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Home – Child Mental Health Blog

Next Child Psychiatry in Primary Care Conference Friday, May 30

Posted: January 13th, 2014 by David Rettew

pcp conference

Please mark your calendars to attend the 8th annual Child Psychiatry in Primary Care conference to be held Friday May 30, 2014 at the Doubletree Hotel in South Burlington, Vermont.  It promises to be another captivating and practically useful event for primary care clinicians, mental health professionals, and educators.

We plan to have our usual mix of lectures, breakout sessions, and the opportunity to ask case-based questions to a panel of experts.

More information will be coming soon and you can check back at this site and the UVM Continuing Medical Education page.

If there are specific suggestions for topics, please use the comment function here or you can email me at david.rettew@med.uvm.edu.

Vermont 34th in Rate of Stimulant Treatment

Posted: January 5th, 2014 by David Rettew

The popular press has been abuzz with articles on ADHD, with many suggesting that the diagnosis is much overused and that medication treatment is basically a way that affluent parents give their children an academic advantage.   In the midst of all this controversy comes a recent and interesting study in the journal Psychiatric Methods, which compared the rates of stimulant treatment in children and adults across regions, states and counties.

Using an IMS Health database, a total of 24.1 million prescriptions were analyzed, all issued in 2008 and representing over three-quarters of all U.S. pharmacies.   Prevalence rates were calculated using weighted statistics based on U.S. census numbers and regression models were applied to examine potential factors that might be related to the variable rates between different areas.  Of note, the authors looked at sustained stimulant treatment and did not count prescriptions that were filled only briefly.

Overall, a total of 2.5% of children were being treated with stimulant medications nationally with the rate being higher in boys (3.5%) than girls (1.5%).  In addition, 0.7% of adults over age 17 were also receiving these medications.  For children, the lowest stimulant rate was in Alaska (0.4%) while the highest was in Delaware (5.1%).  Vermont came in at 34th at about 2%, while neighboring New Hampshire was 14th which was right after Massachusetts. Regional differences (South, Midwest) were smaller than between neighboring states and counties.  About one-third of the treatment came from psychiatrists. Higher rates of treatment was related in children to an increased supply of pediatricians, lower socioeconomic status of the population, and more funding for special education.

Stimulant Rate in VT

In the discussion, the authors perspective was mainly about access to treatment.  They noted that the prevalence of ADHD is generally cited as between 5-10% which would suggest a large number of children not being diagnosed and treated, especially in particular states and counties.  However, the authors also acknowledged that their data could not directly address the question of under or over-diagnosis.   The finding of stimulants generally being related to families with lower socioeconomic status, however, does suggest that they are not being used simply as a study drug for well-to-do kids. It is also important to note that nonstimulant medications such as atomoxetine as well as nonpharmacological treatment were not included in these analyses.

What to make of Vermont as being towards the bottom of the pack?  I must admit that this result was a bit surprising to me and does not quite square up with data from the Department of Vermont Health Access which found much higher rates, at least among kids with Medicaid.  Furthermore, whether this 2% rate found in this study reflects good and careful prescribing, statewide under-recognition of ADHD, or a mixture of both is difficult to say.   There are wide fluctuations even within our small state related to the density of primary care physicians.  At least in rural areas where access to pediatric care is more difficult, these data would suggest that many struggling children have yet to have their ADHD symptoms diagnosed and treated.

 

Reference

McDonald DC, Jalbert SK.  Geographic Variation and Disparity in Stimulant Treatment of Adults and Children in the United States in 2008.  Psych Services 2013;64(11):1079-1086.

Psychotic Symptoms in Adolescence Common and Appear Dimensionsal

Posted: December 10th, 2013 by David Rettew

While there has been increased appreciation that most symptoms in psychiatry exist along a spectrum or continuum, certain domains have continued to be viewed by many as more binary in nature, meaning that a person generally has the symptom or not.  Psychotic symptoms have generally been one of those areas.  A recent study by Ronald and coworkers that appeared as an advance article from the journal Schizophrenia Bulletin, however, challenges that assertion.

Participants for the study came from the Twins Early Development Study (TEDS) which has been following a community sample from England and Wales.  Over 5000 16-year-old twins and their parents participated. Psychotic symptoms were assessed quantitatively using the self-report Specific Psychotic Experiences Questionnaire (SPEQ) at baseline and, for a subsample, again 9 months later.  The responses from the SPEQ were then analyzed pschometrically  to try and identify key dimensions of psychosis.

