related to suicide clusters or contagion.
  • There is concern that the FDA’s decision in 2004 to put a black box warning on antidepressants may have inadvertently led to the underdiagnosis and undertreatment of adolescent depression.  The report outlines a number of different areas of research that are consistent with this hypothesis.

The report also outlines specific recommendations to pediatricians regarding assessment and treatment.  These include the following.

  • Ask questions about suicide, mood disorders, substance use, and other suicide risk factors.  All children between the ages of 11 and 21 should be screened for depression.
  • While the use of screening instruments like the PHQ-9 are recommended, the report emphasizes that these scales should not replace direct questioning.  The article gives very specific suggestions on how to word these questions and bring up the subject.
  • Ask families about access to lethal means such as firearms and medications.  Advise families of patients who are suicidal or at risk of suicide to remove firearms and ammunition from the house.  (I imagine this one is going to be controversial but haven’t looked at the NRA response yet).
  • Educate yourself about suicide, depression, and antidepressants.  Especially if you are in an areas where mental health referrals and consultations are hard to get (probably most primary care docs would say yes to this), consider getting more in-depth training in the diagnosis and management of adolescent mood disorders.
  • Develop good working relationships with other professionals who work in mental health.

Overall the article recognizes suicide is a major public health concern.  It contains quite a bit of important information and specific recommendations and definitely is worth a read not only for pediatricians and family medicine physicians but other mental health professionals as well.

As a bit of a side note, I would also again like to remind folks to try and change some of the language we use when we talk about suicide.  People don’t “commit” suicide, they die from it, and when they do it is hardly something we would want to call “successful.”



Shain B.  Suicide and Suicide Attempts in Adolescents. Pediatrics 2016; epub ahead of print.

Important Resources

Vermont Suicide Prevention Center’s 2015 Vermont Suicide Prevention Platform.  This document has a lot of important and basic information that is nicely prepared and visualized.  It also documents the center’s 11 goals and strategies for reducing suicide in Vermont.

Zero Suicide .  This is a national SAMSHA supported program dedicated to the idea that suicide is preventable with the application of 7 focused areas of care improvement.

AAP Mental Health Toolkit.  This is referenced in the above article.  The full kit needs to be purchased although some information is downloadable for free.

New Video from Stuck in Vermont.  Released on Sept 1, 2016 for Seven Days Vermont and featured on WCAX’s television show The :30, this is the latest video from Stuck in Vermont creator Eva Sollberger.  It features video from family members who have died by suicide and local mental health professionals.  I was happy to be part of this effort.



Study Links Chemical BPA to ADHD Diagnosis

Posted: August 25th, 2016 by David Rettew

Bisphenol A (BPA) is a petrochemical used in the manufacturing of a number of commonly used products including such as reusable water bottles, sports equipment, dental sealants, food cans linings, and adhesives.  There has been a lot of recent attention about BPA due to mounting concerns about possible links between BPA and a number of health problems including cancer, reproductive problems and neurodevelopmental difficulties.  Government agencies have maintained that BPA is safe at low levels, but the public scrutiny has been enough to push the production of many “BPA free” products.  The concern over the neurodevelopmental effects of BPA comes from someBPA animal data suggesting that the chemical can alter dopaminergic activity in the brain.  There have also been a few human studies that have linked BPA and behavioral problems, but these have had some limitations regarding things like sample characteristics and rigor of behavioral assessment.  This new study tries to take the research forward using an older and nationally representative sample and a more stringent assessment for ADHD.

The data for this study comes from the 2003-2004 National Health and Nutrition Examination survey which queries a nationally representative population-based sample that oversampled some minority groups.  For about 30% of the sample, both urinary BPA levels and ADHD diagnoses were available, resulting in a group of 460 children between the ages of 8 and 15.   ADHD was assessed using a structured diagnostic interview, but could also count if a parent reported that the diagnosis had been made by a medical professional.   A total of 17.3% of the sample met at least one of these two criteria. The association between ADHD and BPA exposure was analyzed using logistic regressions, and the analyses controlled for many potential confounds such as income, prenatal smoke exposure, and blood lead level.

