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Home – Child Mental Health Blog

Recent Child Mental Health Summit Explores New Ideas

Posted: September 10th, 2013 by David Rettew

This week, a group of people involved in all aspects of child mental health care in Vermont met in Shelburne to share ideas and visions about how to improve access and quality of behavioral healthcare for Vermont families.  The group included parents of children struggling with emotional behavioral problems, counselors, psychiatrists, primary care clinicians, educators, and leaders from many community mental health centers, among others.  The project was sponsored jointly by the United Way and Fletcher Allen after child mental health care was identified an a particular area of need.Summit

Small groups first discussed the hopes and goals we had for children and their families, with solid agreement that mental health meant much more than simply an absence of symptoms.  From there, specific priorities and strategies to help children thrive were explored.  In my own view, what seemed to rise to the top for many people was the idea that resources needed to be more focused on supporting entire families who are often under great stress.  Another common theme was to use technology to allow both families and those in the mental health community to see in one place what types of programs, providers, and other types resources might be available.   Related to this concept was the idea to improve the coordination and information sharing from one organization to the next.

One often acknowledged obstacle to these lofty ideas is funding, as it was widely recognized that increasing access, reducing waitlists, and extending the reach of this hard working community all require child mental health to be recognized as a  priority when it comes to budgetary decisions.

This meeting was viewed as an important first step that will lead to future dialogue and hopefully specific action to improve the lives of some of the most vulnerable Vermonters and their families that are greatly in need of support.

 

 

 

 

 

 

Documentary Film on Prescription Drug Abuse Premiers at Flynn Sept 27

Posted: September 5th, 2013 by David Rettew

The Gala Premier of Kingdom County Productions’ new documentary film The Hungry Heart will take place at the Flynn Theater in Burlington, VT on Friday September 27 at 7pm.  The film, directed and produced Kingdom County Prod 2by Bess O’Brien, explores prescription drug addiction through the intimate world of Vermont Pediatrician Fred Holmes who works with patients struggling with this disease. The film provides an intimate look at the often hidden world of addiction and recovery and reveals the many challenges that Dr. Holmes and his patients face in confronting a relentless and difficult disease.  The film shines a light on the healing power of conversation and the need for connection that many of these young addicts yearn for but do not have in their lives.

In addition, the film interviews a number of older addicts who talk about their recovery process juxtaposed against Fred’s patients. The road to recovery is paved with both success stories and strewn with relapses, downfalls and tragic losses. However, through the movie we see the many faces and diverse populations of addiction, and their continued search for a life of Kingdom County Prod 1recovery.

Tickets cost $15 and $30 and can be purchased online, at the Flynn Theater, or by calling 802-863-5966.  Ticket revenue will benefit the local Burlington Turning Point and KCP’s tour expenses.  From Burlington, the film will tour in over 30 locations in Vermont.  More information can be found at www.kingdomcounty.org.

Autism Linked to Maternal Antibodies Reacting to Specific Antigens

Posted: September 3rd, 2013 by David Rettew

While there is quite strong support to view autism as a neurodevelopmental disorder, the precise mechanisms that underlie this spectrum remain elusive.  A research group from the University of California at Davis previously found evidence for autism specific antibodies that were able to recognize fetal proteins.  They now turn to the specific targets or antigens for these antibodies that may be present in the developing brain.Autism antibodies

Subjects for this study came from the Childhood Autism Risks from Genetics and Environment study (CHARGE).  A total of 246 children with an autistic spectrum disorder (ASD) were compared to 149 typically developing controls. Maternal blood samples were taken and used to react with fetal rhesus macaque brain tissue.  The authors employed a proteomic antigen identification procedure using tandem mass spectrometry with confirmatory results from western blot analysis.

Results revealed a significantly increased risk of offspring autism related to maternal reactivity to any of implicated antigens either alone or in combination. Reactivity to two or more of the target proteins was found in 23% of mothers of autistic children versus only 1% of non-autistic children. The researchers found 7 primary antigen targets for the maternal antibodies, namely lactate dehydrogenase A and B (LDH), cypin, stress-induced phosphoprotein 1 (STIP1), collapsin response mediator proteins 1 and 2 (CRMP1, CRMP2), and Y-box-binding protein.  The particular antigens are known to be important in neuronal development and cell migration. There was some evidence that maternal reactivity to these antigens was particularly related to stereotypical behaviors.

The authors concluded that these particular antigens may be the targets of maternal antibodies that lead to abnormal neurodevelopment during gestation.   Reactivity to these fetal proteins, they speculated, could be a potential biomarker for autism.