In terms of results, psychotic symptoms were found to be quite common.  For example, 15% of the sample reporting hearing voices that commented on what the person was doing or thinking.  Six principle dimensions of psychosis were found namely: paranoia, hallucinations, cognitive disorganization, grandiosity, anhedonia, and negative symptoms.  These domains were found to be relatively distinct with only small to moderate correlations between them. All of these subscales with the exception of grandiosity were found to correlate significantly with levels of anxiety, depression as well as with personality traits such as neuroticism.  Some sex differences were also found such as boys reporting more grandiosity and girls reporting more hallucinations.  The level of psychotic symptoms showed a wide range of variation, with characteristics more like a quantitative trait rather than a discrete “yes or no” presence.

The authors concluded that psychotic symptoms in adolescence are quite heterogeneous and relatively common, with many adolescents endorsing them without high degrees of distress.

It is important to note that this sample was community based and thus, one cannot conclude that similar properties would occur within a clinical sample of youth with psychotic disorders.  The endorsement of psychotic symptoms seemed quite high and may have been due to the main use of a self-report questionnaire.  Specific associations with drug use were not explored.

Reference

Ronald A, et al. Characterization of Psychotic Experiences in Adolescence Using the Specific Psychotic Experiences Questionnaire: Findings From a Study of 5000 16-Year-Old Twins. Shiz Bulletin 2013; Epub ahead of print.

AAP Releases New Child Media Guidelines

Posted: November 20th, 2013 by David Rettew

The American Academy of Pediatrics (AAP) recently published an updated policy statement paper on recommended limits for media usage in kids.  The new report is designed to incorporate the increase of “new media” devices such as mobile phones and computers that are making up an increasingly larger portion of the total time. The trends necessitate that primary care clinicians adapt in the way that they ask about media usage and make recommendations to families.

video games

Photo courtesy of ImageryMajestic / freedigitialphotos.net

The paper cites data from previous studies, chronicling an astonishing amount of media use among youth.  Total time per day using media for entertainment purposes rises from about 8 hours per day in 8-10 year old to a stunning 11 hours or more in teens (it is hard to figure out the math for that one while still leaving time for school).   Over 70% of youth reportedly have a television in their room, not to mention a phone or tablet connected to the internet.  As many parents of teens already know, texting 50 to 100 times per day is now commonplace and ironically, teens are now one of the demographic groups least likely to use phones for voice communication.  Teens also report that they typically have no clear rules about media use from their parents, although parents tend to give a slightly different story.  These concerns are balanced by evidence that the some forms of media can be positive and enhance learning and social interactions.

The guidelines recommend that pediatricians ask two specific questions about media usage with parents namely  1) How much recreational screen time does your child or teenager consume daily? and 2) Is there a TV set or an Internet connected electronic device in the child’s or teenager’s bedroom?  Specific recommendations about media use include the following:

  • Total media use should be less than 2 hours per day
  • Children under age 2 should be discouraged from any media use
  • TVs and internet connected devices should not be in youth’s bedroom
  • Media use should be monitored and discussed
  • Family rules about media use, such as no usage during meals, should be made (and modeled by parents)

Getting less press attention but also contained in the article are also recommendations that primary care clinicians become more actively involved in educational and political groups to advocate for specific policies and laws, such as trying to ban alcohol advertising on television similar to cigarettes.

Following the release of these guidelines, many parents on the internet responded with some skepticism that such limits are realistic.   Indeed, a potential danger is that parents will dismiss the guidelines altogether rather than try to enforce attainable limits even if they fall somewhat short of the specified numbers.  The authors have commented themselves that the recommendations are not meant to be rigidly followed each day but are rather benchmarks that can be flexibly applied.  There is also a bit of a “one size fits all” approach to the guidelines in that no differentiation is given between, for example, a 3- and a 17-year-old.  Public health messages tend to be made as simple as possible to avoid confusion, and often there is a tacit understanding that some degree of customization will be necessary.  If these quite remarkable statistics are true, however, any concerted effort to bring media use into greater balance is a welcome enterprise, with primary care clinicians needed to support children and the families to make healthier choices.

Reference

Strasburger VC, et al. Children, Adolescents, and the Media.  JAMA Pediatrics. 2013;132(5):958-61

Is Cannabis Really A Gateway Drug?

