Posted: June 2nd, 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.
Posted: July 29th, 2014 by David Rettew
(Editor’s note: I’m very pleased to be able to present this guest post by one of our new child psychiatry fellows, Sean Ackerman, who recently published this important study – DR).
Sean Ackerman, MD
These days autism spectrum disorder (ASD) and assisted reproduction are both medical issues that frequently wind up in the media and are becoming ever more commonplace in our lives. Moreover, at times both issues have been lightning rods of controversy. Not surprisingly then – and in the context of ASD being linked to environmental factors – some have wondered if assisted reproduction and ASD were associated. There has even been some concern that some forms of assisted production – including in vitro fertilization, gamete intrafallopian transfer, or zygote intrafallopian transfer – could possibly even cause autism associated genetic events.
Researchers have looked at this question via a number of epidemiological studies, with mostly reassuring results. However, there has been some conflicting evidence and no genetic studies have been done… until now.
Via a large sample of almost 2,000 children with autism, we examined the use of assisted reproduction and any association with autism associated genetic events, publishing our results recently in the journal Fertility and Sterility. What we found was a completely negative result: no statistically significant differences in copy number variations or autism-associated gene-disrupting events were found when comparing ASD patients exposed to assisted reproduction with those not exposed to assisted reproduction.
Furthermore, in the context of assisted reproduction maternal age was identified as a potential contributor to ASD associated genetic events, meaning the characteristics of parents using assisted reproduction (not assisted reproduction itself) may explain any association previously found in epidemiological studies between ASD and assisted reproduction.
Overall, we believe this finding is important because when people consider assisted reproduction they often have many questions and anxieties. We hope that the above finding can help provide some important information to hopeful parents interested in assisted reproduction who are specifically concerned with the issue of autism.
Ackerman A, Wenegrat J, Rettew D, Althoff R, Bernier R. No increase in autism-associated genetic events in children conceived by assisted reproduction. Fertility and Sterility 2014; May 17 epub ahead of print.
Posted: July 21st, 2014 by David Rettew
It is easy to get stuck into territorial disputes, and one of the most common ones I hear in relation to child mental health is the question of whether a child with a trauma history should be thought of as having “real” ADHD or whether it is better to conceptualize the difficulties as being more directly related to trauma. A great illustration of what many consider to be an important diagnostic dilemma comes from a recent article in the The Atlantic by Rebecca Ruiz entitled “How Childhood Trauma Could Be Mistaken for ADHD.”
The main point of the article was to argue that many children who manifest behaviors of ADHD come from chaotic environments and have suffered many adverse child events. Experts quoted in this article advocated that it is important to recognize these events and address them, and that medications can’t fix a chaotic or abusive environment.
Nothing really to argue about so far. Certainly we can be guilty from time to time of getting overly focused on medications while not paying enough attention to the factors that might be driving or exacerbating the problem.
Unfortunately, where the article lost me was its repeated return to the us versus them, correct diagnosis versus incorrect diagnosis, good doc versus bad doc mentality that so pervasively permeates our field. When it comes to trauma and ADHD, this false dichotomy, in my view, would be similar to a physician stating something like, “He has a history of smoking so I don’t think this is real COPD but rather a reaction to the cigarettes.”
Let me offer a few other points for why I think some of these debates between the “biological” people and the “trauma” people are ultimately moot.
- Kids have only one brain that responds to both genetic and environmental factors. Attention and self-regulation skills begin to be learned early in life. When a negative environment impacts that developmental process, the brain physically changes. Thus, it shouldn’t be surprising that there is no evidence that kids who meet criteria for ADHD but also have trauma histories have a brain that is any less “ADHDish” than kids with ADHD who come from stable happy households. Yet somehow, a dualistic perspective that essentially implies separate brains for separate disorders continues to exist. While it is true that severe anxiety can sabotage attention, in my experience it is much more common that children who have suffered many adverse events, especially early in life, present with both real anxiety and real attention problems.
- You can’t ignore genetics. When it comes to children with trauma histories, many of their parents struggle with psychiatric disorders themselves including, not the of least of all, ADHD. This fact does not excuse parents of responsibility, but it is important to remember that these children can get a double dose of at-risk genes and at-risk environments. The vast majority of studies that link environmental trauma to negative child behavior do not take genetics into account, and the few that do paint a much more complex picture than is generally expressed in this article cited above.
