• A-Z
  • Directory
  • myUVM
  • Loading search...

Home – Child Mental Health Blog

Type 2 Diabetes Risk with Antipsychotic Medication Treatment Reported at 0.72%

Posted: October 15th, 2014 by David Rettew

While the  metabolic risks associated with antipsychotic medications use are now well known, finding some actual numbers about the risk have been slow to come.  A recent study by Nielsen and colleagues published in the Journal of the American Academy of Child and Adolescent Psychiatry offers some specific numbers that can be used when discussing the potential risk of developing Type 2 Diabetes in the course of treatment with antipsychotic medication.JAACAP logo

To arrive at these numbers, a case-control design was used that obtained information from a large Danish registry of psychiatric patients under 18 years of age seen from 1999 to 2010.  The indicator of having Type 2 Diabetes was the prescribing on an oral antidiabetic medication comparing between those who were and were not also prescribed an antipsychotic medication.  Antipsychotic use was counted as positive if one or more prescriptions were filled. Regression analyses were used, controlling for age, sex, and diagnosis in order to assess for the possibility that the diagnosis, rather than the treatment, might be behind any increase in diabetes. The records of nearly 50,000 psychiatrically ill youth were examined.

Overall, the rate of Type 2 Diabetes among youth treated with antipsychotics was 0.72% compared to a rate of 0.27% in psychiatrically ill youth not given antipsychotic medication. This difference, when controlling for potential confounds, resulted in a significantly elevated odds ratio of 1.60.  Being female and being older at the time of diagnosis was also related to diabetes. When metformin was excluded as an indicator of diabetes (because of the possibility that it was being used in many cases to treat wait gain and protect against the development of diabetes), the odds ratio related to antipsychotic use went up to 3.71; however, this odds ratio was no longer significant due to such a small number of cases.  (The authors state in the discussion that metformin is rarely used in Denmark for weight control).  Overall, the number needed to harm was calculated at 224.

The authors concluded that antipsychotic medication use does increase the risk of developing Type 2 Diabetes.  In the Discussion section, they recommend close adherence to indication and metabolic monitoring guidelines.

It is nice to have some specific numbers to talk about when having discussion of potential side effects that don’t rely on small and short-term clinical trials.  At the same time, however, these kinds of large registry databases can struggle with measuring other factors that may be important, such as compliance with treatment and overall duration. If milder diabetes was diagnosed but controlled through nonpharmacological means, for example, this study would have misclassified these children.

It will also be interesting to see how this Diabetes risk will be interpreted.  An 60% increase sounds like a lot, yet the overall rate was 0.72% which is likely lower than many people were expecting.  Several of the authors have rather extensive ties to various pharmaceutical companies, which will likely cause some people to discount the results.  As far as I can see, the study has not received much press at all, perhaps because the results were not that dramatic in either direction.


Nielsen RE, et al.  Risk of Diabetes in Children and Adolescents Exposed to Antipsychotics: A Nationwide 12-Year Case-Control Study. JAACAP. 53(9):971–979, 2014.


The Link Between Adolescent Psychiatric Disorders and Crime

Posted: October 9th, 2014 by David Rettew

Are people with mental illness more likely to commit crimes?  This question has been studied and discussed for decades, fueled by movies of deranged serial killers.  For years, the conventional wisdom was that, despite the hype, individuals who suffer from psychiatric disorders are no more likely than anyone else to commit a crime. More recently, however, there’s been a shift in that stance as increasing evidence points to the conclusion that, while the vast majority of those with mental illness do not break the law, the presence of psychiatric disorders is linked with higher rates of crime.  Less is known, however, about children and adolescents, and a new report on adolescents provides Crimesome useful data for clinicians to know and pass along.

