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Home – Child Mental Health Blog

Post-Irene Book Children, Trauma, and the Arts Distributed Across Vermont

Posted: June 10th, 2013 by David Rettew

The book Children, Trauma, and Arts, a collaborative project  between the Vermont Chapter of the American Academy of Pediatrics (AAP) and the Arts Bus Project was released last week.  The Arts Bus travels from town to town, providing children opportunities to participate in art, theater, and music.  After tropical storm Irene, the bus visited several affected towns and helped local kids express their thoughts and feelings about the storm and its devastating effects.  Children and Arts book

Vermont AAP President Dr. Louis DiNicola partnered with Art Bus board president Anthony Keller to edit this book that contains contributions from many pediatric and mental health professions from across the state.  The book also shows some striking drawings by children that depict scenes of their towns after Irene, some of which can be viewed here.  Among the chapters are two from VCCYF faculty: a chapter by Director Jim Hudziak entitled “Promoting Healthy Brain Development as a Strategy to Deal with Adversity,” and my own chapter “Trauma in Children: Options for Psychiatric Response” that provides tips for helping children after a disaster and signs to recognize possible post traumatic stress disorder.  The book also contains recommendations for how art can help children express and cope with upsetting events that they have experienced.

Arts BusThe book is being distributed free of charge to Vermont pediatricians, as well as some mental health professions, arts leaders, and disaster relief coordinators. It is also available to the public for purchase, although the hope is to secure additional funding so that a wider free distribution can be made.

We congratulate the Arts Bus team and the AAP for putting together such a useful and important work and then getting the book out to many of the people who could benefit from it.

Welcome DSM-5?

Posted: June 5th, 2013 by David Rettew

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was finally released last week after several delays and an amazing amount of controversy and discussion.  The book, published by the American Psychiatric Association, is commonly referred to as the psychiatric “bible” and contains the official list of psychiatric diagnoses and their criteria.  The last version was published way back in 1994 with minor changes issued in a “text revision” in 2000.DSM5

Many experts have remarked on how much things have not changed in over 20 years, including through the entire 1990s “decade of the brain.”  More revolutionary ideas that were floated initially, such as making disorders more dimensional rather than using a yes/no format, were eventually dismissed.  Arguably the two biggest changes as they relate to child disorders is the collapse of all pervasive developmental disorders into a single Autistic Spectrum Disorder diagnosis (no more Aspergers) and the creation of a new Disruptive Mood Dysregulation Disorder to describe chronically irritable and explosive children who don’t meet strict criteria for episodes of mania (but were often being diagnosed as bipolar disorder anyway).  A summary of changes to various disorders can be found here.

While it is hard to imagine how such an undertaking could be performed without triggering heated debate from many sources, DSM-5 has found a way to provoke criticism even from those you might think would be staunch supporters.  The Director of the National Institute of Mental Health, Tom Insel, wrote that patients “deserve better” than a diagnostic system based on committee consensus rather than neuroscience research.  His comments raised enough eyebrows to prompt a statement of solidarity with DSM-5 and the APA, claiming basically that it is the best we can do right now given our current state of knowledge.  The former head of DSM-IV, Allen Frances, has also gone extremely public with his criticism of the DSM-5.  Among other things, he disparaged the frequent conflicts of interest of DSM-5 committee members, although ironically did so in the promotion of two books he wrote on the subject.

Adding further confusion is exactly how the new terminology will be incorporated into our “official” language.  Most medical coding systems use the classification of the International Classification of Disease (ICD) system rather than DSM anyway, so disorders can and do live in one world and not the other.

While it is worth noting that plenty of nonpsychiatric illnesses, from hypertension to migraine headaches, also rely on diagnosis by convention, the pervasive criticism coming from multiple angles may reflect an overall theme of impatience and yes, even some embarrassment that, after all the years and all the hard work, our diagnostic system has stood mostly unchanged for decades despite the widespread acknowledgement that it is fundamentally flawed.

Anybody Home? Parenting Tips for Texting Kids

Posted: May 28th, 2013 by David Rettew

by Jim Hudziak, MD and David Rettew, MD

A few years ago, I was driving my son and three teammates to a hockey tournament in Montreal when I noticed it was oddly quiet in my car. Looking around, I saw four boys, all best pals, texting each other while they sat in the same car. That is when the GLOVE BOX RULE was born (all cell phones in glove box when in car). Quickly followed was the HAT RULE (all phones off and in my baseball cap when eating in restaurants), followed by a number of other technology interventions all aimed at achieving one simple goal: normal human interaction. Phone

It doesn’t take a rocket scientist to understand that technology has changed the landscape of childhood and adolescence. According to a recent Pew Report, 78 percent of teens have a mobile phone; half of them have a smartphone. Many preteens have phones that allow them to access the Internet (and the unfiltered information that lives on the web), which entices them to text and tweet, rather than sit and talk.