- There is little evidence that doing “trauma work” fixes these supposedly misdiagnosed children, especially when the trauma is no longer occurring. While I would be one of the first to agree that a 15 minute “med check” for a child in a tumultuous environment is wildly inappropriate as a sole treatment, I would also have to add that a pleasant 45 minutes of play therapy while struggling parents sit outside in the waiting room is no better. Of course trauma and other environmental factors are incredibly important in the mental health of children. The point is that dismissive explanations of ADHD don’t hold water in study after study.
What can we do instead? The bottom line here is a need to throw out our “this or that” thinking and understand that reactions to adverse environments can contribute to ADHD or be part of ADHD rather than necessarily be mistaken for ADHD. These kids and the families who care for them deserve clinicians who can look at the big picture and proceed with comprehensive multi-faceted interventions. Looking at the world too narrowly through a particular lens (whether it be trauma or ADHD or many other things for that matter) holds everybody back and does not do justice to the amazing complexity of the brain.
Posted: July 1st, 2014 by David Rettew
Suicide remains a leading cause of death and is a major public health concern. Studies have demonstrated that many individuals who die by suicide often see their primary care physician soon before the event. Thus, it is important to know whether suicide screening might potentially prevent some of these tragic deaths. To that end, the U.S. Preventive Services Task Force, an organization that issues guidelines regarding prevention measure in medicine, looked at the evidence once again ten years after an earlier report when the said that they could not make a recommendation for or against the practice due to a lack of data.
Their analysis attempted to focus on adolescents, adults and older adults who were not at an elevated risk for suicide at baseline and did not have an identified psychiatric disorder. The task force attempted to find studies that addressed three areas, namely 1) the accuracy of suicide screening tests, 2) the effectiveness of interventions to decrease suicide, and 3) potential negative effects of suicide screening and treatment.
When it came to results, the authors found only four screening studies on suicide screening, all of which used a different instrument. Not enough data were available to determine if the screening was worthwhile, although the report didn’t really summarize these studies. The task force also found a general lack of evidence regarding the efficacy of treatment and any potential negative effects of suicide screening or treatment.
The overall conclusion of the task force was that, once again, the current database is insufficient to be able weigh the relative benefits and risk of preventive suicide screening in primary care. The task force recommended additional research to fill these significant gaps.
One might wonder in reading this often hard to follow report is why they chose to issue it again if the final conclusion of “insufficient data” remains unchanged. Perhaps it was to spur additional interest and attention. It is important to note that these recommendations (or lack thereof) do not suggest that there are no significant risk factors for suicide worth identifying. Indeed, the group has previously issued a recommendation that screening for depression, probably the strongest risk factor for suicide, be performed in primary care offices.
Lefevre M. Screening for Suicide Risk in Adolescents, Adults, and Older Adults in Primary Care: U.S. Preventive Services Task Force Recommendation. Annals of Internal Medicine 2014;160(10):719-727.
Posted: June 18th, 2014 by David Rettew
A new combined effort between the Vermont Department of Children and Families (DCF), the Vermont Department of Mental Health, and the Child & Adolescent Psychiatry Fellowship Program at the Vermont Center for Children, Youth, and Families (VCCYF) will support caseworkers who often need to make complex medical decisions regarding the children under their care.
While it has been well known that the number of youth who take antipsychotic medication has been increasing nationwide, the rate tends to be about five times higher among youth in state custody. Antipsychotic medications can be an important component of treatment for some, yet these medications also carry the potential for serious risks and side effects including movement disorders, obesity, diabetes, and high cholesterol. When kids enter state custody, DCF caseworkers become responsible for consenting to these and any other medications and medical decisions. This responsibility can be a challenge due to the large caseloads of the social workers and the fact that these children often move around to various placements around the state. Unlike most parents, DCF caseworkers are often unable to attend physician appointments with their children which is where the risks and benefits of medications are typically discussed. DCF caseworkers are also not clinically trained in pharmacology.
