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Home – Child Mental Health Blog

Vermont Center for Children, Youth and Families

Posted: June 4th, 2015 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

Psychiatric Treatment Up, Impairing Mental Illness Down

Posted: June 30th, 2015 by David Rettew

There have been a lot of mixed messages when it comes to the state of child mental health and the amount of psychiatric treatment children are receiving. On the one hand, we hear the alarm sounded by many that too many children without significant mental illness are being diagnosed and prescribed medication.  On the other hand, we hear that psychiatric care is too hard to get and that the major problem continues to be underidentification and undertreatment.

Is there some truth to all these claims? A new study from the New England Journal of Medicine tries to sort out some of these questions. The study followed over 50,000 youth, looking at different time periods over the past 2 decades: 1996-1998, 2003-2005, and 2010-2012. The primary variable of interest was how many children between the ages of 6 and 17 received some kind of mental health care and whether any increases were disproportionately from those children with more severely impairing illness versus those little or no impairment from their behaviors.Medication changes

The results of this study are quite interesting and some were unexpected. Perhaps the broadest finding was that more youth are getting mental health treatment now (13.3%) than in the mid 1990s (9.2%). That part is probably not too surprising, and these increases occurred among the group with more impairing illness and among the group with less impairment.  Further, increases were found both in the rates of psychotherapy and for most classes of medications, as shown in the figure.  The smaller group with more impairing disorders had the largest relative increase in service utilization but, since that group is smaller, those will less severe symptoms had a larger increase in mental health treatment rates in absolute terms.

It is worth noting, however, that even among youth with more severe impairment, the rate of receiving any mental health care was less than half (43.9%).

The finding that the authors admitted was quite unexpected was this: the overall percentage of youth who have more impairing mental illness actually dropped during this period of increased treatment (from 12.8% to 10.7%). Yet while it may be tempting to think that the increase in treatment may be partially the cause of the decrease in impairing mental illness,  the study cannot demonstrate causation.

The study has picked up its fair share of publicity, including an article in the New York Times. One interesting development is that many media outlets are featuring the drop in number of youth with more impairing mental disorders as the primary statistic of interest, despite the fact that this finding was neither a part of the study’s title nor its abstract.

As you can see from these complex results, there is something in this study for everyone to point to on either side of the “psychiatry debate.”  Some will choose to highlight the increase medication usage, some the continued lack of services for severely impaired youth, and some the possible decrease in overall levels of impairing psychopathology…..and they are.  For more moderate voices not inclined to just cherry pick the results that fit our worldview, the picture indeed looks complicated but perhaps not that  shocking overall.   Yes there kids out there who are suffering because of a lack of treatment, and yes there are many kids getting medications they may not need.  We simply need to work on both parts of this equation.

Reference

Olfson M, et al.  Trends in Mental Health Care among Children and Adolescents. NEJM.  Epub May 21, 2015.

 

 

Praising Children: The Type of Praise Matters

Posted: June 11th, 2015 by David Rettew

The topic of praising children has become passionately debated of late.   While it generally has been highly encouraged for decades as a way to motivate kids and build self-esteem, there has more recently been some concern raised that praising children too much might lead to a lack of effort and a generation too dependent on the opinions of others.   In most of these discussions, praise is  considered to be a unitary concept. Some researchers, however, have questioned this uniformity and have hypothesized that different types of praise may have different effects.  Indeed, some short term experimental studies have suggested that process praise in particular, which focuses on effort and actual behaviors rather than character traits, leads to kids being less likely to give up during a challenging task.  What has been missing, however, are studies that are more naturalistic in design and include the kind of praise parents give to their children every day.

