Participants included 40 typically developing infants from the age of 8 to 20 months and their mothers.  Subjects were randomized to four conditions: baby signing, British sign language and two control conditions, a nonintervention and a verbal training condition.  The authors assessed language development using standard measures.  In a second study using a subset of the original sample, recorded and coded interactions were used to assess infant-mother relationship qualities at multiple home visits when infants were at ages 10, 12, 16, and 20 months.

Results showed that the program to encourage baby sign did not result in any improved outcomes with regard to spoken language development, although the infants taught gestures generally were able to use them to communicate.  There was, however, an indication that a few infants, especially those with lower baseline expressive language, may have benefited more than others.  In the second study, significant differences were found in other areas, with mothers who participated in the sign training found to be more attuned to infants’ nonverbal cues and more encouraging of infant autonomy than those in the control group.

The authors concluded that while there was no evidence of accelerated language development with the use of baby signing, benefits were observed for the practice in other areas of the mother-infant relationship.

In light of the expanding market for baby signing classes and products, this study suggest that such things may be unnecessary, at least with regard to typically developing infants and language acquisition.  The authors acknowledged some limitations of the study including recruiting a fairly high SES group of mothers and having a small sample size. Thus, it is possible that there may be benefits to the technique but in groups, unfortunately, that are typically less likely to try baby signing in the first place.  The bottom line here is that there may be good reasons for parents to want to do some baby signing but giving them a leg up in terms of language development probably isn’t one of them.

The data from this study comes from the National Comorbidity Survey – Adolescent Supplement.  The participants are a nationally represented sample of over 10,000 adolescents between the ages of 13 and 18 who were assessed directly at home or at school for the presence of DSM-IV psychiatric disorder using a structured interview.   Medication usage over the past year was also assessed.

Results showed that of youth meeting criteria for any psychiatric disorder, only 14.2% were taking a medication in the past 12 months, with only approximately a quarter receiving any mental health services.  The types of medication participants were taking reflecting the nature of their disorder, although rates of medication usage tended to be low for all disorders.  A total of 20.4% of youth with a diagnosis of ADHD were being treated with stimulants, while 14.1% of adolescents with a mood disorder were taking an antidepressant.  The rate of antipsychotic usage was found to be 1.0% and was generally being prescribed for those with developmental disorders. The proper correspondence between type of disorder and class of medication was found to be more common among youth in the mental health system in comparison to those in general medical care. Looking at the flip side, only 2.5% of adolescents who did not meet criteria for a psychiatric illness had been given a prescription medication.

The authors concluded that the vast majority of youth with mental disorders are not being treated with psychiatric medications.  They argue that their study challenges the common perception that youth are being overprescribed psychiatric medications.

After reading this study, the rates of medication usage in this study are amazingly low.  Perhaps some subjects previously were taking medications but no longer were due to side effects or poor response. Others have questioned the claim that this sample truly is nationally representative with a concern that lower SES groups may be underrepresented (who also tend to have higher rates of medication usage). In the end, however, it is undeniably true that there exist children both who could benefit from medication but don’t take it in addition to those who take medication but don’t need it.  Our efforts might be best utilized by trying to reduce both of these groups rather than arguing over which group is larger.

Reference

Merikangas K, et al. (2013) Medication Use in US Youth With Mental Disorders.  JAMA Pediatrics 167(2):141-148.

The study comes from the Psychiatric Genomics Consortium.  It compares a group of 33,332 individuals with various psychiatric disorders to a group of 27,888 controls. The types of psychiatric disorders examined included autistic spectrum disorders, ADHD, bipolar disorder, major depressive disorder, and schizophrenia.  The subjects have previously been involved in genetic studies looking that tried to pair specific genes with a single disorder. The authors performed a genome-wide association study or GWAS that was able to examine associations between these various disorders and single nucleotide polymorphisms or SNPs.

Results showed that four SNPs attained statistical significance at the genome wide level, which controls for the number of tests made. Significant associations were found at four loci, including 3p21, 10q24 and in two SNPs that involved genes that encode for L-type voltage gated calcium channel subunits.  These SNPs were associated with multiple psychiatric disorders, with the two calcium channel signaling genes related to all five disorders tested.

The authors concluded that there was evidence for some common genetic factors that were related to multiple types of disorders.  The authors advocated for a classification system that went beyond symptom description and was informed by disease mechanisms.

This is an important study in many ways.  Clinicians have long been aware of the fact that the boundaries between supposedly distinct categories of disorders are not very clear, and these data suggest that one of the reasons that these lines can be so fuzzy is that many disorders share a common genetic diathesis.  What is significant further is the hint at what exactly these common genes are, giving researchers a potential target for interventions that could cut across many types of psychopathology.

Reference

Smoller J et al.  Identification of risk loci with shared effects on five major psychiatric disorders: a genome-wide analysis. Lancet. Published online Feb, 2013.