The study comes from National Comorbidity Survey – Adolescent Supplement which is one of our most important sources for epidemiological data on the community rates of adolescent psychopathology.  This survey covers a nationally representative sample of 10,123 adolescents between the ages of 13 and 17.  For this article, the key variables were the presence of a DSM-IV disorder as assessed using structured interviews with the adolescents directly as well as self-reported crime and arrest history. The average age was 15.

In terms of overall results, a total of 47% of the sample met criteria for at least one lifetime psychiatric disorder while 18.4% reported having committed some type of crime. Youth with psychiatric disorders were more likely to commit a crime, including violent crime, than those without psychiatric disorders. For crime resulting in an arrest, the largest elevations were, not surprisingly, related to conduct disorder (with an odds ratio of 57.5), as well as alcohol and drug disorders, but most other diagnoses were significant as well, including things such as anxiety disorders.  In terms of percentages, the rate of violent crime resulting in arrest, for example, was 20.4% for those with a diagnosis of conduct disorder versus 0.4% among those with no diagnosis.  The presence of multiple psychiatric disorders further increased the risk of crime. Excluding patients with conduct disorder weakened the link between psychopathology and arrested crime but less so for crime not associated with arrest. At the same time, over 88% of youth with at least one psychiatric disorder had no history of crime.

The authors concluded that the presence of mental illness raises the risk of crime. The authors advocate that these data should strengthen the case of good access to mental health care.  Stay tuned for a summary about a study that documents a decrease in crime among at-risk children who received a comprehensive mental health program.

The major take away point from this study is both that 1) crime rates are elevated among adolescents with psychiatric disorders, and 2) the vast majority of those who meet criteria for a disorder do not report being involved in crime.  Additionally, however, some side findings in this study were also interesting, like what’s up with the diagnosis of  intermittent explosive disorder (at 14.1%) being the second most common psychiatric disorder, while ADHD is a meager 4%.  One also wonders the degree to which the self-report nature of the criminal behavior affected the results and  the fact that many subjects were not yet through adolescence (both of which might have resulted in under-reporting).


Coker KL.  Crime and Psychiatric Disorders Among Youth in the US Population: An Analysis of the National Comorbidity Survey–Adolescent Supplement.  JAACAP 2014; 53:888-898.


Harvard Reserach Study on Early Psychosis Looking for Participants

Posted: October 7th, 2014 by David Rettew


by Sarah Hope Lincoln

Schizophrenia is a disorder that causes significant impairments in independent functioning. While many may associate the disorder with its ‘positive’ symptoms like delusions and hallucinations, there are many ‘negative’ symptoms as well – social and emotional deficits, as well as a loss of pleasure and motivation. The expression and persistence of these negative symptoms may be stronger predictors of poor functioning and independence as the illness takes its course. Because of this, some researchers are beginning to focus on understanding and developing interventions for these negative impairments before individuals experience a first episode of psychosis.

Several studies (Jones et al., 1994; Neindam, 2003) have shown that individuals who develop schizophrenia show nonspecific precursors to the illness, such as social problems, misreading social cues, and difficulty with relationships. Some of these children can be considered to be at risk for schizophrenia and related disorders, although many will not develop the illness.

By understanding what is going on in the social brain of children who are at clinical high risk, researchers hope to eventually develop targeted skills training that may improve a person’s long-term functioning and possibly prevent the disorder altogether.

One of these research groups is the Social Neuroscience and Psychopathology lab at Harvard University. They investigate the neural underpinnings of social functioning and deficits in different populations, and are currently exploring how the brain processes social situations, and how this relates to children’s relationships and their experiences of the world around them. They are currently seeking participants 8-13 years old who may have had any of the following experiences:

–          Feeling worried that people may be reading his or her mind

–          Worrying about being watched or feeling mistrustful of people

–          Hearing or seeing things that others do not hear

–          Isolating from peers, friends or family

–          Performing worse in school

–          Reporting unusual ideas that are hard to follow or understand.

*As these symptoms may be confusing for the child or parent, helpful referrals can be provided as needed.