Technology is not going to go away. But is there a way that parents can manage how technology is used in their homes and by their children? Only a few years ago, child development experts were urging parents to make sure the home computer was in a public place in the house in order to monitor both content and time spent on the Internet. Now, our children have that technology in their hands.

While it is more challenging than ever to teach responsible technology use, here are some suggestions for parents to consider.

  • Remember you are a parent. You set the rules in your house. While you may hear that “everybody else” has a mobile phone, an X-box, a Facebook account, etc., kids vary on their ability to use these things responsibly. They may think they can’t survive without one right now, but the truth is they can and they will.
  • Practice what you preach. As parents we need to have similar standards for our own use of technology. Put the phone away in the car (parents texting while driving is a certain endorsement for a teen to do the same), when you are at the dinner table, or when you are at one of your child’s performances, games, or activities. By modeling that you can live without technology, your child can learn the same.
  • Be clear about expectations. It is important to have a conversation about the rules of using technology that include clear prohibitions for things like texting while driving (or biking), sexting, cyber-bullying, or giving out personal information on the web. Not only does this encourage safe behavior, it eliminates the “you never told me” defense later on.
  • Collect devices at night. Kids can get caught up in using technology late at night at the expense of sleep and during a time when inappropriate use is more tempting. A daily habit of turning in phones, tablets, computers, TV and video games at least one hour prior to bed time can lead to more responsible use and much better sleep.
  • Show me the money. Mobile phones are expensive. Create a sensible budget and show them the bill. If they go over this amount, come up with a way to pay it off, or consider prepaid plans.
  • Use parental restrictions. While it is harder to keep certain content out of a child’s hands than in the past, parental controls are available for many mobile devices in addition to televisions and video games. With iPhones, for example, they can be accessed at Settings > General > Restrictions.
  • Family Matters. If parents can remain engaged in their children’s lives, they will have less time and less of a need to get lost in technology. Learn more about how to remain an engaged family and to reduce tech time by visiting National Institute of Health’s “We Can” Program which has great ideas for enhancing children’s activity and nutrition.

By following these simple suggestions you can help your child to think of technology as a tool to assist them in their lives, rather than something that demands their immediate and constant attention.

Kids and Chores

Posted: May 28th, 2013 by David Rettew

The idea of chores may seem a little old fashioned to some, but it remains a useful part of home life.  Apart from any direct benefit of getting certain tasks accomplished, chores can teach kids practical skills, instills valuable lessons about work, and helps children feel like they are contributing to the family.  The following is a recent post that discusses how to bring chores into a child’s routine.

Vermont Pediatricians Call for Action on Gun Violence

Posted: May 22nd, 2013 by David Rettew

This month, the Vermont chapter of the American Academy of Pediatrics (AAP) sent a letter to members of the Vermont legislature, executive leadership, and our US senators and representative, calling for specific action to prevent gun violence in the wake of tragedies like the Sandy Hook school shooting last December.   The effort was led by Vermont AAP President Louis DiNicola, MD, FAAP and UVM and Fletcher Allen pediatrician Eliot Nelson.  The letter acknowledges the legitimate use of firearms for many Vermont citizens but urges our government officials to enact tougher measures to decrease the chances of future horrific events.  Specific measures include the following.

  • Better background checks without loopholes
  • Holding gun owners responsible for recklessly stored firearms
  • Limiting access to assault-style weapons and high capacity magazines
  • Tougher gun trafficking laws
  • Removal of federal restrictions that impede firearm injury research
  • Improved mental health care and identification of those with “specific” conditions that would make owning guns unsafe
  • Increased education and research about the root causes of violence

Over 90 pediatricians signed the letter, and an enthusiastic response of support was sent by Senator Leahy.  According to Dr. DiNicola, however, Governor Shumlin “remained committed  to his desire to wait to do anything in Vermont until the federal government acts on this issue.”

While the Vermont legislature is now out of session, the AAP encourages continued advocacy on this issue to our local and national leaders so that another year does not pass without effective measures being undertaken.

Gun letter 1Gun letter 2

 

 

Causes of Adolescent Depression

Posted: May 21st, 2013 by David Rettew

A recent posting on Babysitting.net describes 10 Common Causes for Teenage Depression.  I thought it was a useful post and worth passing along.   I think it is also certainly worth noting that most frequently there isn’t a single cause but several that can conspire to work together.  A child with a genetic predisposition for depression (#6), might be raised in an environment where he or she does not get a lot of parental attention (#8, perhaps due to the parent’s own depression) which can make this adolescent very vulnerable to common stressors like a romantic breakup (#3).