This study adds to the growing evidence suggesting that the mechanism behind at least some cases of autistic spectrum disorders relates to maternal immune dysregulation that results in disruption of neuronal development and migration in the fetal brain. It is worth noting, however, that maternal antibody reactivity was not found in the majority of ASD cases.

Reference

Braunschweig D, et al. (2013). Autism-specific maternal autoantibodies recognize critical proteins in developing brain.  Trans Psychiatry 3:e277.

 

Sibling Conflict Not Just Kid Stuff

Posted: August 26th, 2013 by David Rettew

Brother and sisters fighting with each other is exceedingly common, but these behaviors often get chalked up to typical sibling interactions, or even a rite of passage that can toughen kids up.  A new study from the journal Pediatrics, however, finds evidence that there may be real mental health consequences to these intense conflicts.Sibling Aggression

The data come the National Survey of Children’s Exposure to Violence.  In this national probability sample, over 3500 children and adolescents participated in a telephone interview from phone numbers selected randomly.  Items from the Juvenile Victimization Questionnaire were used to examine three types of aggression occurring in the previous year: psychological (feeling bad or scared due to a sibling’s verbal attacks), property (forcibly taking or destroying something), and physical aggression.  Mental health symptoms were assessed using the Trauma Symptom Checklist.  Analyses of covariance were used to examine mental health scores between children who did and did not experience different types of sibling aggression, controlling for some demographic variables and victimization from other sources.

While not explicitly reported, it appears that 40% of children and adolescents experienced sibling aggression of some form.  Furthermore, those who did were found to have higher mental health distress than those who did not report such sibling conflict.  The effect of “mild” physical aggression (i.e. did not involve a weapon or lead to injury) seemed to be particularly difficult for younger children less than 10 years old.  Cumulative effects were found for those experiencing greater amounts of sibling aggression and those who experienced both peer and sibling aggression.

The authors summarize that there are observable negative effects on children from sibling aggression that should not be dismissed as typical and harmless behavior.  They advocated that current anti-bullying campaigns should consider explicitly including sibling aggression as a target.

This study is a wake-up call to clinicians, warning us not to dismiss sibling aggression as a benign part of growing up.  For clinicians, assessment and treatment of aggressive siblings could likely have positive effects on many family members.  The study would have been strengthened, however, with more anchor points regarding the prevalence of sibling aggression and effect sizes of these behaviors. One aspect that was not accounted for, as is quite common in studies like this, was genetic effects.  It may be that shared genes contribute both to a child’s mental health problems and his or her sibling’s aggression.  Finally, what do we make of the rate of 40% of child and adolescent subjects reporting some sort of sibling aggression in the past year?  This rate seems fairly low and casts some doubt for me on how questions were asked.  Eliminating all sibling conflict seems to be a tall order in my view, and more information on what things can really lead to feelings of fear and intimidation would be useful.

Reference

Tucker CJ, et al.  Association of sibling aggression with child and adolescent mental health.  Pediatrics 2013; 132:79-84.

Early Puberty Plus Temperament Linked to Adolescent Anxiety and Depression

Posted: August 5th, 2013 by David Rettew

The onset of puberty has been occurring earlier for unclear reasons.  Furthermore, a relatively early puberty onset has been associated with internalizing symptoms such as anxiety and depression, especially for girls.  A new study from the journal Development and Psychopathology tests the idea that the effect of this phenomenon may depend on individual attributes such as one’s temperament.Puberty timing

Subjects included 1,025 individuals from the age 11 to 15 who were followed longitudinally for the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development (NICHD SECCYD).  Temperament was measured using items from various scales, internalizing problems was assessed with the Child Behavior Checklist, while puberty timing was assessed by physical exam.  The study focused on temperament dimensions related to emotional reactivity and self-regulation. Structural equation modeling was used to predict age 15 internalizing scores from temperament, puberty timing and their interaction.

Results showed that, for girls, early onset of puberty, higher emotional reactivity, and lower self-regulation predicted internalizing symptoms at age 15.  The relation between puberty timing and internalizing problems was found be a function of temperament with the effect of early puberty strongest among subjects with lower self-regulation.  Controlling for baseline internalizing scores, however, resulted in nonsignificant associations between internalizing problems and both puberty timing and emotional reactivity. For boys, emotional reactivity and low self-regulation was again found to predict internalizing symptoms but no effect of puberty timing was found.

The authors concluded that, for girls only, early puberty is associated with increased internalizing problems, especially for those with specific temperamental vulnerabilities.  This link appears to be due to the association of puberty timing with internalizing problems at age 11 rather than later in adolescence (since controlling for age 11 internalizing problems eliminated the effect of early puberty). 

