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Home – Child Mental Health Blog

Vermont Center for Children, Youth and Families

Posted: October 11th, 2017 by David Rettew

 

Welcome to a new format to assist Vermont primary care clinicians and the general community to access new and quality information to help improve child mental health assessment and treatment.  We know the problem all too well:  emotional and behavioral problems are extremely common, affecting at least 1 in 5 children.  Vermont like every other state has a critical shortage of child psychiatrists, and primary care clinicians are often needed to deliver this important care.   Unfortunately, most pediatricians and family medicine physicians have had little formal training in mental health, and consequently are uncomfortable addressing emotional behavioral problems in their patients.

David Rettew, MD

This blog developed by the Vermont Center for Children, Youth and Families and supported by the Vermont Child Improvement Program (VCHIP) is designed to offer practical and easily assessable information related to child psychiatry.  The regularly updated information will offer the following.

  • Regular postings from VCCYF staff about the assessment and treatment of common child emotional behavioral challenges
  • Links to important local and national resources
  • An ability to send clinical questions to VCCYF faculty that will be responded to in a timely manner

The central model that will be used is the Vermont Family Based Approach – a strategy developed by Dr Jim Hudziak that expands the focus of assessment and treatment beyond the individual symptoms of the child and towards the entire family environment.

 

 

 

Late Onset ADHD? Usually Not

Posted: November 15th, 2017 by David Rettew

Primary care clinicians who work with adolescents and adults are seeing increasing numbers of patients presenting for an ADHD evaluation in which the symptoms didn’t develop until later in childhood or even in adulthood.  These “late onset” cases have traditionally been viewed as being atypical, although there has not been a great deal of systematic investigation.  This study from the well-known Multimodal

Image courtesy of imagerymajestic at FreeDigitalPhotos.net

Treatment Study of ADHD (MTA) takes advantage of their having a rigorously assessed group of individuals who were determined not to meet criteria for ADHD in childhood and examines in close detail the subset of individuals in this group who later present with symptoms of inattention and/or hyperactivity.

The MTA study was initially designed to examine pharmacological and non-pharmacological treatment for ADHD among children initially between 7 and 10 years of age.  As part of the study, a comparison group of 239 youth were also included who were not found to meet criteria for ADHD after a rigorous assessment in childhood.  This group was followed into adolescence and adulthood using an assessment procedure that included rating scales, structured interviews, and examination of substance use.

A total of 8.9% of the comparison sample that did not meet criteria for ADHD at baseline reported DSM-5 level of adolescent-onset ADHD symptoms with associated impairment.  Of these, 14% were judged to be due to heavy cannabis use, 24% attributed to other psychiatric disorders, and 33% only has symptoms in one setting. Excluding these individuals, a total of 2.9% of the original comparison sample had full ADHD symptoms with an adolescent onset and, with further follow-up, the majority of these individuals did not have symptoms that persisted into adulthood. With regard to adults, 4% of the comparison sample met ADHD criteria for symptoms and impairment with adult-onset with again substance use and other mental disorders accounting for a large proportion.  Indeed, only two subjects were deemed to have true adult-onset ADHD, and both had other significant mental health symptoms.  Putting it all together, about 95% of subjects who reported later onset ADHD symptoms were eventually excluded from the eventual diagnosis after careful assessment.

The authors conclude that the majority of what appear to be late-onset ADHD presentation are accounted for by substance use, other psychiatric disorders, or non-impairing cognitive fluctuations.  They advise very careful assessment of individuals who present with what appears to be late-onset ADHD.

While this study goes a long way to demonstrate that what may appear to be ADHD in adolescence and adulthood is often better accounted for by something else, it is important to point out that the 95% statistic quoted for this study probably can’t be applied to the situation encountered in most clinicians’ day to day practice because everyone in this sample was carefully assessed in childhood and found not to meet criteria for ADHD.  In cases in which the primary care clinician has known a patient for many years and is confident that the person did not meet criteria for ADHD in childhood, a similar situation exists as is described in this study.  In many other cases, however, the patient’s behavior in childhood may be less known, raising the possibility that ADHD was present in childhood but that the diagnosis was missed.

