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Home – Child Mental Health Blog

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.


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.



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.


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.


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)


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.

New Website for Vermont Family Based Approach

Posted: March 18th, 2015 by David Rettew

Want more Vermont Family Based Approach?  If you do, a new blog and website has been created that will contain additional news and information.  You can also follow them at Twitter at @theVFBA.  One of the first posts is a link to an incredible video that describes the VFBA by child psychiatry fellow Sean Ackerman, who previously was a film director.  We encourage you to check out the new site and learn more.

Suicide Prevention in Schools

Posted: February 25th, 2015 by David Rettew

Suicide and suicide attempts remain a major public health problem.  There is now evidence that after years of decline, suicidal behavior is once again on the rise.  In Vermont, suicide is now the number two killer of older adolescents.  One can only imagine the attention and public health response that would occur if something like measles or ebola or terrorism was related to this kind of mortality here in Vermont and elsewhere. A recent compelling story on the subject was aired last week on WCAX by Darren Perron entitled Hidden Heartbreak Part 1 and Part 2.YAM

While there have been many initiatives taken to try and prevent suicidal behavior, it has remained a challenge to demonstrate that these efforts are effective, especially when it comes to decreasing discrete behaviors such as suicide attempts.  Since these are (thankfully) relatively rare events, very large sample sizes are needed to show the effect of an intervention.  A recent study, however, attempted to do just that by comparing the efficacy of three different programs in a sample that included over 11,000 adolescents from 168 different schools across 10 EU countries.  The paper was published in the prestigious journal, the Lancet.

The schools were randomized to administer one of three intervention programs.  The first, called Question, Persuade, and Refer focused on training teachers to identify and communicate with high risk youth. The second program, Youth Aware of Mental Health (YAM), was a universal intervention designed to teach all students to change negative perceptions and to enhance coping strategies through lectures, workshops, and educational materials.  The third program, Screening by Professionals, involved examining the study’s baseline mental health data and inviting those students who scored above established cutoffs to get a professional assessment.  There were also control schools that received educational posters only. The primary outcome measure was number of new suicide attempts and presence of severe suicidal ideation at 3 and 12-month follow-up, as assessed through self-report instruments.

At the three month follow-up, there were no significant differences between any of the intervention groups and the control condition.  However, at 12 month follow-up, students who received the Youth Aware of Mental Health (YAM) program had about half (0.70% versus 1.51%) as many suicide attempts compared to the control group and were half as likely to report serious suicidal ideation.  Putting the results another way, having 167 students in the program was found to be related to 1 less suicide attempt. These results did not vary according to sex or age, and there were no completed suicides that occurred during the study period.

The authors concluded that the Youth Aware of Mental Health program is effective in reducing the number of suicide attempts.  They urged more study and broader implementation of universal suicide prevention programs.

What makes this study exciting is that it is one of the first to document actual reductions in suicide attempt related to a school based intervention, as many studies prior to this have focused on increases in education and attitudes.  The YAM program does have a website for people interested in training and implementation of their method.  Doing a little research with help from the Vermont Youth Prevention group, it looks as though many Vermont schools utilize a program called Lifelines that has both primary and secondary prevention components.   This program, from a quick look, appears to have some overlap with the YAM program, although a more thorough review and comparison might be useful.


Wasserman D, et al. School-based suicide prevention programmes: the SEYLE cluster-randomised, controlled trial.  Lancet 2015: epub ahead of print.


Fewer Emergency Department Visits When Children Taking ADHD Medication

Posted: February 19th, 2015 by David Rettew

Children who meet criteria for ADHD are known to be prone to all types of injuries ranging from traffic accidents to colliding with objects at home.  While most of the studies on ADHD treatment concentrate on symptom reduction and school achievement, the small literature on accidents has been inconclusive.  A recent paper published in the journal Pediatrics, however, attempts to use a large database to examine this question more fully.

