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Baby Steps to Exercise

Posted: August 2nd, 2013 by David Rettew

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,

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)

Tags: child wellness, exercise, wellness
Eliza's Wellness Wisdom | No Comments »

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.

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.

Tags: autism, brain connectivity
Autism, Neuroscience | No Comments »

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 and 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.

Tags: copycat suicide, suicide, suicide contagion
Depression, Suicide | No Comments »

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.

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.

Tags: act 264, inpatient, residential care
Access to care | No Comments »

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.

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.

Tags: adhd, eeg, neba
ADHD, Neuroscience | No Comments »

ADHD Medications and School Performance

Posted: July 11th, 2013 by David Rettew

The Wall Street Journal recently published an article casting doubt about the ability of ADHD medications to improve school grades and achievement. Actually, casting doubt might be a little soft as the title was “ADHD Drugs Don’t Boost Grades.” In the article, the author runs through a number of studies (some not published) that find no difference between the grades of children with ADHD who do and do not take medications.

The article raises important questions that those of us who prescribe these medications need to look at objectively. Certainly, if stimulants and other ADHD medications were miracle drugs that make the vast majority of kids do much much better at school, we should be seeing that reflected in these studies, and we don’t.

However, the studies that look at this question can’t really answer it because they don’t do one critically important thing, namely RANDOMIZE. This may sound like methodological minutia, but actually it is vital because without it, the ability of a study to make conclusions about causality is grossly impaired. The other main problem is that the yes/no nature of an ADHD diagnosis doesn’t capture how incredibly different two kids with the same condition can be.

Imagine two 6-year-old children, both of whom meet criteria for ADHD. The first child has mild symptoms, is quite intelligent, and has a very involved and supportive family who do everything they can to help. The second child has more severe symptoms, may have a lower IQ, and the family struggles to provide an optimal environment. Five years later, both kids are assessed. The first one has largely grown out of his symptoms and is doing well at school. He doesn’t take medications because he doesn’t need to take medications. The second child is still having a lot of challenges and, while gaining some benefits of continued medication use, is not doing as well as the first child.

Is the difference in the achievement of these two kids all due to a useless medication? Of course not, but that is basically the design of the studies that are being used to create these headlines. The article cites the well known MTA study as evidence, which randomized subjects initially but not over the long term. Not surprisingly, stronger effects of medication were found during the period that subjects were randomized compared to when subjects were not, but the article skirts around that point.

Ironically, most of the authors of these studies realize that without randomization that their conclusions are quite limited. Their admission is often right there in their own text (usually at the end of a long article). The authors of the MTA study state that “after 14 months the MTA became an uncontrolled naturalistic follow-up study and inferences about potential advantages that might have occurred with continued long-term study-provided treatment are speculation.” Speculation indeed, but not enough to keep reporters from ignoring these limitations and plowing ahead with provocative headlines. After all, nobody reads the fine print and “wishy washy” conclusions don’t get people to buy or, perhaps, click. Another irony is the reason behind why it is so difficult to do these studies “right” and randomize. If you are the parent of a child with ADHD who is starting to do poorly at school, are you ready to sign the consent for a study that basically will give him or her a 50/50 shot at not being allowed to take a mediation for 5 years to order to find out how much they might be useful for other kids?

Those of us who actually work with youth and are responsible for their care need to be able to cut through the mountains of misinformation and guide families to do the same. We also need to be able to tolerate conclusions we might not want to believe, if they are the result of solid scientific data. For this particular and important issue, I think we probably know that ADHD medications a) can really help some kids and b) are not a silver bullet for a great number of others. Between those two statements there is a lot of ground to cover and understand that I don’t think we can trust the popular press to do for us.

