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ADHD Diagnosed in 11% of Youth, According to New York Times

Posted: April 1st, 2013 by David Rettew

The New York Times is reporting data they received from the CDC’s National Survey of Children’s Health that the number of children who have received a diagnosis of ADHD has risen to 11% with some segments of the population, such as high school boys, as high as 20%. The data come from phone interviews of over 76,000 parents who participated in this survey that asked about wide ranging health issues. Of note, the Times reports that they received the raw data themselves and compiled these figures. The findings have not been reported in scientific journals or subjected to a peer review process, although the next edition of the Journal of the American Academy of Child and Adolescent Psychiatry is expected to feature an article about the CDC survey.

As would be expected, the report has generated a firestorm of discussion and debate with many concerned that this rise in ADHD diagnosis represents an excessive broadening of the criteria that subjects too many youth needlessly to the dangers associated with ADHD medications. Unfortunately, these data are unable to answer this question. According to the graph accompanying the article, the rate of diagnosed ADHD in Vermont is around the national average.

As people debate the important questions raised by this survey, it may be important to keep a few things in mind.

1. ADHD is a real brain-based phenomenon with overwhelming scientific evidence to support its validity.

2. ADHD likely exists more like a continuum (similar to blood pressure or cholesterol) rather than in binary form. Consequently, there is no clear boundary or cut-off between typical and abnormal levels of these behaviors.

3. Establishing a diagnosis of ADHD requires a careful evaluation that includes input from multiple sources and assessment of behaviors relative to expected norms of others of the same age and sex.

4. Family-based multimodal treatment of ADHD can result in substantial improvement but need to be weighed against the potential risks of medications.

Bottom line: Are there kids being diagnosed with ADHD and treated who don’t meet criteria for the diagnosis? Yes. Are these also youth who do meet criteria for ADHD who are suffering needlessly because a lack of diagnosis and treatment? You bet. Let’s work then, to reduce BOTH scenarios and leave the finger pointing to those who don’t have kids to care for.

ADHD, Public Policy, Uncategorized | No Comments »

Preschool ADHD: The Picture Six Years Later

Posted: March 27th, 2013 by David Rettew

It is commonly believed inattentive and hyperactive preschool children will likely “grow out” of these problems later in life. Good data to support this claim, however, are lacking. The Preschool Attention-Deficit/Hyperactivity Disorder Treatment Study (PATS) was one of the most comprehensive studies to date on very young children with ADHD. This recent report on the status of these children at follow-up offers important data regarding the stability of early appearing ADHD symptoms.

Of the 304 original participants in PATS, 207 participated in follow-up. Children had an average age of 4.4 years at baseline and 10.4 years at 6 year follow-up. Children were also assessed 3 and 4 years after baseline, at which point they were being treated in the community. The sample was 75% male. Diagnostic assessments included a comprehensive clinical evaluation, enhanced with the use of both quantitative instruments such as the Conner Rating Scales and a structured diagnostic interview.

Results showed that ADHD symptoms significantly dropped from baseline to the first follow-up 3 years later but leveled off after that. On a relative basis, girls tended to have higher baseline scores and steeper drops in symptoms than boys. At follow up assessments, average ADHD scores continued to be in the moderate to severe clinical range for parent ratings, with a surprising 89% of the sample still meeting criteria for ADHD 6 years later. Medication status was not significantly related to whether or not a child met criteria for ADHD at follow-up. Similar patterns were observed for both inattentive and hyperactive/impulsive symptoms.

Study authors concluded that the diagnosis of ADHD in preschool is fairly stable and associated with chronic symptoms into later childhood, even with treatment. They suggest that the conventional tendency for a more hands-off approach to preschool ADHD may be misguided and, by contrast, early and more intensive treatment may be required, including parent training, school-based behavioral interventions, and more effective medications.

Of note, this article focused on ADHD symptom stability and further reports are expected related to other domains such as cognitive and academic functioning. This sample of children, seen in academic medical centers for ADHD, is likely more symptomatic than children seen in the community which could affect the generalizability of the results. Further, the fact that subjects were no longer randomized at follow-up severely limits firm conclusions about the long term benefits of medications. Nevertheless, the number of symptomatic children overall raises concern that the outlook for typical medication treatment, at least for those with preschool-onset ADHD, is not as positive as generally believed. It is interesting that the authors interpreted this finding as evidence for needing more intensive treatment (under the notion that regular treatment is not enough but could be effective at higher levels) rather than evidence for doing less (under the notion that treatment in this group is not that effective anyway). Obviously, more research will be needed to answer that important question.

Reference

Riddle et al., The preschool ADHD treatment study (PATS) 6-year follow up. (2013) J Am Acad Child Adolesc Psychiatry 52 (3):264-278

ADHD, Medications | No Comments »

Joint Custody Initiative Building Momentum

Posted: March 17th, 2013 by David Rettew

It might come as a surprise to many Vermonters, but we are one of the only states left in the country in which judges do NOT have the right to grant joint custody of children in divorce proceedings unless BOTH parents ask for it. As a result, judges are forced to make Solomon-like decisions by awarding full custody to one parent. This policy essentially is a state sanctioned way of marginalizing the non-custodial parent, pushing them into the role of weekend entertainer.

Research shows that children of divorced parents do best when both parents are actively involved in the lives of the children. If we say we want both parents to make the emotional, financial, and time investments required to raise a child right, we cannot perpetuate a legal policy that works so effectively against that goal.