Posted: November 12th, 2013 by David Rettew

Cannabis and addiction

Across the country, there have been several initiatives to decriminalize and even legalize marijuana, including efforts here in Vermont.   A common sentiment behind these movements is that cannabis in not really addictive or harmful. These efforts have reignited the debate about the potential dangers associated with cannabis use, particularly among adolescents.  A recent review paper by Hurd and colleagues in the journal Neuropharmacology examined the literature on the link between early cannabis use and later addiction and provides some practical conclusions that can be useful in discussions with patients.

Adolescence is a period during which there is a lot of brain plasticity, thus rendering the stage as potentially susceptible to the influence of substances such as cannabis. Cannabaniod receptors are highly expressed in the brain, particularly in regions such as the prefrontal cortex, cerebellum, amygdala, and hippocampus that are critical for cognitive and emotional functioning.

Regarding the “gateway hypothesis,” which states that early cannabis use increases the risk of addiction for other drugs, there is good evidence from multiple studies that the intensity of cannabis exposure is directly related to the use of ‘heavy’ drugs. Further, early cannabis use has been linked to poorer outcomes in a number of areas including educational achievement, employment, rule-breaking behaviors, and assuming more adult roles.  Human studies of cannabis often have methodological flaws that make it difficult to demonstrate a clear causal action of cannabis use on later outcomes.  In other words, it can be quite difficult to determine if cannabis is truly the problem itself or if a common genetic or environmental factor drives both cannabis use and psychopathology (Harder et al., 2008).  Animal studies, however,  are often free of these complications and have demonstrated a direct relation between cannabis exposure and increased intake of opiates. Animal studies also show links between THC exposure and later behavioral changes (although the study about pot smoking rats being less likely to attend college is inconclusive). In humans, behavioral effects tend to be seen in a subset of cannabis abusing adolescents and include negative affect, decreased goal directed behavior, aggression, and less frequently psychosis.

Overall, then, the available evidence does point to cannabis use in adolescents being related to increased vulnerability to future addiction and poorer outcomes; however, there is much that remains to be learned about how cannabis interacts with other factors in development.  The article provides a great deal of useful information about the risks associated with cannabis use while not glossing over the significant gaps in knowledge that need to be addressed.

Reference

Harder VS, et al.  Adolescent cannabis problems and young adult depression: Male-female stratified propensity score analyses.  Am J Epidemiol 2008; 168:592-601.

Hurd YL, et al. Trajectory of adolescent cannabis use on addiction vulnerability.  Neurophrarmacology 2013.  Epub ahead of print.

Parent Training Rated as First Line Treatment for Preschool ADHD

Posted: October 29th, 2013 by David Rettew

Recent practice guideline from the American Academy of Pediatrics now include a recommendation for assessment and intervention for ADHD before they begin elementary school, but many clinicians are unsure about exactly what treatment to recommend.  A recent paper sponsored by the US Agency for Healthcare Research and Quality and published in the the journal JAMA Pediatrics attempts to perform a meta-analysis of ADHD treatment studies in preschoolers in order to provide a more specific evidence base.  Stimulants are not approved for children below the age of 6, although medication treatment of preschool age children is not uncommon.Preschool PBT

The authors identified treatment studies of children with disruptive behavior symptoms below the age of 6.  The overall strength of evidence was rated as good, moderate, low, or insufficient based on previously published guidelines that incorporated many aspects of the studies that assessed that intervention.  While the study authors had planned to provide quantitative analyses of multiple types of treatment, only Parent Behavioral Training (PBT) had enough studies to allow for the use of meta-analysis techniques while methylphenidate treatment and combined home and school/day care interventions needed to be summarized descriptively.  A total of 55 studies were found (34 for parent behavioral training and 15 for pharmacotherapy).

Parent behavioral training studies were found to result in a moderate effect size that favored its use.  These studies showed improvement in child disruptive behavior, ADHD symptoms, and parental skill.  With regard to medication, only the Preschool ADHD Treatment Study (PATS) was deemed to be of “high” quality.  The lack of additional high quality studies and amount of adverse effects with medications thus caused the overall recommendation for methylphenidate use to be low.  Studies that combined PBT with school or daycare based interventions were found too conflicting to make an overall conclusion.

Based on their review of the data, the authors concluded that the research evidence suggest that parent behavioral training should be considered first line treatment for preschool ADHD.

For those less familiar with PBT, the goal of parent behavioral training is to teach parents strategies that help them manage their child’s challenging behaviors through promotion of a positive behavior and employing rewards and punishments for negative behavior.   Unlike other types of child therapy, PBT tends to be quite structured and, as the name suggests, focused quite a bit on the parents. Many of these programs have individual names (Incredible Years, Parent-Child Interaction Therapy) and manuals but utilize a similar overall framework.  In this study, no particular program was found to be clinically superior.