Tags: add, adhd, grades, school performance
ADHD, Medications | No Comments »

A Note About Our Clinic Waitlist

Posted: July 5th, 2013 by David Rettew

As of early July, the waitlist for new patients and families wishing to be seen by any one of our clinicians for an initial Pediatric Psychiatry Evaluation is about 6 weeks, once we have received the completed packet of rating scales and questionnaires. While any delay for a family in need can feel unacceptably long, we have worked hard to keep this waitlist to a minimum during a challenging period. In addition to our own clinical reduction of one child psychiatrist here at the VCCYF, there have also been other clinicians in the community that have closed their practice recently, resulting in large number of families needing someone new for psychiatric care. There further remains little progress in outpatient child psychiatry access in northeastern New York, with families often traveling 5 hours or more roundtrip to be seen here in Burlington.

What can be done in the meantime? Remember that all Vermont primary care clinicians can sign up at no cost to have one of the child psychiatrists or nurse practitioners be assigned to your practice and be available for phone or email “curbside” questions. To register, contact Eliza Pillard at eliza.pillard@vtmednet.org. This service is made available by the Vermont Child Health Improvement Program or VCHIP.

It is also important to keep our voices heard when it comes to our elected officials. There seems to be lots of discussion about improving child mental health care here in Vermont and across the country but having talk turn to action will require continued advocacy .

Uncategorized | No Comments »

Texting While Driving Remains Common Among Teens Despite Laws

Posted: July 1st, 2013 by David Rettew

Anyone driving today has likely encountered distracted drivers with their hands busily working their phone texting or emailing rather than being on the wheel. While these behavior are a safety concern for all, they may be particularly problematic for teens who are relatively new to driving (and also known to be quite fond of text messages). Motor vehicle accidents are the most common cause of death for older adolescents. This study recently published in the journal Pediatrics, utilizes data from the Youth Risk Behavior Survey to document the rate of texting and/or emailing while driving among teens.

Subjects for the study included 8505 teens from a nationally representative sample who were at least 16 years of age. The participants completed the CDC’s 2011 Youth Risk Behavior Survey which asked about driving behaviors in the preceding 30 days.

In terms of results, slightly less than half of the respondents (44.5%) reported texting or emailing while driving at least once in the last 30 days. Of those, approximately one-quarter reported texting while driving every day. Rates were higher among white students compared to black students and higher in males compared to females. Furthermore, those individuals who engage in texting/emailing while driving are somewhat more likely to engage in other risky driving behaviors such as drinking while driving, riding with someone else who is drinking, and not using a seatbelt.

The authors concluded that there was a high rate of texting or emailing while driving that is related to other types of risky driving behavior. These individuals are at increased risk of hurting themselves and others. The study authors discuss the laws enacted in many states against texting or emailing while driving (including one here in Vermont) but note that there is little evidence these laws are having a major effect in reducing these behavior among adolescents. They cite evidence that good parental monitoring and explanation of driving rules may be the most effective strategy for producing safe driving behavior.

What is the role of primary care here? For one, primary care clinicians are encouraged to bring up this important issue as part of regular anticipatory guidance not only with teens directly but with the parents as well in order to help them spell out clear ground-rules for driving. The finding of higher rates among adolescent males also flies against some prevailing gender stereotypes, and may remind parents of teen boys to have this issue on their radar screen too.

Reference

Olson E, et al. Texting While Driving and Other Risky Motor Vehicle Behaviors Among US High School Students. Pediatrics 2013;131;e1708-e1715.

Parenting, Public Policy | 1 Comment »

Youth Mental Illness Affects 1 in 5 According to New CDC Report

Posted: June 28th, 2013 by David Rettew

The Center for Disease Control (CDC) released a major report last month, focusing on child mental health from the period of 2005 through 2011. The report features new summary statistics on the prevalence of mental health disorders as well as estimates of the costs of these conditions.

The report summarizes results from a number of federal surveillance systems and the surveys that are generated from them. The methods of data collection do vary in line with different priorities of the collecting agency, with mental health data imbedded in broader health assessment for some of the systems.

