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Home – Child Mental Health Blog

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.


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.


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.


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.


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.


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.

Primary Care Phone and Email Consultation Program Begins Second Year

Posted: September 19th, 2013 by David Rettew

The Vermont Center for Children, Youth and Families at FAHC/UVM, in partnership with VCHIP, is pleased to announce we are entering our second year of the Child Psychiatric Phone and Email Consultation Program.  The goal of this program is to provide healthcare providers with curbside phone and email consultation to assist in the management of emotional and behavioral problems in primary care settings.  Examples of these consultations include assisting in assessment, diagnosis, medication management and Family Wellness recommendations.Consult program

Results taken from a questionnaire given before and after PCP’s have accessed our consultation service show that users confirm an increased ability to quickly access expert psychiatric consultation as well as experience an increase in confidence in diagnosing and treating children’s mental health issues.

Whether you are already “signed up” or familiar with our consultation services or hearing about them for the first time please review the below commitment.

We will:

1)      Assign one of our child psychiatry team members to be your direct contact at the VCCYF for phone and E-mail consultation.  Members of our team will return phone calls within 24 hours during the regular work week (weekend coverage is already available through the on call system).

2)      Provide you and your staff with phone and E-mail access to our experienced Family Wellness Coach, Eliza Pillard, LICSW, who can help guide your practice in the search for evidence based interventions for emotional and behavioral problems on behalf of your patients.

3)      Connect you to our VCCYF Primary Care blog which delivers regular postings on topics that may be relevant for your patients, such as updates on child mental health and family wellness research.

4)      Update all participants with news of access to our services (e.g., our Autism Assessment Clinic), educational opportunities, and advances in our field.

Please note that this program will not serve as a rapid conduit for in-person assessment and consultation at the VCCYF.  In fairness to the many families in need, we are obligated to serve families on a first-come-first-serve basis.

If you are interested in this program, please contact Eliza at eliza.pillard@vtmednet.org.  We look forward to hearing from you.




Jim Hudziak, MD, Director

Vermont Center for Children, Youth, and Families


Eliza Pillard, LICSW

Family Wellness Coach

Limiting Antipsychotic Medications Shows Long-Term Benefits

Posted: September 16th, 2013 by David Rettew

The renewed debate surrounding the risk/benefit ratio of using antipsychotic medications for new onset psychotic illness has challenged the traditional recommendation of continued medication treatment for at least one year after remission.  While previous studies have documented an increased rates of relapse among those whose medications are discontinued, this risk is weighed against the potential adverse effects of theseAntipsychotic reduction medications and continued questions about long-term efficacy. Into this discussion are now some much needed data that examine the longitudinal outcomes of a group of patients who medications were reduced or discontinued versus those who received maintenance treatment.

In the original trial, a group of 257 subjects with first episode psychosis who had remitted and stayed well for 6 months were randomized into a group that received maintenance treatment and a group that underwent dose reduction or discontinuation.  These groupings were maintained for 18 months, with analyses showing  little added benefit for the dose reduction group. For this follow-up study, 103 patients from the original sample were followed for a total of 7 years during which time medications could be modified at the judgment of the clinical team.  The primary outcome variable for the study was recovery which was defined as symptomatic and functional remission.

Patients in the dose reduction/discontinuation group showed a rate of recovery of 40.4% which was significantly above the 18.7% rate in the maintenance group. Rates of functional remission, but not symptomatic remission, were also significantly higher at 7 year follow-up for the dose reduction/discontinuation group. The mean dose during the final two years of the follow-up period of those in the dose reduction/discontinuation group remained significantly lower than the maintenance group (3.60 versus 2.27 mg/day of haloperidol equivalent), despite that fact that subjects in both groups were able to be treated as clinically indicated.   A total of 11 patients were not using any antipsychotic medication in the last two years of follow-up.

The authors concluded that dose reduction/discontinuation provides superior long term recovery rates in comparison to conventional maintenance treatment.

This study shows some striking advantages of dose reduction/discontinuation that were not evident in the original study after 18 months of randomization.  It suggests that while achieving dose reduction or discontinuation can be difficult, there may be some long term benefits. The authors state that additional data confirming these findings are needed before such a strategy is put into general clinical use.  It is also worth noting that medications continued to be used for most patients in the dose reduction/continuation group, albeit as lower doses.

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.

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