This is a two-part study that involves a behavioral session that includes questionnaires and interviews with a researcher, as well as a one-hour long brain scan during which your child will be asked to do simple tasks. Throughout the study, the Social Neuroscience and Psychopathology lab makes every effort to ensure the child is safe and comfortable participating in the research. For many children, the experience can be both fun and interesting. All travel costs to and from Boston will be covered, and the child and family will be compensated for each part of the study, possibly up to $110 gift cards for the child and $110 for the family.

To learn more about participating, contact Sarah Hope Lincoln at 559-904-4431 or email childsocialstudy@gmail.com

Vermont Pediatrician, Dr. Joseph Hagan, Running for AAP President-Elect

Posted: September 29th, 2014 by David Rettew

(Note: parts of this posting have previously appeared in online posts for Psychology Today and for Pediatric News)

One of our own Vermont pediatricians, Dr. Joseph Hagan, is running to be President-elect of the national organization, the American Academy of Pediatrics (AAP). Many people around the state and elsewhere know Joe well and support his candidacy. Dr. Hagan has been involved in shaping pediatric mental health care policy for years as the former chair of the AAP’s  Committee on the Psychosocial Aspects of Child and Family Health and Hagan photo rotatedco-editor of the Bright Futures Guidelines.

To provide some more information about Dr. Hagan and elicit his thoughts especially related to child mental health, I sat down with him recently for an informal interview. The following are some excerpts from that meeting.

Q: How did you become interested in running for AAP President?

A: People have asked me and I’ve always said ‘no’ but in the past few years it’s occurred to me that it’s a job that I can do. I’m ready for it and have the skill set necessary, and I felt that I could contribute something. I’ve been asked to do a number of things with the Academy over the years and I’m really proud of the fact that my academy experience over the past ten years has put me in a room with a lot of smart people and let me chair the meetings. We’ll give you product.


Q: Where do you see child mental health on your list of priorities with all the other things you would have to do?

A: I think it has been front and center for the Academy for a long time. I don’t see that changing. I’m going to use every opportunity I get to continue to work at it. It’s sort of who I am as a practitioner. It’s fascinating how capitated managed care decapitated mental health. I don’t know why we decided that the head is any different. We don’t think the kidney is different.


Q: What do you see as some of the key issues affecting child mental health care?

A: One of the things I haven’t heard a lot about is that there are not enough therapists to see kids. The system has traditionally been based upon procedures and not on time and that’s a problem. Therapists get paid less than the shop rate of your local auto mechanic, and of course, anyone who sees kids has to talk to schools and parents outside of the session. That’s non-billable, and we wonder why nobody will see kids. Mental health is part of health and the earlier we invest, the bigger the return. Since our practice was certified as a Family Centered Medical Home and now has access to a Community Health Team, my life has changed because we now have services that we didn’t have before. The problem with screening in the past has been “What if you find something?” Now we have so much more to offer.


Q: How much should a pediatrician really be expected to know and do when it comes to child behavioral problems? Is there a floor of knowledge and skills when it comes to mental health that all pediatricians should attain?

A: I think there definitely is. Behavioral and mental health problems can be managed in our offices and everyone ought to be able to manage the majority of kids with not only with ADHD, but also with oppositional defiant disorder, anxiety and depression. I mean, there are certain mental health problems that are part of pediatrics. To refer a standard ADHD child is absurd because it really is a day to day problem that needs to be managed in your primary care medical home. Everybody needs to know how to do that and do it well. It is a chronic illness and you need to hang in there with these kids.


Q: Psychiatric medications certainly have become even more controversial lately. What advice do you have for pediatricians when they prescribe them?

A: Tell families the expected effects and potential side effects. If you don’t, Dr. Google will. Start low and go slow, but titrate until desired effect of recovery. Remember if you are 100% anxious and miserable, you’ll look and feel great when your only 50% anxious, but you’re still only halfway better! It’s also important to discuss with your patient when you start meds how long you are going to continue them, lest they feel good and stop prematurely.