The authors utilized a large electronic database of health care information for patients living in Hong Kong.  The main outcome variable was the n

Copyright (C) 2010 Rajan Chawla / University of Vermont Medical Photography

Copyright (C) 2010 Rajan Chawla / University of Vermont Medical Photography

umber of trauma-related emergency department (ED) admissions between 2001 and 2013 for over 17,000 youth between the ages of 6 to 19 who at one time were prescribed methylphenidate.  The study design was such that each child served as his or her own control.  In other words,  ED admission rates were analyzed by comparing the number that occurred when the  child was taking medication versus time the same child was not taking medications. Incident rate ratios (IRR), similar to odds ratios, were calculated, controlling for age and season.  The authors also checked admission rates for ED visits not related to trauma as a control for their findings, under the hypothesis that methylphenidate would have no association in these cases.  They also examined their data in different ways to make sure their findings held.

Overall, they found that approximately 28% of children in the study had a trauma-related ED admission during the study period. The rate of admission during times children were being prescribed methylphenidate was significantly lower than during periods when the child was not prescribed methylphenidate, with an IRR of 0.91 (roughly a 9% reduction). This effect was found for both girls and boys and was particularly strong for older adolescents, where an impressive 32% reduction was found. Bolstering confidence for the results was that no association with methylphenidate was found for non-traumatic ED visits.  They also found similar results when they categorized their data slightly different ways.

The authors concluded that they were able to detect a protective association for methylphenidate related to traumatic injuries resulting in emergency department visits. The authors suggest that this factor be taken into account when deciding about treatment.

In looking at the raw numbers in their Table 1, it appears like these results would not have been significant had they not controlled for age and season. What that means isn’t exactly clear and the authors, unfortunately, did not comment on this. We also don’t know exactly what types of injuries did occur.

Lending additional confidence to the findings, however, relates to the study’s design in which each subject served as their own control.  The authors state that this aspect helped them reduce bias related to ADHD severity.  However, it is also possible that subjects more likely received medication when their symptoms were more severe.  If so, then this element would have biased the authors against finding the result that they did.  Finally, it should be noted that several of the authors did have financial ties to the pharmaceutical industry.

Lest anyone think that this post is all about advocating just for medications, I also can’t help but make reference to a similar study http://www.bmj.com/content/331/7531/1505 done in 2005 in England that showed an association between decreased ED visits for trauma and the release dates of two Harry Potter novels.  There is obviously more than one way to help children stay safe.


Man KKC, et al., Methylphenidate and the Risk of Trauma.  Pediatrics 2015:135:40-48.


Postconcussive Symptoms and Cortical Thickness in Hockey Players

Posted: February 9th, 2015 by David Rettew

There has been a lot of concern lately about concussions suffered all levels of sports competition. Some research exists that repetitive blows to the head can result in accelerated thinning of the cortex: a marker of possible compromised cytoarchitectonic integrity. This recent study published in the Journal of Pediatrics by the University of Vermont’s Dr. Jim Hudziak and coworkers examines the cortical thickness of ice hockey players as it related to a history of concussion and post-concussive symptoms.

Hockey - Photo by Steve Mitchell

photo by Steve Mitchell

The subjects for this study were 29 healthy male hockey players between the ages of 14 and 23, playing on preparatory school or collegiate ice hockey teams.   A total of 16 of them reported that they had been diagnosed with a concussion at least once by a medical professional. Five subjects in this sample had been previously diagnosed with ADHD. Current post-concussive symptoms were assessed using the Immediate Post-Concussion Assessment and Cogntive Testing (ImPACT) battery, a computerized assessment that probes a number of domains including memory, processing speed, impulse control, and reaction time.  As the name suggests, this instrument is often used soon after a concussive event. Thus, what makes this study more novel is that these players had not recently been concussed and were not currently complaining of symptoms.   Levels of behavioral problems were also assessed using the Youth Self Report and the Adult Self-Report instruments. Anatomical MRI scans were obtained with the main variable of interest being the thickness of the cortex in relation to the total score on the ImPACT, after controlling for age.