Photo by stockimages

Photo by stockimages

That is where this recent study by Gunderson and colleagues, published in the journal Child Development, comes in.  She and her colleagues examined whether different types of parental praise is associated with a child’s motivational frameworks and the way they tend to attribute causes of success or failure. The subjects were 53 child/parent dyads from the Chicago area. When the child was approximately 1, 2, and 3 years, video recordings were made of the child acting regularly at home. The transcripts were coded and amount of praise measured (although the examiners did not disclose that this was the variable of interest at the time). Coders quantified the amount of process praise, namely praise devoted to what a child did or how they did it, versus person praise, such as saying a child is smart or talented, that refers to a more fixed trait or characteristic. When the children were 7 to 8 years old, they completed questionnaires related to the degree to which a child believed in what is called an incremental framework, which includes ideas that traits are more malleable and success due more to effort than intrinsic fixed characteristics.

Overall, praise was found to account for 3% of parent utterances and this amount varied quite a bit from parent to parent.   As hypothesized, the amount of process praise, but not other types, was significantly related to children believing success was more due to effort than innate ability.  Another important finding was that process praise accounted for about 20% of total praise and was found to be given more to boys than girls.  The authors concluded that their results support the idea that praise which targets effort and strategy (e.g. “You really worked hard completing that puzzle!”) can contribute positively to a child’s belief system relative to praise focused on specific traits, (i.e. “You are so smart!”).

The authors are currently looking at the degree to which these styles predict actual academic success in future publications, Dr. Gunderson stated in her recent Grand Rounds presentation here at the Department of Psychiatry.  She acknowledged that these data do not speak directly to questions about overpraising, but suggested that the specific type of praise might be an important variable to consider in ongoing discussions about praise.  Another point worth making in my view is that while there may be some families that overpraise their kids, it is also true that there continue to be many children growing up in more hostile environments who are routinely subjected to harsh insults and humiliation and starving for any kind of positive and encouraging words.

 

Reference

Gunderson EA, et al.  Parent Praise to 1-3 Year-Olds Predicts Children’s Motivational Frameworks 5 Years Later. Child Development 2013;84:1526-1541.

Help Support a New Documentary on the Vermont Family Based Approach

Posted: June 8th, 2015 by David Rettew

What happens when you combine an innovate and effective new method of delivering mental health care, a family that benefited from the approach and wants to spread the word, and a child psychiatry fellow with a previous life as a film director?  A new documentary about the Vermont Family Based Approach, of course.

The Kelly Gibson Story

The Kelly Gibson Story

The Vermont Family Based Approach (VFBA) is a new model of child psychiatry that was developed by Dr. Jim Hudziak at the Vermont Center for Children, Youth, and Families.  The approach emphasizes the incorporation of wellness and health promotion strategies into the overall treatment plan.  Over several years, the model has become increasingly recognized and accepted, yet much more work is needed to bring this approach into mainstream practice.  As part of that effort, Dr. Hudziak has teamed with the Gibson family and child psychiatry fellow Dr. Sean Ackerman to produce a full length documentary called the Kelly Gibson Story.

Funding is needed to turn this project into a reality, and a Kickstarter campaign has been launched to raise $40,000 (a shoestring budget by today’s standards but enough to get this story told and promoted).  Please visit the site and encourage others to do so as well.  The deadline for the funding support is July 5.  Spread the word on social media, and let’s all help get this important message out that stands to potentially transform the way that mental health care is conceptualized and practiced.

 

 

Coaching Parents About Time-Outs

Posted: April 29th, 2015 by David Rettew

Allison Hall, MD

 

 

 

 

 

 

 

by Allison Hall, MD

(Note: this post was primarily written by my colleague, child psychiatrist Dr. Allison Hall who, aside from seeing children and families directly, trains other counselors and therapists in parent behavioral training techniques. If you are interested further in the topic, she will be presenting at next month’s Child Psychiatry in Primary Care conference.)

Parents will often announce that time-outs don’t work with children who have challenging behavior. This may be true in some cases; however, very often there are problems with how time-outs arephoto by satit_srihin being used. The origin of the term “time out” comes from “time out from reinforcement”. Reinforcement just means things that make behavior more likely to occur in the future. One of the most important of these for children is parental attention.