To support DCF caseworkers in this challenging task, a new program will begin next month that will help them in deciding whether or not a antipsychotic medication that is being considered for a child in custody is appropriate. This includes the following:
1. Additional training provided to the caseworkers about antipsychotic medications and their potential risks and benefits.
2. A more rigorous written informed consent process that will be required between the DCF caseworker and prescribing clinician to ensure that children in DCF custody who are being prescribed antipsychotics are getting these medications for the right reasons and being monitored according to best practice guidelines.
3. The opportunity for caseworkers who may have questions or concerns about the consideration of antipsychotic medications for one of their clients to get an independent opinion from one of the child psychiatry fellows in the VCCYF training program who is supervised by UVM child psychiatry faculty. These free consultations can occur whenever the caseworkers would like one and are required in certain situations (such as a child under six years old).
The project has been led at DCF by Cindy Walcott, Deputy Commissioner for Family Services. We are excited to be part of this effort both to help make sure these vulnerable children are getting the best care possible and to give our child psychiatry fellows a valuable educational experience. Vermont has already seen a decrease in the use of antipsychotic prescriptions among youth over the past several years. Improving access to evidence-based psychotherapy for oppositional and aggressive children, educating prescribers on when and how to reduce or discontinue these medications when appropriate, enhancing the flow of medical information between different practices, and using technology to remind physicians about the need for regular labwork can all help the prescribing of this class of medications to be closer to best practice recommendations.
The new policy begins on July 1. Primary care clinicians who prescribe antipsychotic medications to children in DCF custody can expect to be asked to complete this informed consent process with the child’s caseworker over the next few months.
Posted: June 2nd, 2014 by David Rettew
There have been many studies that have demonstrated links between excessive childhood screen time and negative outcomes including attention problems and aggression. Most of them imply causation but generally can’t prove it because the studies don’t measure child behavior before the screen time occurs. Yes playing Minecraft for 6 hours per day might cause problems, but it could also be true that kids whose have attention problems are drawn more to the bells and whistles of video games. A recent study published in the journal Pediatrics examined this question in relation to poor infant self-regulation and media usage at age 2.
The study comes from the Early Childhood Longitudinal Study – Birth Cohort and included 7450 children from the community, oversampled for higher rates of ethnic minorities. Infants were assessed for the regulatory abilities at an age of 9 months using a shortened version of the Infant Toddlers Symptom Checklist. Items involving fussiness, needing constant attention, and sleep problems loaded onto the overall score of regulation problems. Media usage was measured at age 2 by simply asking caregivers about average media use. Regression analyses were performed to examine the link between infant regulatory abilities and media use, controlling for other potential confounds. The authors examined the data both quantitatively (i.e. using the actual numbers of media time) and categorically dividing toddlers into groups that watched more or less than 2 hours per day (based on the AAP guidelines of two hours per day maximum of screen time).
Overall, a small but statistically significant link was found between infant regulatory abilities and age-two media use. The analyses showed that children with poorer regulatory skills (which was about 39% of the sample) consumed approximately 14 more minutes (9 minutes when adjusted for other variables) of media per day than those with good regulatory skills. At age 2, children averaged about 2.3 hours of media use per day with 40% of the sample going above the recommended 2 hours per day. The association between dysregulation and media use was stronger for children who remained dysregulated at age 2 and for children from English speaking and lower SES families.
The authors’ conclusions were somewhat unexpected. Despite showing evidence that dsyregulation might be a cause rather than a result of media use, the authors argued that the amount of use associated with infant dysregulation was too small to account for the finding from other studies that excessive screen time is linked to negative child behavior. They cautioned about a cycle in which fussier infants are more likely to be placed in front of screens (to give parents a break or occupy them in a safe place) which then in turn exposes them to the negative effects of increased screen time and thus reinforces the initial problem. While this is certainly a plausible hypothesis, it requires a study that assesses child behavior, parent behavior, and screen time at multiple time points. We are still waiting for that one, as far as I know.