In terms of results, total concussion symptoms were significantly associated with a thinner cortex in multiple brain regions including the left dorsolateral, ventrolateral, and orbitofrontal cortices and the right dorsomedial cortex, and bilaterally in the tempoparietal cortices. These associations remained even after controlling for levels of presumably baseline behavioral problems. Additional analyses revealed that the brain changes were related especially to symptoms such as difficulty paying attention or remembering, fatigue, or the feeling of being in a mental fog.

Interestingly, a history of concussion by itself was not related to brain thinning overall, although a significant interaction was found between concussion history and age such that in several brain regions, subjects with no history of concussion exhibited age-related thinning in those areas while those with a history of concussion did not.   Another intruiging findings was that levels of attention problems, irregardless of cause,  were related to reduced thickness in the left anterior cingulate, left ventromedial prefrontal cortex, and left dorsomedial prefrontal cortex.

The authors report that this is the first study to find an association between brain structure and post-concussive symptoms in healthy male athletes.  They state that their findings related to brain changes and post-concussive symptoms in the absence of there being a direct link with concussion history suggests that it may be the more numerous and subtle blows that impact the brain more than discrete concussive episodes.

These data will likely add to the growing concern and effort to keep brains safe during sports so that the many benefits of exercise and team sport participation can be realized.


Albaugh M, et al.  Postconcussive Symptoms Are Associated with Cerebral Cortical Thickness in Healthy Collegiate and Preparatory School Ice Hockey Players. J Pediatrics, 2014, epub ahead of print.

Treating Parental Depression Benefits Children

Posted: January 28th, 2015 by David Rettew

At our clinic at the Vermont Center for Children, Youth, and Families, one unique component of our child psychiatry evaluations is the provision of also assessing mental health problems in the parents, using validated rating scales.  This element was included in the face of mounting data showing that successful treatment of psychiatric disorders in parents can result in behavioral improvements in their children.  Now, a recent study adds some new wrinkles to this issue while giving clues about how this effect might work.Parental depression

The study is a randomized double-blind 12 week clinical trial for 78 mothers with clinical depression that compares  two different antidepressants and their combination.  One group was treated with buproprion (Wellbutrin) only, one with escitalopram (Lexapro) only, and another group treated with their combination. Behavior problems in their 135 children, ages 7 to 17, were also assessed. Additionally, parenting behavior and maternal negative affectivity (guilt, hostility/irritability, anxiety) were also evaluated.

Treatment of the maternal depression was relatively effective with remission occurring in 67% of the sample.  There were no significant differences in remission between the treatment groups. However, the association between improvement in the mothers’ symptoms and improvement in their children’s depressive symptoms and functioning was significant for mothers in the escitalopram only group. In examining possible mechanisms for the child improvement, there was some evidence that mothers in the escitalopram group had improved abilities to listen and communicate with their kids. The children in this group corroborated the mothers’ report by noting greater maternal care and affection with treatment. Further, child scores improved among mothers with high levels of negative affectivity again for patients in the escitalopram only group but not for the other groups.

The authors concluded that the effect of children’s behavior improving as their mother’s depressive symptoms improve may depend of the type of treatment. They hypothesized that treatments that improve maternal anxiety and irritability may be especially helpful through their effect on parenting.

In discussing their results, the authors admit being somewhat surprised and puzzled with why the escitalopram only group seemed to fare better than the other two groups when it came to child behavior.  It also is important to note that this study does not imply that medications should be the sole focus of treatment for depressed parents, as another study found similar benefits when using interpersonal therapy (one of the evidence-based psychotherapies for depression).   Also worth noting is that this study was conducted before the FDA warning on ecitalopram that recommend not exceeding a dose of 20mg.  In this study, patients received as high as 40mg.

In summary, this study nicely helps connects the dots between changes in maternal symptoms, changes in child symptoms, and possible mechanisms for this effect through modifications in parenting behavior.  For primary care clinicians, it is important to ask about emotional-behavioral problems in parents when evaluating children.  Family physicians may particularly be in prime position to help their child patients by addressing the mental health concerns of the parents.



Weissman M, et al.  Treatment of Maternal Depression in a Medication Clinical Trial and Its Effect on Children.  Am J Psychiatry 2014, epublication ahead of print.

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