From our experience and those of others, the following are five of the most common mistakes that are made when parents try to use time-outs. If a parent expresses during a primary care appointment a lack of success for time-outs, it can be very useful to review this list.

  1. Forgetting the part about paying lots of positive attention to your child. First and foremost, if time-out (or any discipline technique) is going to work, it is vital that parents offer plenty of attention to the child when he or she is being cooperative and having fun. Positive attention can include noticing and commenting on things your child is doing, a smile, a wink, a pat on the back, and just spending happy time together. The phrase “catch your child being good” has become cliché, but it’s still important.
  2. Not planning ahead. What behaviors should earn a time-out? Where should a time-out occur? For how long? These questions should be thought through before a time-out is used. Many parents reserve time-outs for hitting. Whatever parents have decided, however, it is important to be very consistent. Pick a place ahead of time away from toys, the television, and other distractions while not choosing an isolated, dark, or scary place. A chair in the hallway is a good choice. As for length, here the main thing is not too long. What makes a consequence work is not how severe it is but how consistent it is – swift and certain. Talk to children about the time out process first. Even better, practice with them, giving them a chance to pretend to be naughty.
  3. Losing one’s own temper during a time-out. Parents should work hard not to lecture, shame, yell, or physically fight to get the child in time out. All of those things are forms of attention which may accidentally reinforce the negative behavior. They can also have negative consequences of their own. Instead, just say “Because you hit your brother, you must go to time out” and point to the chair.
  4. Not having a back-up plan if the child leaves time-out early. While some people advocate taking the child back into the time-out chair over and over again if they get out, this may not always be the best approach. Alternatively, another trick is to have a back-up consequence – like losing a half hour of electronics. That way, if the child refuses to take the time-out, he loses that privilege.
  5. Staying mad. Once time out is over, be positive with your child again. This can definitely be easier said than done, especially if the parent has been hit or called really nasty names, but one of the beauties of time-out is that it happens and then it is over. Work to find something pleasant to say. If a parents needs to talk about some aspect of what happened, it’s best to try this a little later when the child is not upset or defensive.

Time-outs sound easy but can be challenging, so parents shouldn’t be afraid to ask for some help. Having a coach to help practice and problem solve can be really helpful. There are also some excellent videos available at this CDC website.

 

Energy Drinks, Sugary Beverages, and ADHD Behaviors

Posted: April 21st, 2015 by David Rettew

As the Vermont legislature debates the possibility of a tax on sweetened beverages, a recent study from the journal Academic Pediatrics adds a new wrinkle to the discussion.  This paper looks not only at traditional sugary beverages like soda but also energy drinks, which are becoming increasingly popular among youth and contain high amounts of both sugar and caffeine.  The goal was to gather some basic data on how much different types of these drinks are consumed and whether or not they might be associated with behavioral problems such as inattention or hyperactivity.

The subjects for this study were over 1600 middle school students across 12 schools in the same urban area. The average age was 12 years old and the sample was predominantly Hispanic or black. The students completed a survey about sweetened beverage use over just the past 24 hours.  They also filled out the 5-item inattention/hyperactivity subscale of the Strength and Difficulties Energy DrinkQuestionnaire with scores above 5 categorized has reflecting high levels of symptoms.  This was a cross-sectional study (ie assessing variables only at one time point) so in an attempt to tease out the association specifically between ADHD behaviors and sweetened beverages, the analyses controlled for a number of demographic variables, as well as the amount of sugar consumed from other foods.

Results showed that consumption of sugary beverages varied by sex and race with boys drinking more than girls and Hispanic and black students consuming more than white students. On average, children drank 2.24 sweetened beverages per day.  Students with higher levels of hyperactivity/inattention drank more sweetened beverages the day before than those in the normal range (2.7 versus 2.2).   Looking at their data another way, regression analyses revealed a significant association between sweetened beverage consumption and inattention/hyperactivity. Controlling for other factors, the risk of high levels of inattention/hyperactivity increased by 14% for every beverage consumed. Regarding specific kinds of beverages, energy drinks were the only individual type that was found to have an independent association with inattention/hyperactivity.