While the headline of the study was related to the effect of puberty, what stands out for both boys and girls was the association between  later psychopathology and temperament. Like many studies that examine the relations between temperament and psychiatric symptoms, however, it is important to remember that the items used to measure both constructs are often quite similar.

With apologies for the shameless plug, I invite those interested in learning more about the connection between temperament and psychiatric symptoms to check out my new book on the subject to be released next month.

Reference

Crockett LJ, et al.   The role of pubertal timing and temperametal vulnerability in adolescents’ internalizing problems.  Development and Psychopathology 2013; 25(2):377-389.

 

Baby Steps to Exercise

Posted: August 2nd, 2013 by David Rettew

 

Eliza banner

by Eliza Pillard, LiCSW

We all know by now that exercise improves mental health and physical wellness, yet how many times have we told ourselves “I will start exercising regularly tomorrow”, then, inevitably tomorrow comes and there just isn’t enough time or you are not feeling 100% so decide to wait. A great strategy, that worked for me over ten years ago and is still working, is to ‘baby step’ yourself into getting outside and moving. Don’t scare yourself by imaging yourself out there grunting and groaning, running 5 miles. Or lie to yourself by imaging yourself out there smiling happily as you run 5 miles. Instead tell yourself as you crawl into bed “all I have to do tomorrow is put on my exercise clothes that I laid out, ready to go”. The trick is to have listened to the weather report for the next day and chose appropriate clothing to suit the weather, then lay the clothes out in a pile in the order you will be putting them on. That way, even if you are bleary eyed tired the task won’t be too daunting. Then, dressed for success, enjoy your cup of coffee, reading the paper etc., that’s it! The next day, do the same, just this time tell yourself “All I have to do is go outside and walk to the end of the driveway and back”, give yourself a pat on the back when you have completed this and go back to your usual morning routine. Each day, add on a tiny bit more,Baby Steps

Day 3: jog to the end of the driveway.

Day 4: jog to the end of the driveway then walk to the neighbor’s mailbox.

Day 5: jog to the end of the driveway, walk to neighbor’s mail box, jog back to your front door.

Day 6: you get the idea, the key is to always plan ahead regarding what you are going to wear and make it a habit of putting on these clothes, it is O.K. to go backwards and if you are not in the mood back it up to walking to the end of the driveway, or just drinking your cup of coffee dressed in your workout clothes. Do not let yourself get carried away, it is better to under shoot and feel impatient at how slowly you are building up your routine. If you do over do it, that is O.K., don’t give up! Any exercise is better than no exercise. Making getting on exercise clothes a habit will train your brain to expect a little exercise (like brushing your teeth before bed, cues your body it is time for sleep).

Reference: Lally, P., van Jaarsveld, C. H. M., Potts, H. W. W., & Wardle, J. (2010). How are habits formed: Modelling habit formation in the real world. European Journal of Social Psychology, 40, 998-1009. (http://onlinelibrary.wiley.com/doi/10.1002/ejsp.674/abstract)

Increaed Brain Connectivity Found in Childhood Autism

Posted: July 28th, 2013 by David Rettew

While there have been many findings in the literature demonstrating that the brains of those with autism differ from non-autistic individuals, the results often do not agree.  This study used neuroimaging techniques to examine the degree to which the level of brain connectivity was a distinguishing feature of autism. Salience network

The study compared 20 rigorously diagnosed high-functioning autistic children (average age 10) with 20 controls who were matched by age, sex and IQ.  Functional and anatomical MRIs were obtained with the primary measure of interest being the level of functional connectivity (ie how closely wired these regions were) within 10 large scale brain networks. A classification algorithm was then applied to test whether the connectivity data within a network could successfully classify a subject as autistic or non-autistic.

A higher level of functional connectivity was found in the autistic versus the control group in several functional brain networks including the salience, posterior default mode network, frontotemporal, motor, and visual.  The salience network, which is comprised of the anterior insular cortex and dorsal anterior cingulate gyrus, is involved in functions such as attention, interoception, reward processing, and subjective awareness.  This network was found to be most discriminating of autism with a classification accuracy of 78% (75% sensitivity, 80% specificity).

The authors concluded that hyperconnectivity of major brain networks is a central neurobiological component of autism, at least in children.  A hyperconnected salience network in particular may be a distinguishing feature of autistic spectrum disorder and may be useful as a potential biomarker for autism.

The authors speculated that brain “network isolation” might result in some of the core symptoms of autism in that these systems may have more limited interaction between them.  These findings are in contrast to the network HYPOconnectivity that has been found previously, but these studies tend to be with older samples and suggest the possibility of important developmental differences both before and after birth.