With regard to prevalence, the report concluded that up to 1 in 5 youth meet criteria for a diagnosable mental disorder in a given year with the rate appearing to rise since the mid-1990s. The most common disorders include ADHD (6.8%), conduct problems (3.5%), anxiety (3.0%), depression (2.1%), and autistic spectrum disorders (1.1%). The rate of a drug use and alcohol disorder in the previous year was 4.7% and 4.2% respectively while the prevalence of cigarette dependence within the previous month was 2.8%. These rates varied considerably by sex and ethnicity. A total of 40% of individuals with one disorder met criteria for at least one other. Suicide was found to be the second leading cause of death among youth between the ages of 12 and 17, with an overall rate of 4.5 suicides per 100,000 persons (ages 10 to 17) . Moreover, the total cost of psychiatric disorders in youth was estimated at $247 billion dollars and are now some of the mostly costly medical problems to treat. Inpatient hospitalizations for children and adolescents have also risen. The rate of hospitalization for mood disorders has risen 80% from 1997 to 2010, resulting in mood disorder being one of the most common principle causes of inpatient hospitalization overall.

The authors of the report concluded that mental illness among youth remains a major public health issue in need of more comprehensive surveillance systems.

While determining the rate of youth psychiatric disorders seems like a relatively straightforward question, this report illustrates how complicated such an undertaking can be. The wide range of techniques used to come up with such epidemiological data result in significant challenges when it comes to aggregating results from a number of reports and the summary numbers presented here should certainly not be seen as set in stone. As the authors suggest, improving the consistency and reliability of surveillance studies are an important part of making progress overall in the approach to youth with emotional behavioral problems.

Reference

Perou R, et al. Mental health surveillance among children – United States 2005-2011. Morbidity and Mortality Report 2013;62:1-35.

Diagnosis, Public Policy | No Comments »

Mental Health of Fathers Also Matter to Their Children

Posted: June 14th, 2013 by David Rettew

With Father’s Day coming this Sunday, it seems appropriate to mention a recent article that likely confirms something most of us believe yet hasn’t been documented as much as one might expect. To date, the vast majority of data linking parental mental health to child mental health comes from the study of mothers. Fathers are often left out of these investigations either on purpose or due to family circumstances. Although there is evidence that paternal mental health in the post natal period influences child behavior later in development, this study recently published in Pediatrics examines the relations between paternal mental health in the prenatal period and child behavior at age 3.

The data for this study come from, ironically enough, the Norwegian Mother and Child Cohort Study. Over 28,000 fathers and 31,000 children participated in this study. Mental health of expecting fathers was assessed with the Hopkins Symptom Checklist at around 17 to 18 weeks of gestation (of the child, that is). Child behavior was assessed through a procedure that combined items from several validated questionnaires. Regression analyses were used to examine the link between depressive and anxiety problems in fathers and child behavior at age 3 while controlling for potentially confounding variables such as maternal mental health, demographic factors, and lifestyle variables.

Although effect sizes were relatively small, a statistically significant association was found between levels of father emotional distress and offspring levels at age three of behavioral difficulties, emotional difficulties, and social functioning, even after controlling for other factors. No differences were found between girls and boys. A total of 3% of fathers reported high levels of psychological distress.

The authors concluded that increased paternal emotional problems increase the risk of offspring behavioral difficulties. Helping fathers during the prenatal period could be an opportunity for intervention.

This study is the largest one to date that examines this question. Its design, however, cannot exclude the possibility that the link between father and child emotional problems is at least partially related to genetics. The authors write that another possible mechanism relates to an association between mother and father distress. While this possibility seemed testable with these data, they do not report on this possible link.

Reference

Kvalevaag et al., Paternal mental health and socioemotional and behavioral development in their children. Pediatrics, 131(2): e463-e469, 2013

Tags: child behavior, father, parent mental health
Parenting | No Comments »

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