Radesky JS, et al. Infant Self-Regulation and Early Childhood Media Exposure. Pediatric; online publication April 14, 2014
Posted: May 27th, 2014 by David Rettew
by Allison Hall, MD
Principals of good parenting like paying attention to positive behavior and using time out may sound easy but can be difficult to put into practice. The Center for Disease Control (CDC) has recently created a website on parenting young children with some excellent explanations, useful forms such as schedules and charts as well as videos which illustrate parenting techniques which are supported by decades of research. The videos, which have a humorous touch, illustrate pitfalls we often tumble into as parents and show concrete examples of how to communicate positively, give clear instructions, create structure, and set rules and use consequences including time out.
The site has a very supportive, non-critical tone. It recognizes that all children are different and there is no one size fits all method of parenting. The short videos could be an excellent jumping off place for discussing the use of these techniques with parents.
Posted: May 20th, 2014 by David Rettew
Characterizing the precise pathology in autistic spectrum disorders, let alone other psychiatric disorders, has remained challenging. Postmortem studies of actual brain tissue are rare but have the potential to provide important clues regarding specific abnormalities in neurodevelopment that are not detectable through other means such as neuroimaging. This major study published in the New England Journal of Medicine provides direct and provocative evidence of specific neuronal pathology that may underlie some of the core features of autism.
The authors used RNA in situ hybridization techniques in order to look for gene expression patterns of 25 potential genes that have been implicated in the pathogenesis of autism and mark the presence of particular types of cells at different layers in the cortex. These analyses were performed on areas within the frontal, temporal, and occipital lobes of 11 children with autism and 11 children controls from two established brain banks. Children were between 2 and 15 years of age and the autistic sample was predominantly male.
In 10 out of 11 children with autism, compared to 1 out of 11 children without it, the study found focal areas of significant cytoarchitectural disorganization in the prefrontal and temporal cortex but not in the occipital cortex. These areas were referred to as “patches” and tended to be between 5 and 7mm long, often existing right next to unaffected cortex. The dysfunction was found for different types of neurons but not glial cells. While there was variability found in terms of the precise types of cells and cortical layers that were most affected in the autistic group, such a relatively unique and consistent finding is a major step forward towards understand the precise brain differences in children with autistic spectrum disorder. The data also strongly points to autism beginning in the prenatal period when cortical layering and cellular differentiation are occurring.
The authors wrote that they were somewhat surprised to see such as similar pathological feature across so many children with autism given its heterogeneous nature. They also note that while the presence of these patches was evident, their study does not suggest a mechanism for how these abnormalities in neuronal migration and differentiation they develop.
For those interested in visualizing these brain changes, the NIMH released a YouTube video that shows what the patches look like. I would definitely recommend looking at this to better flavor of these intriguing findings.
Stoner R, et al. Patches of disorganization in the neocortex of children with autism. NEJM 2014;370:1209-1219.
Posted: April 28th, 2014 by David Rettew
Newly analyzed data from the Department of Vermont Health Access is revealing important trends regarding psychiatric medication use in Vermont children and adolescents. The data examines Medicaid insured youth who took at least one medication in various classes (antidepressants, ADHD medications, antipsychotics, etc.) over the course of the year, comparing rates between 2009, 2011, and 2013. Efforts were made to ensure that children were counted only if the medication was used for psychiatric conditions rather than other causes such as seizures or allergies. Separate statistics were computed for children within the foster care system.
One of the highlights is a decrease in the use of antipsychotics among youth. Among 6-12 year olds, the rate dropped from 3.1% in 2011 to 1.7% in 2013, a 45% drop. For adolescents, the rate went from 4.8% in 2009 to 3.5% in 2013. Among foster care children aged 6-12, the rate drop was even more dramatic (17.2% in 2009 to 7.2% in 2013). Antidepressant rates were relatively flat, while ADHD medications increased somewhat. For example, the percentage of adolescents aged 13-17 taking ADHD medications such as stimulants increased from 12.10% in 2009 to 14.1% in 2013, while for younger children (6-12 years old) the rate was pretty stable (13.0% in 2009 to 13.4% in 2013).
These data continue to support the conclusion that the pattern of psychiatric medication usage in Vermont youth is different than most parts of the country. While it is unclear what is responsible for these trends, many efforts have been launched across the state by individuals here at the Vermont Center for Children, Youth, and Families and elsewhere to try an ensure that medications are used carefully and only as a component of a more comprehensive treatment plan that includes many health promotion strategies.