The authors concluded that their finding support the link between sweetened beverages and behavioral problems and support recommendations to limit their consumption in youth. They urged that intervention efforts be targeted not only at soda but things like energy, coffee, and sports drinks.

Before taking this well publicized study to the legislature, however, it is worth pointing out some oddities and limitations that are present in the study.  While it is tempting to view this study as supporting the long debated link between sugar and ADHD, keep in mind that the authors actually controlled for other sources of sugar intake in their analyses in order to try and statistically isolate the association with sweetened beverages.  Thus, to make the argument, one would have to explain why sugar in beverages has a different effect than sugar from other sources.  Furthermore, the modest increase for higher ADHD behaviors of 14% actually demonstrates how many factors other than sugar must be involved in ADHD.  These important qualifications, unfortunately, don’t stop people from describing this study with titles such as “Energy Drinks Cause Hyperactivity and Attention Disorders.” Additionally, the strongest link with behavior appears to be with energy drinks which, as was mentioned, contain high amounts of sugar and caffeine.  Finally, the cross sectional nature of the study (even with the statistical controls) renders the study unable to rule out the possibility of reverse causation, namely that those with more hyperactive/inattentive problems are drawn to consume more sweetened beverages.

These limitations notwithstanding, there certainly is merit from many angles to try and limit consumption of sweetened beverages in children and avoid the use of energy drinks, as is recommended by the American Academy of Pediatrics.

Reference

Swartz DL, et al.  Energy Drinks and Youth Self-Reported Hyperactivity/Inattention Symptoms.  Academic Pediatrics 2015; epub ahead of print.

1st Developmental Psychopathology Special Lecture Tomorrow

Posted: April 16th, 2015 by David Rettew

The Vermont Center for Children, Youth and Families and the Research Center for Children, Youth, & Families is proud to introduce the first annual visiting professorship in developmental psychopathology.  Our inaugural recipient is Frank Verhulst, MD, PhD from Erasmus University and Sophia Children’s Hospital in Rotterdam, The Netherlands.  As part of his professorship, he will be giving Grand Rounds for the Department of Psychiatry on Friday April 17.  The title of his talk is “Epidemiology of Child Psychopathology: Major Milestones.”  Please see the following flyer for more information and don’t miss this important event.

Verhulst

 

Effects of Recreational Cannabis

Posted: April 7th, 2015 by David Rettew

CannabisAs Vermont considers whether to join other states in legalizing recreational cannabis use, clinicians and the public alike are struggling to find good information about the risks, or lack thereof, that may be involved.  Complicating matters as the issue becomes more and more political is the phenomenon of dueling research evidence, as folks who are already strongly for or against legalization cherry pick the studies that support their view.

Recently, the top-tier journal, Addiction, published a review of the evidence entitled, “What has research over the past two decades revealed about the adverse health effects of recreational
cannabis use?”  The paper was authored by Wayne Hall who is a Professor and Director of the Centre for Youth Substance Abuse Research at the University of Queensland, Australia.  With 165 references, the article strives to summarize what is really known on the subject by focusing on studies published from 1993 to 2013 that employ more solid methodological techniques.

A summary of the key findings are as follows.

  • The risk of a fatal overdose is extremely low (with the possible exception of some cardiovascular risks as described below).
  • An approximate doubling of the risk of a car accident, a rate which is elevated overall but lower relative to alcohol intoxication.
  • Use during pregnancy has been associated with reduced birthweight and possibly lower offspring cognitive abilities.
  • For chronic cannabis use, there evidence for both withdrawal and dependence at a rate of approximately 10% among regular users.
  • Furthermore, research supports the hypothesis that regular cannabis use roughly doubles the risk of psychosis.  Newer studies have helped argue against “reverse causation” mechanisms (i.e. that people with psychosis tend to use cannabis rather than cannabis causing psychosis) but “common-cause” mechanisms (i.e. that there is another factor causing both psychosis and cannabis use) have not been completely excluded.
  • Deficits in verbal learning, memory, and attention and IQ have also been associated with chronic use and may not be reversible with cessation. These effects may be strongest for those who begin using cannabis in adolescence.
  • Poorer educational outcomes have also been documented in some studies, although a recent twin study showed no difference in leaving school early among twins discordant for early cannabis use.
  • The gateway hypothesis that cannabis leads to the use of other drugs continues to be supported.
  • Cardiovascular risks, particularly among older adults, have also been documented as well as testicular cancer.