The subjects of the study were 297 college students (88% women) who completed very brief questionnaires regarding their current mental health and life satisfaction and their perceptions of the way they were parented.  The authors developed their own measure of helicopter versus autonomy-supported parenting (specifically mothering) that the students completed regarding CURRENT parenting behavior.  Path analyses were used to test for significant associations and the hypothesis that the associations between helicopter parenting and negative outcomes were due to feelings of reduced autonomy.

The results indicated that subjects who reported having more overcontrolling parents manifested significantly higher depression scores (although they were not clinically depressed) and lower scores on life satisfaction.  This effect appeared to be mediated through the subjects’ feeling that their developmental needs for autonomy and independence were not met adequately.

The authors concluded that excessively high levels of parental monitoring and control are related to negative child behavior and lower life satisfaction. They interpreted their results in the context of self-determination theory which posits that individuals have innate needs for autonomy, feeling competent, and being involved in caring relationships. However, they acknowledged that their data were cross-sectional and thus they could not be sure that more helicopter-style parenting was a result rather than a cause of more depressed children.

While this is certainly an interesting study worthy of discussion, the article received an usually high degree of media coverage for a study that essentially gave college students several questionnaires at a single point in time. This attention was due to the timeliness of the topic.  Indeed, the way this study was portrayed in the media is as much of the story as the study itself, in my view.  Many summaries of the article, such as what appeared in Time magazine,  featured a picture of a much younger child. Obvious flaws in the study were rarely discussed except, ironically, by the authors themselves. Questions about nonlinear relations between supervision and child outcomes (in other words, maybe there is a bell shaped curve rather than a line in the relations between monitoring and child health) or about different levels of supervision needed at different developmental levels were absent. Patients and family members often are influenced by these quick media summaries of scientific articles, and it is important for clinicians to help educate others not only about the findings of a study, but also its limitations.

Reference

Schiffrin H, et al.  (2013) Helping or hovering? The effect of helicopter parenting on college student’s well being.  J Child Fam Studies.  Published online in Feb, 2013.

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.

As would be expected, the report has generated a firestorm of discussion and debate with many concerned that this rise in ADHD diagnosis represents an excessive broadening of the criteria that subjects too many youth needlessly to the dangers associated with ADHD medications.   Unfortunately, these data are unable to answer this question.  According to the graph accompanying the article, the rate of diagnosed ADHD in Vermont is around the national average.

As people debate the important questions raised by this survey, it may be important to keep a few things in mind.

1.  ADHD is a real brain-based phenomenon with overwhelming scientific evidence to support its validity.

2.  ADHD likely exists more like a continuum (similar to blood pressure or cholesterol) rather than in binary form.  Consequently, there is no clear boundary or cut-off between typical and abnormal levels of these behaviors.

3.  Establishing a diagnosis of ADHD requires a careful evaluation that includes input from multiple sources and assessment of behaviors relative to expected norms of others of the same age and sex.

4.  Family-based multimodal treatment of ADHD can result in substantial improvement but need to be weighed against the potential risks of medications.

Bottom line:  Are there kids being diagnosed with ADHD and treated who don’t meet criteria for the diagnosis?  Yes.  Are these also youth who do meet criteria for ADHD who are suffering needlessly because a lack of diagnosis and treatment?  You bet.  Let’s work then, to reduce BOTH scenarios and leave the finger pointing to those who don’t have kids to care for.

Of the 304 original participants in PATS, 207 participated in follow-up.   Children had an average age of 4.4 years at baseline and 10.4 years at 6 year follow-up. Children were also assessed 3 and 4 years after baseline, at which point they were being treated in the community. The sample was 75% male.  Diagnostic assessments included a comprehensive clinical evaluation, enhanced with the use of both quantitative instruments such as the Conner Rating Scales and a structured diagnostic interview.

Results showed that ADHD symptoms significantly dropped from baseline to the first follow-up 3 years later but leveled off after that.  On a relative basis, girls tended to have higher baseline scores and steeper drops in symptoms than boys.  At follow up assessments, average ADHD scores continued to be in the moderate to severe clinical range for parent ratings, with a surprising 89% of the sample still meeting criteria for ADHD 6 years later. Medication status was not significantly related to whether or not a child met criteria for ADHD at follow-up. Similar patterns were observed for both inattentive and hyperactive/impulsive symptoms.

Study authors concluded that the diagnosis of ADHD in preschool is fairly stable and associated with chronic symptoms into later childhood, even with treatment.  They suggest that the conventional tendency for a more hands-off approach to preschool ADHD may be misguided and, by contrast, early and more intensive treatment may be required, including parent training, school-based behavioral interventions, and more effective medications.