Q: There are a lot of efforts these days to extend the education of pediatricians and provide consulting back up while the patient remains directly in the care of pediatrician. Do you think those efforts are enough or should we be more focused on providing more psychiatrists and other mental health clinicians that pediatricians can refer to?

A: We need to be able to do this (mental health) work but part of being successful is having someone to consult with and someone to refer to. Just like with cardiac or GI problems, there are cases we can take care of all by ourselves, cases where we will need to reach out to a consultant for help, and cases that need referral. Yes we need more child psychiatrists. Co-located and collaborative care are best-case scenarios.


More information about mental health care from the American Academy of Pediatrics can be found here.  More information about Dr. Hagan can be found here .

Voting for members of the AAP will take place from October 10 through November 10. If you are not a member, you can’t vote, but you still can help spread the word to pediatricians who can. Turnout for elections like these can often be rather low so motivating a few people to vote can make a big difference.  Good luck Joe!

New Study Examines a “Suicide Gene”

Posted: September 10th, 2014 by David Rettew

To keep in mind National Suicide Prevention Suicide Week as well as to offer some hopeful news, this week’s post summarizes a recent study from the American Journal of Psychiatry that claims to have found a gene that is related to suicidal behavior.  It is somewhat of a complicated study with multiple samples (it’s hard to publish single gene studies anymore without an independent replication sample) and Suicide prevention logoassociations related both to the actual gene and its DNA code as well as epigenetic differences in the amount of methylation the gene has undergone: all of which in turn affects how much of the gene product is expressed.  The gene under scrutiny is involved in the regulation of the hypothalamic-pituitary-adrenal (HPA) axis function: a key factor in a body’s response to stress. Previous research in both animals and humans has suggested that genes involved in this process might be an important place to look.

This study used prefrontal cortex tissue from several brain banks that included many individuals with depression, some of whom died by suicide. Possible candidate genes that emerged were then validated in tissue from other individuals as well as gene expression analyses from three groups of living patients (coming from blood not brain, obviously), where levels of anxiety and stress were assessed as well as concentrations of salivary cortisol.

The signal for suicide and suicidal behavior was found to be related to the SKA2 gene on chromosome 17. As mentioned, a significant association was found both related to DNA, specifically a single nucleotide polymorphism (SNP) at location rs7208505, and more strongly to epigenetic changes of that gene.  Here, increased methylation was related to higher rates of suicide as well as higher rates of suicidal behavior. The accuracy of predicting suicidal behavior from these genetic and epigenetic variations in the living group was quite high at 80%, particularly the progression from suicidal ideation into attempt.  However, this number comes from complicated statistical models and does not lend itself to an easy yes/no prediction of suicidal behavior based on the result of simple blood test.

The authors concluded that the SKA2 gene and its level of epigenetic changes may be an important biomarker for suicidal behavior. In saying this, however, it is important to remember that the term “suicide gene,” just like an “ADHD gene” or a “depression gene” is really a misnomer, as genes don’t code for diseases per se but rather for products involved in some kind of brain activity.  In this case, the SKA2 gene is thought to help “chaperone” a glucocorticoid receptor (which may play an important step in regulating down the stress response) to the nucleus and can thus play a role in HPA axis function.  While certainly an important and thought provoking study, the authors cautioned that their sample size was small and results should be considered preliminary.  Lest people also start thinking that certain people are destined to be depressed and suicidal, it is also important to note that epigenetic changes to genes such as the ones found to be important in this study can be strongly related to the quality of one’s environment.


Guintivano J, et al.  Identification and Replication of a Combined Epigenetic and Genetic Biomarker Predicting Suicide and Suicidal Behaviors.  Am J Psychiatry 2014, epub ahead of print.

How Well are ADHD Medications (or any Drug) Tested Prior to FDA Approval?