The author concluded that more recent and better methodological studies have generally strengthened the evidence that links cannabis with a variety of negative health outcomes, particularly for adolescents.

While the paper comes across as relatively unbiased and points out areas where the link with adverse events is not well documented, I’m sure those more inclined towards legalization will find Dr. Hall’s review to be somewhat biased (especially anything published in a journal called Addiction).  Nevertheless, I found this paper to be quite useful in helping me sort out the swirling opinions out there at a time when some good information is sorely needed.

Reference

Hall W.  What has research over the past two decades revealed about the adverse health effects of recreational cannabis use? Addiction 2015; 110:19-35.

Effects of ADHD Medications on the Brain

Posted: March 31st, 2015 by David Rettew

A common and legitimate concern that is often voiced by parents when considering medication treatment for their child’s ADHD symptoms relates to the effects of these agents on the developing

from Rubia et al., 2009

from Rubia et al., 2009

brain.  Raising some alarm have been findings from some animal studies that have suggested detrimental long-term changes; however, these studies often use very high doses administered intravenously.  Neruoimaging studies in people on this question have slowly been accumulating to the point that there is a critical mass to review for common findings.   This review paper by Spencer and colleagues that was published in the Journal of Clinical Psychiatry offers a summary of neuroimaging studies that have examined structural and functional changes related to ADHD treatment with stimulants.

A total of 29 studies were identified that met the authors’ inclusion criteria. Among them were 20 functional MRI studies, 6 structural MRI studies, and 3 spectroscopy studies. Between studies, a great deal of variability was found related to methodology.  Despite this fact, however, overall results were fairly consistent in finding that treatment with stimulants resulted in brain structure and function closer to non-ADHD controls and farther from ADHD patients who were not treated with medications. Related to the structural MRI studies, the attenuation of structural “abnormalities” tended to be in specific to particular regions rather than reflecting overall changes in grey or white matter volume. Functional MRI studies were relatively consistent regarding findings with the striatum and anterior cingulate gyrus while the prefrontal cortex showed the most variability in results across studies.

The authors concluded that oral doses of stimulants tend to attenuate the brain alterations that have been identified in ADHD.

While this study should be somewhat reassuring to both clinicians and parents alike, it is important in my view not to take these results too far.  Most of the studies reviewed were naturalistic in design which means that assignment to medication or not was not random and thus other factors might account for group differences.  In addition, these studies are unable to detect more subtle changes that may be occurring on a smaller scale or over long periods of time.

Reference

Spencer T, et al.  Effect of Psychostimulants on Brain Structure and Function in ADHD: A Qualitative Literature Review of MRI-Based Neuroimaging Studies.  J Clin Psychiatry 74(9):902-917, 2013.

Are Doctors Following Best Practice When Prescribing Antipsychotic Meds to Kids?

Posted: March 19th, 2015 by David Rettew

(NOTE: the following is reprinted with permission from an article published in The Conversation on March 18, 2015)

Antipsychotics

Photo from Shutterstock

There’s been a lot of attention in the media about the number of children taking antipsychotic and other psychiatric medications. The assumption behind most of these stories is that these drugs are being overprescribed, and given to children with minor behavioral issues. A recent story in a European newspaper about the increased use of ADHD medications, for example, was headlined “Zombie Generation.” Yet the reality is there’s very little data to tell us the degree to which these medications are being used appropriately or not.