Of note,  this article focused on ADHD symptom stability and further reports are expected related to other domains such as cognitive and academic functioning.  This sample of children, seen in academic medical centers for ADHD, is likely more symptomatic than children seen in the community which could affect the generalizability of the results.  Further, the fact that subjects were no longer randomized at follow-up severely limits firm conclusions about the long term benefits of medications.  Nevertheless, the number of symptomatic children overall raises concern that the outlook for typical medication treatment, at least for those with preschool-onset ADHD, is not as positive as generally believed.  It is interesting that the authors interpreted this finding as evidence for needing more intensive treatment (under the notion that regular treatment is not enough but could be effective at higher levels) rather than evidence for doing less (under the notion that treatment in this group is not that effective anyway).  Obviously, more research will be needed to answer that important question.

Reference

Riddle et al., The preschool ADHD treatment study (PATS) 6-year follow up.  (2013)  J Am Acad Child Adolesc Psychiatry 52 (3):264-278

Research shows that children of divorced parents do best when both parents are actively involved in the lives of the children.  If we say we want  both parents to make the emotional, financial, and time investments required to raise a child right, we cannot perpetuate a legal policy that works so effectively against that goal.

Fortunately, a growing movement, headed by Chris Weinberg of Jericho, is trying to move Vermont forward and encourage our legislature to change this antiquated and destructive policy.  There has been some opposition to the proposal, based on the concern that incompetent parents will be given too much access and control.  This worry is misguided in my view.  To be clear, nobody supporting this legislation is interested in having unfit or abusive continue to influence their children’s lives, and judges would be free to award single custody when that is in the best interests of the child.  What would change is that judges would no longer be forced to send a good parent to the sidelines when joint custody would be more appropriate.

You can find out more at JointCustodyVT.org and sign an online petition at Change.com.  To make sure this issue gets the attention it deserves in January, we need to convince our legislature that Vermonters want this issue on the agenda in 2014 with no more delays.

Study participants come from the well-known Dunedin Multidisciplinary Health and Development Study, which is perhaps best known for a landmark gene-environment interaction study. The sample included 1037 individuals who were evaluated initially at the age of 11 for psychotic symptoms using a structured interview and followed until age 38.

A total of 1.7% of children at age 11 reported clear psychotic symptoms. By age 38, 3.7% of the sample had been diagnosed with schizophrenia or met criteria for the illness. Results showed that psychotic symptoms present at age 11 were significantly associated with schizophrenia. A total of 23% of those with psychotic symptoms at age 11 had the diagnoses as compared to 3% of those without clear childhood symptoms, for a relative risk of 7.24.   However, children with psychotic symptoms were also at significantly elevated risk for PTSD (RR=3.03) and suicide attempts (RR=3.82).  The rate of adult PTSD in the group with child psychotic symptoms was 46.2%, and few were free of any diagnosable psychopathology. None of those children with psychotic symptoms at age 11 went on to be diagnosed with an episode of mania.

The authors concluded that early appearing psychotic symptoms was a risk factor for later schizophrenia but was also related to adult PTSD and suicide attempts. Overall, child psychotic symptoms appeared to be a strong indicator for  higher levels of adult psychopathology in general.

While the overall n of the study is impressive, it is important to remember that the n for most of these analyses was only 13. Nonetheless, the conversion rate to schizophrenia of 23% among those with early psychotic symptoms is similar to other reports and is a percentage that clinicians might want to remember when talking to families.  The lack of bipolar disorder is also worth mentioning as conventional wisdom from much of the American literature suggests a strong link between psychotic symptoms in childhood and bipolar disorder.

Reference

Fisher et al. (2013).  Specificity of childhood psychotic symptoms for predicting schizophrenia by 38 years of age: A birth cohort study. Psychol Med, January, 1-10

March is the right time to start planning your children’s summer camps and activities. There tends to be a lot of fun options in Vermont, but many will get filled up before you can say “snow’s gone”. A good place to begin your search is by talking to friends and contacting your local recreation department, there are also a number of web sites which list a variety of Vermont based camps:

http://www.findandgoseek.net/

http://www.vermontcamps.org/

http://www.vtliving.com/summercamps/index.shtml

http://www.kidsvt.com/

These days the variety of camp options is mind boggling, there are acting camps, animal care camps, fantasy writer’s camps, magic camps, computer programmer camps as well as the usual arts and crafts, outdoor activity and sports camps. The more focused theme and sports camps often appeal to the older camper.

Camps vary greatly in cost, multiple week sleep away camps can cost from $400 to over $1000 a week, local day camps are generally $200-400 a week, and frequently scholarships are available and should be applied for early.

Tip: If your children are anything like mine were, they will dismiss the need for camp altogether. “Don’t sign me up for any of those camps this summer, I am just going to hang with my friends”, don’t be fooled, “hang with my friends” is slang for “keep the shades pulled down in the basement and play computer/video games all day”. Better to offer a choice of camps and stay firm that not going to camp is not an option, then walk away! Many of my best memories and the skills that I am most proud of today (wicked crawl stroke) are from the summers I spent at camp.