Posted: August 27th, 2014 by David Rettew

ADHD medications are some of the most common drugs given to children and adolescents. Most clinicians prescribe them within approved FDA indications.  Moreover, the existence of an FDA approval often provides some comfort to the prescribing clinician that the medication has received rigorous testing for efficacy and safety.  But has it?  A recent study in PLOS One attempted to summarize how extensively ADHD medications were studied prior to the FDA approval with particular attention to the ability to detect rare side effects or safety over the Ritalinlong-term. Guidelines for the optimal testing of medications used for chronic conditions do exist  from an organization called the International Conference on Harmonization of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH).

The authors gathered data on all clinical trials performed on ADHD medications that have been approved by the FDA. Much of the information came from what are called FDA Drug Approval Packages that contain a large amount of data related to the approval process of a new drug. Key variables of interest for this study included the number of participants in the trials and the length of the studies.

A total of 32 trials were found that evaluated 20 different medications. Of interest, the oldest ADHD drug, Ritalin, was approved in 1955 based on clinical experience rather than a clinical trial. A total of seven drugs, including Adderall, were approved without a clinical trial of ADHD subjects. Only eight of the trials were published in the medical literature. The median number of participants per drug was 75 while the median length of a clinical trial was 4 weeks (the ICH recommends at least 300 patients studied for at least six months). For six medications, approval was contingent on collecting data post approval, although this occurred in only two cases.

The authors concluded that the amount of data collected in the process of obtaining FDA approval is inadequate to evaluate both for rare side effects or long-term safety.  These trials fall well short of ICH recommendations, although the authors acknowledge that for many of these medications there now exists much more data from various sources.

In reading this study as a psychiatrist, I had two main take-away impressions.  The first was some surprise at how  small and short many of the trials were.  While certainly one might expect similar efficacy and safety profiles for compounds that are so similar chemically, its probably safe to say that most clinicians assume a little more has been done to obtain FDA approval.  The second impression (and this was the nagging question that kept coming into my mind as a read the article) was whether these holes in premarketing research were specific to ADHD medications versus being present for other classes of drugs. It was quite amazing to me how the authors barely addressed this obvious and important question, and its absence made the article seem more politically than scientifically motivated.  Are asthma drugs any different?  Probably not, and not acknowledging this adequately just fuels a fire against psychiatric medications that everyone knows is easily ignited.


Bourgeois FT, Kim JM, Mandl KD. Premarket Safety and Efficacy Studies for ADHD Medications in Children.  PLOS One 2014: 9(7) e102249

Teacher Depressive Symptoms and Child Behavior

Posted: August 19th, 2014 by David Rettew

It has been widely shown at this point that psychiatric problems in parents can negatively affect child behavior, but what about teachers?  These days, many children spend as much if not more of their waking hours with teachers and other childcare providers than they do with parents.  As such, it seems logical to extend the investigation of adult emotional-behavioral symptoms affecting children beyond studies involving just Mom and Dad.  A recent study  by Jeon and colleagues, published in the Journal of Consulting and Clinical Psychology, did just that.Teacher

The data come from the Fragile Families and Child Wellbeing Study in which 761 3-year-old children and their mothers (mainly from disadvantaged backgrounds) were assessed along with their preschool teachers.  While teachers were not formally diagnosed or evaluated, they did report on their own mood using a short 6-item version of the Johns Hopkins Symptom Checklist.  Child behavior, meanwhile,  was assessed with our favorite instruments, namely the Teacher Report Form (teacher report) and Child Behavior Checklist (parent report). Path analyses were used to examine the link between teacher depressed mood and child internalizing and externalizing problems, and to test the possibility that any association is mediated through a lower quality of childcare as measured through observer ratings.