Antipsychotic medications, such as Risperdal, Seroquel and Abilify, were developed to treat adults with major mental illnesses including schizophrenia and bipolar disorder. But in recent years, their use has extended to treat conditions such as autism and attention-deficit/hyperactivity disorder (ADHD) in children and adolescents.

How these medications work remains somewhat of a mystery, although we know they affect multiple brain neurotransmitters such as dopamine and serotonin.

Because these medications’ side effects include an increased risk for conditions such as obesity, diabetes and movement disorders, they’re subject to extra scrutiny to make sure that the right medications are being prescribed to the right patients at the right time.

For instance, the American Academy of Child and Adolescent Psychiatry has a list of 19 “best practice” recommendations. These include using just one medication at a time, avoiding the medications in very young children, monitoring for side effects, and trying other treatments first for things like ADHD and aggressive behavior.

Are doctors following prescribing guidelines?

With the rise in antipsychotic medication prescriptions, we wanted to know how well doctors were following these recommendations.

As a member of the Vermont Psychiatric Medications for Children and Adolescents Trend Monitoring workgroup, we were tasked with offering recommendations to our state legislature and other government agencies about psychiatric medication use in youth. We knew antipsychotic prescribing rates in Vermont had been somewhat high, but had dropped in recent years relative to other states. Without digging deeper, we couldn’t actually tell what this trend meant.

To learn more about why and when these medications are prescribed, we sent a survey to every provider who had prescribed an antipsychotic medication to a child covered by Medicaid in Vermont. We focused on Medicaid because we did not have access to commercial insurance databases.

Our survey was required in order for the prescription to be refilled, which meant our return rate (80%) was much higher that it would have been for a truly voluntary survey.

Clinicians aren’t always following guidelines

To our knowledge the study, which was recently published in Pediatrics, is the first one to compare antispychotic prescribing patterns to best practice guidelines.

We found evidence that these medications aren’t being doled out to treat minor behavioral problems, which is reassuring. But we also found places where doctors weren’t following best practice guidelines.

Perhaps the biggest finding was that an antipsychotic prescription followed best practice guidelines only about half the time. We also found that these medications were prescribed for an FDA-approved use only a quarter of the time.

By itself, this is bad news and means that there needs to be a greater effort to make sure these medications are being prescribed appropriately. Increasing access to child therapists who do evidence-based psychotherapy could help. So would making it easier for medical records to follow patients, particularly for kids in foster care who often move from place to place.

It turns out that most providers who prescribe antipsychotic medications are not psychiatrists. About half are primary care clinicians such as pediatricians or family physicians. And 42% of the time the doctor who is responsible for maintaining the antipsychotic medication isn’t the one who originally prescribed it. This can be a problem because a doctor may be less comfortable stopping a medication that someone else started. He or she also may not know the whole story behind why the child was prescribed the medication in the first place.

The most common reason by far that prescriptions failed to meet best practice standards was because the patient was not getting the recommended lab work – for instance, monitoring blood glucose to check for early diabetes. This is a problem, but there are other ways to monitor for potential side effects of these medications. And new electronic medical records may make it easier to remind doctors when these kinds of tests should be ordered.

Using antipsychotic drugs to treat bad behavior isn’t the norm

While some of the study’s results are discouraging, there is also good news. For example, using antipsychotic medications for relatively minor behavior problems – like temper tantrums in young kids – was relatively uncommon.

Further, over 90% of the time antipsychotic medications were being used only when other types of interventions, including different medications or psychotherapy, had failed. However, in many cases the type of psychotherapy tried first was not of a type that’s been shown to be most effective in treating the child’s particular problem.

And in cases when the patient was diagnosed with a condition that antipsychotic medications are not officially approved to treat, such as oppositonal defiant disorder, the actual behavior being targeted was often something with scientific evidence to support using antipsychotic medication, like physical aggression.

In our view, these medications do indeed have a place in treatment. But too many are getting to that place too quickly and without the appropriate level of monitoring. Our hope is that Vermont and other states will keep studying this issue and support doctors, patients and families to ensure that these medications are being used appropriately and safely.

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