Reference

Sibley MH.  Late-Onset ADHD Reconsidered With Comprehensive Repeated Assessments Between Ages 10 and 25. Am J Psychiatry, epub ahead of print.

Your ADHD Treatment Plan

Posted: October 11th, 2017 by David Rettew

When someone presents for evaluation and treatment of ADHD, what does your treatment plan look like?  Sure medications are often considered, and hopefully also some parent behavioral coaching too.  Anything else?   A new meta-analysis, recently published in the Journal of the American Academy of Child and Adolescent Psychiatry, provides some strong evidence about the the cognitive benefits associated with physical activity.

The meta-analysis examined  36 studies, mostly randomized-controlled trials.  Over 5,000 children were in the interventions in total and children (taken from the general population and not specifically targeting those with ADHD) ranged in age from 4 to 14.  Most of the physical activity programs occurred at school.  With a few exceptions, these program increased physical activity from 15 to 120 minutes per day for 4 to 54 weeks.

Overall, 29 of the 36 studies showed gains related to the physical activity intervention and core executive functioning.  Significant effects were also found for working memory, selective attention, cognitive flexibility, and metacognition (more global measures of cognitive ability).

The authors concluded that physical activity programs can be effective for promoting many cognitive domains in youth, and they note that this increasing evidence comes at the same time that many physical education programs at school are being cut back.

While the benefits of exercise certainly appear to be present for children in general, primary care physicians would do well to keep these kinds of studies in mind when working with children who meet criteria for ADHD.

The hope is that the Assessment/Plan section of your progress note might change from something like this……

A: ADHD   P: methylphenidate

To something like this…..

A:  ADHD  P: methylphenidate, parent behavioral therapy, daily physical activity, reduction in screen time, nutritional counseling, reading outside of school, mindfulness training, sleep hygiene counseling

Easier said than done of course, but these important and evidence-based elements will never get addressed if they don’t even get into the treatment plan.

Reference

Alvarez-Bueno C, et al.  The Effect of Physical Activity Interventions on Children’s Cognition and Metacognition: A Systematic Review and Meta-Analysis.  JAACAP 2017:56(9):729-738.

Pretend Parents Learn How Hard It Is to Get Child Mental Health Care

Posted: July 5th, 2017 by David Rettew

Getting access to child mental health services isn’t easy, even when armed with a big list of names provided by an prominent insurance company.

A group of researchers recently published the results of an interesting study in which the authors called the offices of pediatricians and child

Image by botabateauTH

psychiatrists while posing as the parent of a 12-year old with depression.  They were looking to see if they could book an appointment and, if so, how long it would take.  Calls were made to physicians in 5 different urban areas (Seattle, Boston, Chapel Hill, Houston, and Minneapolis).  Phone numbers were obtained from online lists of providers who were in-network for Blue Cross Blue Shield.   The calls varied in-terms of how the service would be paid for (private insurance, Medicaid, and self-pay).   All told, the offices of 601 pediatricians and 312 child psychiatrists were contacted.   If there was no response after a first call to an office, a second one was placed.

Overall, an initial appointment was able to be made from only 40% of  the calls to pediatricians and only 17% of the calls to child psychiatrists.  The average wait time when an appointment was made was 17 days for pediatricians and 43 days for a child psychiatrist.   Significant differences were found in the ability to obtain an appointment by geographic region and by insurance, with calls claiming Medicaid as the insurance being less successful than private insurance and self-pay.  Interestingly, the most common reason that an initial appointment was not made was that the phone number was incorrect, with the contacted provider often no longer working there.

The authors concluded that appointment availability for child mental health services is low across a diverse range of locations. They urged additional efforts in increasing the workforce of child psychiatrists and additional training in mental health for primary care clinicians.

While this study probably doesn’t tell most primary care clinicians something they don’t already know, it does add some specific numbers to the problem and points out that access to behavioral health care can be difficult in both primary care and specialist settings.   It also highlights a problem that many people (including me) find really surprising in 2017, namely how challenging it is for families or referring physicians to get even an accurate and updated list of mental health professionals who are taking new patients and who take different types of payment. Finally, it should be reminded that these calls were placed just to pediatricians and child psychiatrists and not to other types of mental health professionals.