The authors acknowledged that many of the parent behavioral training studies have some methodological limitations with a sizable proportion of eligible parents not completing the course of treatment.  It is also worth noting that others might quibble with their determination that only one pharmacological study is worthy of a high quality rating.

Nonetheless, it seems quite reasonable in my view to follow the recommendation that parent behavioral training be tried first for preschoolers with ADHD and other types of disruptive behavior.  Finding it can be a challenge, and it may be worthwhile for clinicians to ask about it specifically or encourage parents to ask potential therapists about their experience with these techniques.

Reference

Charach et al., Interventions for preschool children at high risk for ADHD: A comparative effectiveness review. Pediatrics; 2013;131:e1584–e1604

 

Age 5 Behavior Linked to Maternal and Child Nutrition

Posted: October 22nd, 2013 by David Rettew

Many studies have found associations between specific nutrition deficiency states or gross malnutrition and child behavior, but lacking are more global studies that examine the link between more typical diets in general and behavioral outcomes.Nutrition

The Norwegian Mother and Child Cohort Study is a prospective study that recruited mothers when they were pregnant and followed them and their children in serial assessments up until the child was 5 years old.  Over 23,000 mothers and their children were assessed using mailed questionnaires.  For this study, raters made a dichotomous judgment of whether a mother’s or child’s diet was high or low in both healthy foods and unhealthy foods.  This variable was used to predict child internalizing and externalizing scores at age 5 using latent growth curve models.  The authors attempted to control for some potential confounds including socioeconomic status and maternal smoking, among others. Unfortunately, factors such as the home environment or parenting, were not included in these models.

In terms of results, a significant link was found between a mother’s unhealthy diet during pregnancy and child level of externalizing problems.  Regarding the child’s diet early in life, both higher intake of unhealthy foods and lower intake of healthy foods were associated with both internalizing and externalizing problems. The effect of diet was most evident early in a child’s life and diminished by age 5 for some types of problems.

The authors concluded that both an increased intake of unhealthy foods and a decreased intake of healthy foods was related to negative child behavior at age 5.   They advocated that adhering to good dietary principles is an important factor for optimal child mental.

While the effect sizes for this study tended to be small (correlations between diet quality and child behavior less than 0.1), these data give us additional scientific backing for our recommendation to eat well during pregnancy and to provide healthy food choices early in a child’s life.  In addition to factors such as parental mental health, sleep, exercise, structured activities, and screen time limits, good nutrition is an important target of intervention in a child’s overall mental health treatment and is “an important part of a good breakfast” when it comes to wellness promotion.

One nice resource for families is the USDA’s Choose My Plate website.

Reference

Jacka FN, et al.  Maternal and Early Postnatal Nutrition and Mental Health of Offspring by Age 5 Years: A Prospective Cohort Study. J. Am. Acad. Child Adolesc. Psychiatry, 2013;52(10):1038–1047.

 

Parental Bed Sharing with Infants More Popular

Posted: October 8th, 2013 by David Rettew

Parents co-sleeping with their infants is a common and accepted practice worldwide.  In response to data linking co-sleeping with an increased rate of sudden infant death syndrome, however, the American Academy of Pediatrics since 1992 has recommended that infants share a room but not a bed with their infants.    This recent study from the journal JAMA Pediatrics utilizes data from the National Infant Sleep Position study to examine the rates of infant bed sharing from 1993 to 2000 and factors related to the practice.Cosleeping

Participants in this study were a national sample of parents (80% mothers) of infants 7 months or younger who were identified from a commercial list and contacted by phone.  The final sample of nearly 19,000 individuals was more likely to be Caucasian, older, and well educated compared to national norms.  Participation rates varied widely from year to year and generally got worse from 1993 to 2010.  Subjects were asked if a parent or guardian usually sleeps with the child.  They were also asked if the topic was discussed with their doctor and if the physician’s attitude was positive or negative.  The median infant age was about 4.5 months.

Results showed that, 0verall, 11.2% of parents reported that they usually slept with their infant.  The prevalence rose 6.5% in 1993 to 13.5% in 2010.  Race appeared to be strongly liked with infant bed sharing.  In 2010, nearly 40% of black infants slept with a parent compared to just under 10% of white infants.  This point was highlighted by the authors as the rate of SIDS is also higher in African American families.