The results depended a bit on who rated the child’s behavior.  When child behavior was assessed by teachers, a teacher’s self-reported depression score was both directly related to child internalizing and externalizing problems and indirectly related through a reduced quality of childcare. When child behavior was assessed by parents, however, only a direct significant association was found between teacher mood and child level of internalizing problems. While statistically significant, the magnitude of the effects were not overwhelming.  For example, the raw correlation between teacher depression score and childcare quality was a fairly meager -.12.   

The authors concluded that there was some evidence that depressive symptoms in teachers can be related to child behavior problems both through lower quality of childcare and through other means yet to be determined. They advocated for additional efforts to support the psychological well-being of teachers, both for its own sake and as a means to optimize the quality of childcare.

One important sidenote not addressed by the authors is that this study, in my view, strengthens the argument that parental mental health really does affect a child’s behavior because by looking at teacher effects, they remove the potential confound of shared genes that can muddy the waters in studies with parents.  Some people might also be interested in how depressed the teachers actually were.  Again, this was not focused upon in the paper other  than reporting that their mean score was 8 on a scale that went from 0 to 18.


Jeon L, et al. Pathways From Teacher Depression and Child-Care Quality to Child Behavioral Problems.  J Consult Clin Psychology 2014;82(2):225-235.


Child Victimization on the Decline

Posted: August 11th, 2014 by David Rettew

You may not know it from looking at the news, but the rates of many forms of child maltreatment and victimization may actually be falling.

A recent study from JAMA Pediatrics documents the rate youth victimization from 2003 to 2011. Random telephone surveys (those annoying phone calls we often get and ignore) were conducted in 2003, 2008, and 2011 among 2,030, 4,046, and 4,107 households, respectively.  A strength of the study was that the same questionnaire was used at all time periods. This instrument queried a number of child maltreatment domains such events of abuse, violence, or other Family shotforms of victimization that occurred in the past year. The researchers were interested in changes in victimization rates from 2003 to 2011 and also probed the 2008-2011 interval which included the most recent economic recession. For younger children, a parent was interviewed while for older kids, the child was interviewed directly.

Results revealed that the rate of victimization significantly dropped from 2003 to 2011 for slightly over half of the variables studied, including things such as bullying, assault victimization, sexual victimization.  Also falling were rates of violence and property crime that the youth questioned perpetrated on others. The overall rate of child maltreatment during this period dropped by 26 percent. Declines were also observed for the period between 2008 and 2011, although these were not as pronounced. For no variables did the rate significantly increase. Furthermore, most of the observed trends were widespread and did not pertain just to certain groups based on age, gender, or other demographic variables.

While one can conclude only so much from a telephone survey study, the results are consistent with several others that document that many indices of child mental health are improving, despite headlines to the contrary. While the authors could not determine why these rates are declining, some potential candidates were mentioned. One of them was the presence of direct efforts on the part of many organizations to reduce child victimization. Also mentioned by the authors is the frequently maligned increase of psychiatric treatment that has occurred over the past couple of decades as people recognize that some of the bullies and parents and other individuals who are at risk of harming children meet criteria for psychiatric illness and aren’t “just” being bad.  The authors even speculated that increased use of electronics might be decreasing overall negative face to face encounters in addition to providing a quick route to alert other people when they occur.

Obviously these data shouldn’t cause us to slow our pace against the prevention of adverse child events that continue to exact huge tolls on our kids.  However, these numbers are encouraging and need to be given the same media attention as many of the negative headlines that predominate the media.


Finkelhor D, et al., Trends in Children’s Exposure to Violence, 2003 to 2011.  JAMA Pediatrics 2014;168(6):540-546

No Link Between Assisted Reproduction Techniques and Autism Related Genetic Events

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

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. Autism and Assisted repro

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.

Trauma or ADHD? You May Not Need to Decide

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.”ADHD and trauma blog

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.

  1. 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.
  2. 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.
  3. 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.

Contact Us ©2010 The University of Vermont – Burlington, VT 05405 – (802) 656-3131