Reference

Cama S, Malowney M et al.  Availability of Outpatient Mental Health Care by Pediatricians and Child Psychiatrists in Five U.S. Cities. International Journal of Health Services.  2017:  epub ahead of print.

Optimal Sleep Duration for Teens Different between Academics and Mental Health

Posted: May 31st, 2017 by David Rettew

While few people argue over the importance of sleep,  just how much sleep is optimal has remained a surprisingly elusive question.  Complicating things further is the possibility that the best amount might differ between domains such as academic achievement and optimal mental health as well as the importance of other sleep parameters such as the amount of day-to-day variation.

To address some of these questions a research group from UCLA and Arizona State studied 421 9th and 10th grade Mexican-American adolescents in the Los Angeles area.   The subjects recorded their sleep duration daily for two weeks.  A measure of sleep variability was also calculated.  Grade point average, standardized test scores, and school absences were also obtained.  Levels of emotional-behavioral problems were assessed using the Child Behavior Checklist (of course!).  The participants repeated this procedure about one year later.

The researchers found that the average amount of sleep for 9th, 10th, and 11th graders 8.1, 8.0, and 7.9 hours, respectively with about 1.4 hours of variation across nights.  Non-linear associations were found between sleep duration and academic achievement with the optimal level found to be about 7.5 hours for GPA and around 7 hours for a standardized English test, with no association found with a standardized math test.  A different optimal point, however, was found for behavior problems, with the lowest levels associated at approximately 9 hours per night.  The implications for sleep on mental health appeared stronger than they did for academic achievement.  More sleep variability was also significantly related to higher levels of behavioral problems, although the pattern was less evident and more mixed with regard to academics.

The authors concluded that there might be a trade-off in the optimal level of sleep with regards to academic achievement and mental health with more sleep related to better mental health at the slight cost of some academic achievement.  Of course, causation was not established in this study and it could be that mental health problems are associated with reduced sleep rather than the other way around.   

Reference

Fuligni AJ, et al.  Adolescent Sleep Duration, Variability, and Peak Levels of Achievement and Mental Health.  Child Development, epub ahead of print

Long Term Stimulant Treatment Associated with 1 inch Reduction in Height

Posted: April 5th, 2017 by David Rettew

When considering stimulant treatment for ADHD, one concern that is often voiced by parents is about height loss associated with long-term use.  Answering this question has been difficult, in part because the available literature has been inconsistent.  Some long term studies have shown no differences while other show reductions in over an inch. To help provide some more definitive data, a study was recently published that reports on the long term follow-up into adulthood of subjects who took part in the well-known Multimodal Treatment Study of Children with ADHD or MTA.   As a reminder, this government funded trials was one of the most comprehensive treatment studies ever done.  Back in 1994, over 500 children with ADHD were randomized to receive short term treatment with stimulants, behavioral therapy, combined treatment or treatment as usual in the community.  After 14 months, however, patients and families were free to choose the best treatment for them and the study was naturalistic in design from that point forward.

During the follow-up period, investigators performed multiple assessments at regular intervals until subjects were on average about 25 years of age.  Based on their recorded patterns of medication use, subjects were divided up into groups of those who consistently took medications into adulthood, those who inconsistently took medications, and those who took negligible amount of medications.  A community sample was also recruited for comparison.

In terms of results, one somewhat surprising finding was that only a minority of subjects (14.3%) took medications regularly across the study period.  While there was evidence that symptoms of ADHD persisted into adulthood compared to the comparison group, no significant differences in severity were found among ADHD patients between the three groups with regard to overall medication usage (consistent, inconsistent, and negligible).  Differences were found, however, with regard to height.  Specifically, the consistent and inconsistent groups were approximately 2.55 cm or about 1 inch shorter than the negligible group.

The authors concluded that symptom benefits of medication may dissipate over time but that the impact on growth may persist into adulthood.