Infant bed sharing was also found to be related to the following factors:  lower level of education and income, younger infant age, preterm birth, and geography (higher in the west and south).

Regarding conversations with their doctor, a total of 54% of the sample reported no input from their physician.  Of those who did receive advice, nearly three-quarters reported being advised against the practice.  Parents who were cautioned against the practice were less likely to share a bed with their child (or perhaps were less likely to admit it).

The authors suggested that more frequent and consistent advice from physicians could help change practices to be more in line with recommendations.  An accompanying editorial, however, describes some problems with the data on which these recommendations are made, suggesting that it may be premature to condemn this practice based on the available evidence.  It has been suggested that other factors, such as paternal substance use or infant sleeping in other places such as sofas, may be more moderating factors to consider in the link between cosleeping and SIDS.

Reference

Colson E, et al.  Trends and Factors Associated With Infant Bed Sharing, 1993-2010: The National Infant Sleep Position Study.  JAMA Pediatrics 2013; published online Sept 20.

 

Talking About Obesity in the Age of Eating Disorders

Posted: September 30th, 2013 by David Rettew

A common issue that comes up as parents and clinicians try to help adolescents avoid both eating disorders and obesity is the concern that a conversation about obesity with a child might trigger eating disorder behaviors.  The dilemma leads to a lot of discomfort as to the best way to have this conversation, if at all.Eating Discussion

Directly addressing this question are some new survey data from the Eating and Activity in Teens Study and the Project Families and Eating and Activities in Teens Project.  Over 2000 teens from 20 public schools around the Minneapolis/St Paul area were assessed using school based surveys while parents also completed questionnaires.  The mean age of the adolescents was 14.4 years and the sample was ethnically diverse with 81% from an ethnic minority and most coming from lower income households.

Most parents reported engaging in some kind of conversation with their children about eating behaviors.  For one-third of parents of nonoverweight teens, these discussions were focused on weight.  For parents of overweight teens, the rate rose to 60%.  Compared to conversations about healthy eating, maternal discussions focused on weight were significantly more likely to be associated with dieting and unhealthy weight control behaviors for both overweight (64% versus 40%) and nonoverweight teens (39% versus 30%). However, the difference in rate of extreme unhealthy weight control behaviors was not different among adolescents whose mothers discussed healthy eating (8.5%) versus weight (9.5%).  Similar but not identical trends emerged for fathers.

The authors concluded that parents should have conversations related to healthy eating rather than weight, particularly with adolescents who are overweight.

While this is an interesting study that offers data about a common clinical dilemma, one needs to be mindful not to overinterpret these findings.  While much of the attention for this article relates to eating disorders per se, significant associations were not generally found between the content of parental eating discussions and more extreme weight loss behavior, and eating disorders were not diagnosed directly in this sample. Furthermore, eating disorder symptoms were quite common among teens whose parents focused their discussions on healthy eating too. Parents may also have under-reported the amount of weight focus of their conversations.

That said, the study does offer some empirical support to a practice that many clinicians already advocate, namely to make weight a secondary issue and instead focus on more healthy eating.

Reference

Berge J, et al., Parent Conversations About Healthful Eating and Weight: Associations With Adolescent Disordered Eating Behaviors.  JAMA Pediatrics 2013;167(8):746-753.

New Option for Adolescent Substance Abuse Treatment in Burlington, VT

Posted: September 25th, 2013 by David Rettew

Spectrum Youth and Family Services announced a new program called Teen Intervention Program for Substance Use (TIPS) that will provide for intake assessment followed by a 26-week treatment program for adolescents with substance abuse problems aged 12-18. Spectrum

The treatment is family-based and uses a motivational and behavioral framework.  Parents need to attend and be involved in the fourteen 90-minute sessions. There is no group therapy component, but there will be verification of substance use through breathalyzers and urine drug screens.

After five sessions, this program is FREE for participants, as the treatment is part of an NIH funded research study, looking at ways to improve outpatient substance use treatment.  The study will be led by Spectrum’s Associate Director Annie Ramniceanu along with two Dartmouth (and previously UVM) psychologists Dr. Cathy Stanger and Dr. Alan Budney.   Of note, there is no “waitlist control” arm of the study and all participants will receive active treatment.

This looks to be a great opportunity for intensive evidence-based treatment for one of Vermont’s most entrenched problems.

More information can be found here.

Self and professional referrals can be made by calling (802) 864-7423 ext 319.

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