It is important to remember when hearing about promising sensitivity and specificity numbers based on an objective test that clinical utility generally rests not in distinguishing a disorder from a group of typically developing individuals but in distinguishing one disorder from another.  This classification procedure is not ready for clinical use but may help pave the way for future procedures as diagnostic aids.

Reference

Uddin et al., Salience network-based classification and prediction of symptom severity in children with autism.  Arch Gen Psychiatry 2013; June online first: e1-e11.

Suicide Contagion: New Reserach, New Resources

Posted: July 25th, 2013 by David Rettew

One of the many disturbing aspects of youth suicide is the concern that they can be “contagious” in the sense that one suicide or suicide attempt increases the risk that others around them will follow suit.

A recent study that surveyed thousands of Canadian adolescents did indeed find that having a schoolmate that died by suicide or knowing someone personally who died by suicide was found to increase the personal risk of both suicide ideation Suicide reponse in schoolsand attempts.  Compared to respondents who reported no suicide exposure, those who did were five times as likely to report suicide ideation at age 12-13 and nearly three times as likely at age 14-15.  There was also a three to fourfold risk of attempts among exposed youth at all age groups. For example, among 12-13 year olds, a total of 7.5% of children exposed to suicide reported their own attempt versus 1.7% of unexposed children. Personally knowing the schoolmate who died by suicide did not increase the risk.  These effects were slightly increased with the presence of other stressful events but surprisingly, were not modified by levels of social support, own prior suicidality, depression, or anxiety.  Furthermore, the effect was found to persist even years after the event.

In the already tragic aftermath of a youth suicide, it can be extremely difficult to balance legitimate needs for community expression and support with efforts to try and limit any possible contagion effects.  However challenging, this study informs us that were are not off the hook for this important task.

The American Foundation for Suicide Prevention has developed a free, downloadable, and quite practical toolkit to guide schools and others on how to navigate this very tricky water following the suicide of an adolescent of not wanting to increase stigma for suicide and mental health conditions while also trying to minimize any possible contagion effects.  Some of the main points include the following.

  • Schools should have a crisis response plan for such an event that includes an appointed team leader who, in term, can rapidly put together a crisis team if needed
  • Emphasizing that suicide is often the result of potentially treatable mental illness rather than a more romanticized story
  • Trying to keep to regular school hours and dismissals
  • Strong encouragement of the media to follow procedures that can reduce contagion

With school out of session, this could be a very good time to make sure we are all as prepared as possible for these mercifully rare but very troubling contingencies.

Reference

Swanson SA, Colman I.  Associations between exposure to suicide and suicide outcomes in youth.  Can Med Assoc Journal 2013; 185: 870-877.

Navigating Residential Services for Vermont Youth

Posted: July 18th, 2013 by David Rettew

(editor’s note:  I’m happy to post this guest blog by some colleagues at HowardCenter on a topic that comes up all the time for parents and clinicians – DR)

By Cyrus Patten MSW, Jessica Coleman LCMHC, and Robin Yandell APRN

HowardCenter

When children and youth are experiencing challenging emotional and behavioral issues  that are not improving with traditional outpatient therapies or educational supports in school, parents may begin to seek out of home or residential care to meet their children’s needs.  Accessing this system in a time of crisis is often confusing  for families and providers if they are unfamiliar with who to ask and who pays for what.  Almost all out of home care in Vermont is funded by the public mental health system. The community mental health system has noticed an increase in children or youth entering the public system in crisis having never interfaced with it before.  The following information on the high end system of care may be helpful for primary care providers.Navigate

Vermont’s community mental health system is made up of ten designated agencies (DA’s) and one specialized services agency covering various districts in the state. These private nonprofit agencies are under contract with the state to deliver many public mental health services, as well as accepting most private insurances. While private insurance usually covers outpatient and inpatient care, these community agencies provide many of the needed supports in between. In addition to outpatient services, the DA’s also provide services such as in-home family work, one-to-one community skills workers, care coordination, respite, school-based supports, early childhood mental health supports, crisis response, and specialized out of home care such as foster care, crisis placements, and residential care. Some, but not all, of these services require the child to be Medicaid eligible and there is a waiting list for some services.  Within this continuum, many mental health services have in-home family work as a model that focuses on supporting the child and family with mental health stabilization and reducing the risk of psychiatric admissions or out-of-home placement. Local mental health agencies have a variety of programs for this in-home work that range in intensity from 1-2 family contacts per month to multiple hours a week. Home and community-based waivers may also be available to eligible families based on meeting criteria for inpatient psychiatric placement.  These “wraparound” services provide a high level of intensive supports to promote the goal of keeping children in their communities.