While some would love to interpret the lack of significant differences in ADHD symptoms between the three medications groups as evidence that stimulants don’t work over the long term, it is crucial to point out, perhaps over and over again, that the naturalistic design of the follow-up period drastically impairs the ability to make that conclusion.  Yes if stimulants were a miracle cure for everyone then we would see differences, but in the real world case of a condition that varies in severity and treatment responsivity, what tends to happen of course is that more refractory cases continue taking medications while less severe cases often stop their medication successfully.

Then there is what to make of the fairly robust height differences which are larger than what most other studies have reported.  Do we just add it to the heap of studies showing different things and tell patients that we still don’t know the definitive answer, or do we give this study a little more weight?  In my view, it’s the latter.  The MTA study is arguably the most rigorous study ever done on ADHD treatment and, while no study is perfect, needs to be considered carefully.  The 1 inch differences will now be part of my standard spiel in doing informed consent with stimulant medications.

Reference

Swason JM, et al.  Young adult outcomes in the follow-up of the multimodal treatment study of attention-deficit/
hyperactivity disorder: symptom persistence, source discrepancy, and height suppression.  J Child Psychiatry Psychology 2017; epub ahead of print.

Vermont Legislature Busy with Mental Health Bills

Posted: February 24th, 2017 by David Rettew

Vermont’s 2017 legislation session is in full swing and this year there seems to be an unusually large number of bills that have direct impact on mental health.  What follows is a short list and update of the legislation as well as a few personal thoughts.

Improvements to the state mental health system (S90).  The current crisis that has many Vermonters with emotional/behavioral struggles stuck for long periods of time in emergency departments and hospitals has not gone unnoticed.  While there continues to be discussion about short-term interventions, people are also looking at the big picture.  S90 requires the Deputy Secretary of Human Services to coordinate a prevention and treatment program for victims of child trauma and adverse events.  It includes a statewide home visiting program and implementation of evidence based parenting and wellness programs.  Our Vermont Family Based approach is listed by name.  As you might expect, those of us in child psychiatry are strongly in support of this legislation.

Psychologist Prescribing Privileges (H280).  This bill would allow psychologists the ability to prescribe psychiatric medications after some additional training.  While on the surface this might appear to be a way to improve access to mental health care, there are concerns about the level of training needed to prescribe medications safely and specifically the need not only for pharmacological knowledge but true medical training as well.  This bill is now at the House Committee on Health Care.

Kuligoski clarification and possible reversal (S3).  As many people know, a VT Supreme Court decision known as the Kuligoski ruling drastically increased the circumstances for which confidential patient information would need to be breached for people who might even be at chronic risk for harming others (the previous standard was for imminent risk to identifiable people).  This judgment has left mental health professionals confused about what their responsibilities now are.  Some officials from the state believe that the ruling is partially responsible for the increased back-up of patients in emergency departments and hospitals.  This bill aims to bring the “duty to warn” closer to the original standard. While this bill is quite welcome by many patients and mental health professionals alike, some new language in the bill about the need to disclose “all necessary information” to caretakers at discharge has led some people to wonder how much of an improvement the bill actually would be in its present form. This bill is out of the Senate Judiciary Committee and going to the floor.

Medical and recreational marijuana (H170, H207, S16).  Despite recreational cannabis being voted down last year, it is back again just a year later in many different forms.  While the main legalization bill no longer opens up a broad commercial market, it does allow Vermonters to grow quite a bit of their own marijuana legally.  Many health professionals continue to voice concerns about the public health effects of legal cannabis, particularly when our state’s substance abuse resources are so limited. This bill is currently in the House Judiciary Committee and sponsors are trying to fast track it so that it is not reviewed by any health care committee.  A separate bill regarding marijuana expands the allowable indications, including PTSD.  Not only is there a lack of research evidence that cannabis helps PTSD but there are studies demonstrating that over the long-term cannabis worsens things like aggression, anxiety, and other types of substance use. S16 is now at the House Committee on Human Services. H207 would also allow psychologists to sign the medical verification form.