Baby Sign Shown Not to Accelerate Language Development

Posted: May 15th, 2013 by David Rettew

An increasingly popular activity for parents of infants and early childhood education centers is to demonstrate to babies and encourage the use of basic sign language or “baby sign” for words such as “milk” or “hot.”  One touted benefit of the practice is the possibility that such activities foster accelerated language development, although this finding is inconsistent and has not been subjected to rigorous evaluation. This study by Kirk and colleagues, recently published in the journal Child Development, is the first randomized controlled study of the impact of infant signing on language development.Baby Sign

Participants included 40 typically developing infants from the age of 8 to 20 months and their mothers.  Subjects were randomized to four conditions: baby signing, British sign language and two control conditions, a nonintervention and a verbal training condition.  The authors assessed language development using standard measures.  In a second study using a subset of the original sample, recorded and coded interactions were used to assess infant-mother relationship qualities at multiple home visits when infants were at ages 10, 12, 16, and 20 months.

Results showed that the program to encourage baby sign did not result in any improved outcomes with regard to spoken language development, although the infants taught gestures generally were able to use them to communicate.  There was, however, an indication that a few infants, especially those with lower baseline expressive language, may have benefited more than others.  In the second study, significant differences were found in other areas, with mothers who participated in the sign training found to be more attuned to infants’ nonverbal cues and more encouraging of infant autonomy than those in the control group.

The authors concluded that while there was no evidence of accelerated language development with the use of baby signing, benefits were observed for the practice in other areas of the mother-infant relationship.

In light of the expanding market for baby signing classes and products, this study suggest that such things may be unnecessary, at least with regard to typically developing infants and language acquisition.  The authors acknowledged some limitations of the study including recruiting a fairly high SES group of mothers and having a small sample size. Thus, it is possible that there may be benefits to the technique but in groups, unfortunately, that are typically less likely to try baby signing in the first place.  The bottom line here is that there may be good reasons for parents to want to do some baby signing but giving them a leg up in terms of language development probably isn’t one of them.

Study Challenges Youth Overmedication Perception

Posted: April 29th, 2013 by David Rettew

Are children and adolescents in the United States too easily given psychiatric medications?  There has been a lot of attention to this question lately with many people both within and outside of the mental health community believing that the answer is a resounding yes.   Yet while there is ample evidence suggesting that the percentage of youth taking psychiatric medications is rising, there remain fewer data that weigh in on the question of whether those who meet criteria for a psychiatric illness have been saturated with too much treatment.  Into this debate comes an important study by Merikangas and colleagues from the National Institute of Mental Health that was recently published in the journal JAMA Pediatrics.

The data from this study comes from the National Comorbidity Survey – Adolescent Supplement.  The participants are a nationally represented sample of over 10,000 adolescents between the ages of 13 and 18 who were assessed directly at home or at school for the presence of DSM-IV psychiatric disorder using a structured interview.   Medication usage over the past year was also assessed. Medication usage table

Results showed that of youth meeting criteria for any psychiatric disorder, only 14.2% were taking a medication in the past 12 months, with only approximately a quarter receiving any mental health services.  The types of medication participants were taking reflecting the nature of their disorder, although rates of medication usage tended to be low for all disorders.  A total of 20.4% of youth with a diagnosis of ADHD were being treated with stimulants, while 14.1% of adolescents with a mood disorder were taking an antidepressant.  The rate of antipsychotic usage was found to be 1.0% and was generally being prescribed for those with developmental disorders. The proper correspondence between type of disorder and class of medication was found to be more common among youth in the mental health system in comparison to those in general medical care. Looking at the flip side, only 2.5% of adolescents who did not meet criteria for a psychiatric illness had been given a prescription medication.

The authors concluded that the vast majority of youth with mental disorders are not being treated with psychiatric medications.  They argue that their study challenges the common perception that youth are being overprescribed psychiatric medications.

After reading this study, the rates of medication usage in this study are amazingly low.  Perhaps some subjects previously were taking medications but no longer were due to side effects or poor response. Others have questioned the claim that this sample truly is nationally representative with a concern that lower SES groups may be underrepresented (who also tend to have higher rates of medication usage). In the end, however, it is undeniably true that there exist children both who could benefit from medication but don’t take it in addition to those who take medication but don’t need it.  Our efforts might be best utilized by trying to reduce both of these groups rather than arguing over which group is larger.