Vermont’s public mental health system operates on the belief that it is important to access the lowest possible  or “least restrictive” level of care before moving up to higher levels. The desired outcome is to keep children within their home, school and community with services that meet their needs and promote their safety and success.  Sometimes, despite providers’ and families’ best efforts, out of home treatment is needed. For the most part, high-end services such as intensive in-home or out of home mental health treatment are only available through the public system.  Families not familiar with the system have experienced  frustration when they must participate in sometimes lengthy referral processes, eligibility determinations and limited options when they are already in a crisis.

As primary care providers, if you are working with a child or youth who may likely need intensive services at some point, it is best to help the family become familiar with the public system ahead of time. Because Vermont has a robust but varying network of DA’s and providers, the state enacted legislation in 1988 under ACT 264 which mandates that a multidisciplinary team of providers meet and collaborate around care in the best interest of families before allowing access to high end, out of home, publicly funded services.  In addition to the family, this team is comprised of representatives from Department of Education, Department for Children and Families, the local Designated Mental Health Agency, and others critical to implementing a Coordinated Services Plan (CSP).  Having an Act 264 meeting and the creation of such a plan is the first step in accessing out of home care in Vermont. This collaborative process is a helpful tool to ensure the child and family have tried or been considered for community-based levels of care before out of home care is accessed. If out-of-home care is determined to be needed for a child or youth, the team then follows the CSP outline to complete a referral to the Case Review Committee at the state level. One final note is that despite close collaboration between the public mental health and education systems, development of an IEP (individualized education plan) or educational placement is a separate process that occurs solely with the local school district.

Partnering is a critical component of effective, intensive mental health treatment.  Multidisciplinary teams must work collaboratively in order to minimize barriers to success for Vermont’s children and families in need of the highest levels of intervention.  To achieve this, the local mental health agencies should be involved early and often.  Be sure to include your designated mental health agency when

  • a child may need intensive mental health services in the foreseeable future
  • a child’s plan includes a step-down from an out of state or inpatient setting
  • a child’s needs are not fully being met with community-based or private resources
  • the team needs additional consultation or services to fill gaps in a treatment plan

Other resources for families seeking support navigating the public mental health system of care are the Vermont Family Network (876-5315) and the Vermont Federation of Families for Children’s Mental Health (876-7021 or 800-639-6071).  Both of these organizations have parents working in them who can act as peer supports for other families. In Chittenden County, parents can also contact First Call, HowardCenter’s children’s crisis team,  to answer questions about the Act 264 process or how to access higher levels of care.

FDA approves EEG Diagnostic Aid for ADHD

Posted: July 16th, 2013 by David Rettew

One of the holy grails in mental health assessment is the search for some kind of objective test that can accurately diagnose psychiatric disorders.  While the literature is full of genetic, imaging, neuropsychological, and other factors that show statistically significant links with many psychiatric conditions, none has proven robust enough for clinical use.EEG

However, the Food and Drug Administration (FDA) just approved the first electroencephalogram test (EEG) test to help diagnose ADHD.   The procedure is called Neuropsychiatric EEG-Based Assessment Aid (NEBA) and reportedly lasts about 15 to 20 minutes.  It focuses on the combination of theta and beta waves produced by the brain.  An increased theta/beta wave ratio has been found to be related to ADHD.   The FDA approval came after the makers of the test, NEBA Health, studied 275 youth with ADHD and examined the utility of the test above and beyond traditional methods such as clinically reviewing the diagnostic criteria and applying behavioral questionnaires.    Unfortunately, these data are not publicly available, and many experts remain quite skeptical about how much this test will improve the accuracy of the diagnosis.

You can read the FDA announcement here which states that the test should be used in conjunction with a “complete medical and psychological examination.” The statement goes on to say that the procedure allowed for a “more accurate diagnosis” of ADHD when used in addition to other diagnostic measures, but no details are provided.   The press is all over this story but nobody seems to have much additional information other than what is presented here.

Having objective tests to aid in the diagnosis of psychiatric disorders and their treatment would be a major advance that likely is coming soon.  Such tests could be beneficial in many ways.  In addition to improving diagnostic accuracy, they could reduce stigma and might even help improve access to care, especially if having reliable “procedures” finally gives the mental health field something to bill other than time (which is reimbursed miserably).  Nevertheless, in our clinic we aren’t rushing out to buy our system just yet, and will wait until more information becomes available for scrutiny.

 

 

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