This list doesn’t even include other legislation regarding nutritional requirements for children’s meals (S70) or raising the tobacco smoking age to 21 (S88), and many other healthcare related bills.

These potential actions could have major impacts on the health of Vermonters and our elective officials are eager to learn from the medical community and hear our views.  Especially in a small state like Vermont, voicing your views to your legislators and letting the relevant committees know your science-based opinions can make a big difference so please speak up.  You can find more information about the specific bills here.

Autism Severity Criteria Has Dropped

Posted: February 3rd, 2017 by David Rettew

The increased prevalence of autism over the last several decades has been widely reported with rates now peaking at around 1 in 68 children, according to the CDC.  This rise has triggered alarm in many circles as well as mass speculation over its potential causes, including the widely discredited hypothesis regarding vaccines.  Tempering this concern, however, is the commonly held view that what appears to be a new epidemic probably isn’t, and that the increase in number of cases is mainly due to three main factors, namely 1) increased awareness and screening of autism, 2) a shifting from other developmental diagnosis to autism over the years, and 3) a reduction in the severity threshold for what qualifies for an autism diagnosis.  Regarding #3, this means that the diagnosis used to be mainly reserved for children who manifested very apparent and severe symptoms but more recently has been increasingly invoked for individuals with much milder, although still impairing, challenges.  Yet despite the broad consensus about this hypothesis, direct evidence to support it has been lacking….until now.

Researchers recently published data from an Australian registry that contained information on new autism cases between the years 200 and 2006: a time during which the rate of autism rose sharply.  The official diagnoses in these cases came from a standardized procedure and included an experienced clinician’s rating of the severity of individual symptoms as mild/moderate or extreme.  For a portion of the sample, the Vineland Adaptive Behavior Scale was also performed.

A total of 1252 cases were analyzed, all under 18 years of age.  The main finding was that the number of individuals who were rated as having extreme levels of many diagnostic criteria, or who had extreme levels of any symptom, dropped significantly over the study period.  The percentage of individuals who had an extreme rating on any symptom, for example, dropped from 38% to 15% over the study period.  Scores on the Vineland scale also dropped with time.

The authors wrote that theirs was the first study to demonstrate directly that the severity level of symptoms among people newly diagnosed with autism has been decreasing.  They suspect that this phenomenon underlies what appears to be an increasing prevalence of the diagnosis.

In some ways, this is a study that proves something everyone already knew.  Nevertheless, it is important to have some solid data behind a claim that is hopefully reassuring to most people.  At the same time, the data underscore some new questions.  Is it good thing to use this diagnosis for less severely impacted children?  Does it open the door for needed services or cause unnecessary stigma while taking away resources from those who may need it most?  The study also cannot rule out the possibility that a “true” increase is autism is also occurring, albeit at less striking rates.

Reference

Whitehouse AJO, et al. Evidence of a Reduction over Time in the Behavioral Severity of Autistic Disorder Diagnoses.  Autism Research 2017; epub ahead of print.

 

Where Would We Be Without Research?

Posted: January 12th, 2017 by David Rettew

(Editor’s Note:  I am pleased to offer this guest blog by Hannah Frering who is the research coordinator at the Child Emotion Regulation Lab, Vermont Center for Children, Youth, and Families – DCR)

Medicine has come quite a long way since the medieval era where doctors would amputate at the first sign of infection, or would quickly diagnose patients’ terminal problems and send them away without intervention. The advancement of science and technology is the crucial step to how doctors are able to prescribe lifesaving drugs, and control robots that operate on patients. But, how do uncover the science and technology necessary for treatment of medical problems? hannahResearch.

The University of Vermont is a leader of education in the science and technology fields, with the College of Engineering and Mathematical Sciences, College of Agriculture and Life Sciences, Honors College, and the Rubenstein School of Environment and Natural Resources all performing ground breaking research. Furthermore, clinical and laboratory research being conducted at the University of Vermont Medical Center is central to the mission of the University. Spanning from clinical vaccine trials of a dengue fever vaccine, to neuroimaging assessing the relationship of drugs and the human brain, the UVM College of Medicine hosts 15 academic departments engaging in research.