Detectable BPA was found in 97.1% of the sample at widely varying concentrations.  Dividing the sample by mean BPA level (3.9 ug/l), those with higher levels were found to be significantly more likely to have an ADHD diagnosis (11.2% vs 2.9% if assessed through the structured interview).   Looking at a more quantitative association using regression analyses that controlled for confounding variables, children with higher levels of BPA were found to be more than five times as likely to have an ADHD diagnosis (OR 5.86).  This association was found much more strongly in boys with the link in girls being less significant or statistically non-significant in girls, depending upon how ADHD was assessed.

The authors concluded that higher BPA concentrations is associated with ADHD, particularly among boys.

After the study’s release, the article received some publicity but not as much as one might expect given the findings.  This might have occurred because it was published in the less well-known journal, Environmental Research, in the summer.  One certainly might be interested to know if the authors tried to publish the report in a more prominent journal and if they did, why it was not accepted.  I myself can’t see any fatal flaws, although the authors do acknowledge that they only measured BPA once in the study which is probably not the best way to assess its long term presence when it has a half-life of about 6 hours.  Also of interest would be additional analyses to determine if there is some cutoff point beyond which the risk for ADHD is much higher, as the authors in this study used a fairly arbitrary median split for their main result.  At the same time, the fact that these findings were present given the way they divided the sample is somewhat concerning as it suggests that there may be risk associated with BPA levels that are very commonly found.


Tewar S, et al.  Association ofBisphenolAexposureandAttention-Deficit/HyperactivityDisorderinanationalsampleofU.S.children.  Environmental Research.  2016: June 6 epub ahead of print.

Infant Sleep Training Methods Compared

Posted: July 21st, 2016 by David Rettew

The longstanding debate over sleep training methods, in particular those that include some aspect of  “crying it out,” picked up a new chapter recently after a new study was published in the journal Pediatrics.  What was more unique about this study was its head to head comparison of two methods, one using graduated extinction (the technical term for parents delaying their giving comfort to infants for designated periods of time) to what might be described as a more gentle method that does not involve extinction.  These alternative methods have increasingly cropped up due to lingering concerns that extinction-based methods might be experienced as traumatic and disrupt

photo from freedigitalphotos.net

photo from freedigitalphotos.net

parent-child despite there being no direct evidence of this.

In this Australian study,  a total of 43 infants around 10 months of age, all of whom were experiencing sleep problems, were recruited and randomized to one of three groups. One was taught a graduated extinction approach in which parents returned to the crib at progressively longer intervals over the course of a week. Another group used an approach called “bedtime fading” in which the infant’s bedtime was moved forward or backwards until the child sleep latency time was consistently less than 15 minutes. After that, parents were told to do what they normally do for nighttime awakenings. There was also a control group that received sleep educational materials. Sleep was assessed using both questionnaires and more objectively using ankle monitors, and saliva cortisol levels were also ascertained at follow-up as a measure of physiological stress. Attachment status was also assessed with the Strange Situation procedure.

At 3 month follow-up, significant improvements were found for both treatment conditions relative to controls with regard to length of sleep latency time and time to waking after sleep onset. The graduated extinction technique showed improvements relative both to the control and bedtime fading condition for reducing the number of nighttime awakenings, while total sleep time increased for the graduated extinction and control conditions. In terms of markers of stress, afternoon infant cortisol levels and levels of maternal stress were found to decrease for the two behavioral treatment groups relative to controls.  When the sample was assessed again at 12 month follow-up, no group differences were found related to attachment or levels of behavioral problems.

The authors concluded that their data support the effectiveness of brief behavioral sleep interventions without causing long-term stress or behavioral problems.

Will this study end the debate on sleep training?  For sure it will not, but the study does add some additional evidence that such techniques can work and do not represent traumatic experiences for children that result in harm.  At the same time, what might be more novel to some parents and primary care physicians alike is the realization that there are other evidence-based methods out there that have been shown to be effective and may be more palatable to parents than techniques that involve some aspect of crying it out.


GradisarM, et al.  Behavioral Interventions for Infant Sleep Problems: A Randomized Controlled Trial.  Pediatrics 2016; 137(6): epub ahead of print

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