Reference

Merikangas K, et al. (2013) Medication Use in US Youth With Mental Disorders.  JAMA Pediatrics 167(2):141-148.

Same Genes, Different Disorders

Posted: April 10th, 2013 by David Rettew

The phenomenon of comorbidity is extremely common in psychiatry.  While the term is used to denote the occurrence of two or more independent psychiatric disorders in the same individual, there is increasing evidence to suggest that different types of psychopathology share common etiologic factors.  This molecular genetic study, recently published in The Lancet, was done to examine the question of whether different categories of disorders were associated with common risk genes.

The study comes from the Psychiatric Genomics Consortium.  It compares a group of 33,332 individuals with various psychiatric disorders to a group of 27,888 controls. The types of psychiatric disorders examined included autistic spectrum dnadisorders, ADHD, bipolar disorder, major depressive disorder, and schizophrenia.  The subjects have previously been involved in genetic studies looking that tried to pair specific genes with a single disorder. The authors performed a genome-wide association study or GWAS that was able to examine associations between these various disorders and single nucleotide polymorphisms or SNPs.

Results showed that four SNPs attained statistical significance at the genome wide level, which controls for the number of tests made. Significant associations were found at four loci, including 3p21, 10q24 and in two SNPs that involved genes that encode for L-type voltage gated calcium channel subunits.  These SNPs were associated with multiple psychiatric disorders, with the two calcium channel signaling genes related to all five disorders tested.

The authors concluded that there was evidence for some common genetic factors that were related to multiple types of disorders.  The authors advocated for a classification system that went beyond symptom description and was informed by disease mechanisms.

This is an important study in many ways.  Clinicians have long been aware of the fact that the boundaries between supposedly distinct categories of disorders are not very clear, and these data suggest that one of the reasons that these lines can be so fuzzy is that many disorders share a common genetic diathesis.  What is significant further is the hint at what exactly these common genes are, giving researchers a potential target for interventions that could cut across many types of psychopathology.

Reference

Smoller J et al.  Identification of risk loci with shared effects on five major psychiatric disorders: a genome-wide analysis. Lancet. Published online Feb, 2013.

Helicopter Parenting: Little Study, Big Soundbites

Posted: April 4th, 2013 by David Rettew

The media has been full lately with discussions and advice about the merits of different types of parenting (see previous blog posting of June 2012: Tiger-Attachment-Ferberization Parenting).  Adding further to the debate is a recent study by Schiffrin and colleagues from the Journal of Child and Family Studies regarding a more intrusive and controlling parenting style, also known as helicopter parenting.

The subjects of the study were 297 college students (88% women) who completed very brief questionnaires regarding their current mental health and life satisfaction and their perceptions of the way they were parented.  The authors developed their own measure of helicopter versus autonomy-supported parenting (specifically mothering) that the students completed regarding CURRENT parenting behavior.  Path analyses were used to test for significant associations and the hypothesis that the associations between helicopter parenting and negative outcomes were due to feelings of reduced autonomy.Helicopter

The results indicated that subjects who reported having more overcontrolling parents manifested significantly higher depression scores (although they were not clinically depressed) and lower scores on life satisfaction.  This effect appeared to be mediated through the subjects’ feeling that their developmental needs for autonomy and independence were not met adequately.

The authors concluded that excessively high levels of parental monitoring and control are related to negative child behavior and lower life satisfaction. They interpreted their results in the context of self-determination theory which posits that individuals have innate needs for autonomy, feeling competent, and being involved in caring relationships. However, they acknowledged that their data were cross-sectional and thus they could not be sure that more helicopter-style parenting was a result rather than a cause of more depressed children.

While this is certainly an interesting study worthy of discussion, the article received an usually high degree of media coverage for a study that essentially gave college students several questionnaires at a single point in time. This attention was due to the timeliness of the topic.  Indeed, the way this study was portrayed in the media is as much of the story as the study itself, in my view.  Many summaries of the article, such as what appeared in Time magazine,  featured a picture of a much younger child. Obvious flaws in the study were rarely discussed except, ironically, by the authors themselves. Questions about nonlinear relations between supervision and child outcomes (in other words, maybe there is a bell shaped curve rather than a line in the relations between monitoring and child health) or about different levels of supervision needed at different developmental levels were absent. Patients and family members often are influenced by these quick media summaries of scientific articles, and it is important for clinicians to help educate others not only about the findings of a study, but also its limitations.

Reference

Schiffrin H, et al.  (2013) Helping or hovering? The effect of helicopter parenting on college student’s well being.  J Child Fam Studies.  Published online in Feb, 2013.

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