At any time in the Vermont Center for Children, Youth, and Families, we have multiple studies recruiting for participants both from the pediatric psychiatry clinic and from the community. Principal investigator Dr. Robert Althoff is currently recruiting patients and families through collaboration with the Vermont Center on Behavior and Health. This major project investigates the epigenetic and psychophysiological mechanisms underlying severe forms of childhood psychiatric disorders. This work seeks to understand the long-term consequences of these disorders on psychiatric and non-psychiatric health in adulthood. In addition to this, there are two smaller projects recruiting through the Child Emotion Regulation Lab. One of the other studies is striving to examine the influence of television pacing and attentional symptoms, involving executive functioning. With funding from the University of Vermont Medical Group, Dr. James Hudziak is conducting a large clinical trial of the Vermont Family Based Approach in pediatrics clinics. This new way of treating whole families represents the culmination of years of research on the individual components of wellness, prevention, and family-based intervention. Dr. David Rettew is studying medication utilization at a state level, child temperament, and bullying.

So, why are we investigating these topics? Children diagnosed with psychiatric disorders need assistance to focus, self-regulate, and perform adequately in school. Research in child psychiatry has lagged far behind other medical fields and we are trying to catch up. Research in the Vermont Center for Children, Youth, and Families seeks to connect symptoms found in kids with attentional problems, or self-regulation problems to issues that may arise later in life, like metabolic problems or substance abuse. This research is essential not only for determining causes of psychiatric problems, but leading to solutions.

Interested in participating in research in the VCCYF? Check out our VCCYF and Child Emotion Regulation Lab webpages.

Psychiatric Medication Usage Among Vermont Medicaid-Insured Youth Drops by 42%

Posted: December 12th, 2016 by David Rettew

A new report prepared by Change Healthcare for the Department of Vermont Health Access documents a sharp drop in the number of Vermont Medicaid-insured youth who are prescribed psychiatric medications.  The report stems from a project called Improving the Use of Psychotropic Medications among Children and Youth in Foster Care. Vermont is one of six states involved in the project.

Some of the highlights include the following for Vermont Medicaid-insured youth not in foster care.

  • Between 2012 and 2016, the percentage of youth taking at least one psychiatric medication dropped by about 42% for both the 6-12 age group and the 13-17 age group.  In 2016, approximately 13% of Medicaid insured youth from the ages of 6-12 had taken a psychiatric medication in the past 6 months while for adolescents in 2016 the percentage was just under 20%.
  • For all age groups, ADHD medication usage dropped by about half.
  • Antipsychotics, a class of medications that many clinicians worry about most, had the biggest drop in prevalence, falling  74% in the 6-12 year old age group.  This class of medications continued to drop between 2014 and 2016 while for ADHD medications and antidepressants, the rate was relatively stable across the last 2 years after a more pronounced drop between 2012 and 2014.

While the usage of many types of medications across many age groups dropped, there were some exceptions.  For example, as ADHD medication usage among children under age 6 dropped between 2012 to 2016, the rate increased among those in foster care, although this was due to a very small number of children.    At the same time, antipsychotic usage among very young children in foster care dropped from 1.1% to 0.3%.  Overall, psychiatric medication usage among children in foster care continue to be much higher compared to kids not in foster care, although for many ages and medication classes there appeared to be a modest drop between 2012 and 2016.

The million dollar question, of course, and one that the report does not attempt to answer, is what might be behind these drops in usage. Most likely, the trends are due to a combination of factors some of which are more newsworthy than others. There were increases in the number of kids enrolled in Medicaid during this time and shifting demographics of the new enrollees could have been a factor.  There also, however, appears to be a change in culture with clinicians becoming more cautious about medications while trying to emphasize non-pharmacological treatments and wellness activities.

Another important question is whether or not all of these decreases are a good thing.  Most people, including myself, generally interpret these findings as positive, but the numbers alone can’t tell us the degree to which these usage decreases represent a more balanced approach to child emotional-behavioral problems versus the reduction of treatment among those who need it.  Further study is planned with these data to understand more fully what may be occurring and why.

medication-trends

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