Fortunately, a growing movement, headed by Chris Weinberg of Jericho, is trying to move Vermont forward and encourage our legislature to change this antiquated and destructive policy. There has been some opposition to the proposal, based on the concern that incompetent parents will be given too much access and control. This worry is misguided in my view. To be clear, nobody supporting this legislation is interested in having unfit or abusive continue to influence their children’s lives, and judges would be free to award single custody when that is in the best interests of the child. What would change is that judges would no longer be forced to send a good parent to the sidelines when joint custody would be more appropriate.

You can find out more at JointCustodyVT.org and sign an online petition at Change.com. To make sure this issue gets the attention it deserves in January, we need to convince our legislature that Vermonters want this issue on the agenda in 2014 with no more delays.

Parenting, Public Policy | No Comments »

Psychotic Symptoms in Childhood Not Specific To Adult Schizophrenia

Posted: March 11th, 2013 by David Rettew

Psychotic symptoms in children and adolescence, such as paranoia, hallucinations, and delusions, are relatively common and can be associated with a range of diagnoses. Nevertheless, their presence understandably leads to tremendous concern on the part of patients, families, and clinicians about the possibility of an emerging thought disorder such as schizophrenia. This article offers important long-term data regarding the outcome of early appearing psychotic symptoms.

Study participants come from the well-known Dunedin Multidisciplinary Health and Development Study, which is perhaps best known for a landmark gene-environment interaction study. The sample included 1037 individuals who were evaluated initially at the age of 11 for psychotic symptoms using a structured interview and followed until age 38.

A total of 1.7% of children at age 11 reported clear psychotic symptoms. By age 38, 3.7% of the sample had been diagnosed with schizophrenia or met criteria for the illness. Results showed that psychotic symptoms present at age 11 were significantly associated with schizophrenia. A total of 23% of those with psychotic symptoms at age 11 had the diagnoses as compared to 3% of those without clear childhood symptoms, for a relative risk of 7.24. However, children with psychotic symptoms were also at significantly elevated risk for PTSD (RR=3.03) and suicide attempts (RR=3.82). The rate of adult PTSD in the group with child psychotic symptoms was 46.2%, and few were free of any diagnosable psychopathology. None of those children with psychotic symptoms at age 11 went on to be diagnosed with an episode of mania.

The authors concluded that early appearing psychotic symptoms was a risk factor for later schizophrenia but was also related to adult PTSD and suicide attempts. Overall, child psychotic symptoms appeared to be a strong indicator for higher levels of adult psychopathology in general.

While the overall n of the study is impressive, it is important to remember that the n for most of these analyses was only 13. Nonetheless, the conversion rate to schizophrenia of 23% among those with early psychotic symptoms is similar to other reports and is a percentage that clinicians might want to remember when talking to families. The lack of bipolar disorder is also worth mentioning as conventional wisdom from much of the American literature suggests a strong link between psychotic symptoms in childhood and bipolar disorder.

Reference

Fisher et al. (2013). Specificity of childhood psychotic symptoms for predicting schizophrenia by 38 years of age: A birth cohort study. Psychol Med, January, 1-10

Tags: psychosis, schizophrenia
Psychosis | No Comments »

Eliza’a Wellness Pearls – Say No! to a Summer Filled with Screen Time

Posted: March 5th, 2013 by David Rettew

(Editor’s Note: I am very pleased to begin a new series of posts by our clinic’s family coach and social worker, Eliza Pillard, entitled “Eliza’s Wellness Pearls,” featuring tips for child wellness and health promotion. Stay tuned for more posts in the future and please feel free to suggest topics – DR)

March is the right time to start planning your children’s summer camps and activities. There tends to be a lot of fun options in Vermont, but many will get filled up before you can say “snow’s gone”. A good place to begin your search is by talking to friends and contacting your local recreation department, there are also a number of web sites which list a variety of Vermont based camps:

http://www.findandgoseek.net/

http://www.vermontcamps.org/

http://www.vtliving.com/summercamps/index.shtml

http://www.kidsvt.com/

These days the variety of camp options is mind boggling, there are acting camps, animal care camps, fantasy writer’s camps, magic camps, computer programmer camps as well as the usual arts and crafts, outdoor activity and sports camps. The more focused theme and sports camps often appeal to the older camper.

Camps vary greatly in cost, multiple week sleep away camps can cost from $400 to over $1000 a week, local day camps are generally $200-400 a week, and frequently scholarships are available and should be applied for early.

Tip: If your children are anything like mine were, they will dismiss the need for camp altogether. “Don’t sign me up for any of those camps this summer, I am just going to hang with my friends”, don’t be fooled, “hang with my friends” is slang for “keep the shades pulled down in the basement and play computer/video games all day”. Better to offer a choice of camps and stay firm that not going to camp is not an option, then walk away! Many of my best memories and the skills that I am most proud of today (wicked crawl stroke) are from the summers I spent at camp.

Eliza's Wellness Wisdom, General Family Based Appraoch, Parenting | No Comments »

Youth Incarceration Down, Lowest in Vermont

Posted: March 4th, 2013 by David Rettew

The number of children and adolescents (under age 21) who are incarcerated has been steadily dropping since the mid-1990s according to a report by the Annie E. Casey Foundation that presents data from the U.S. Department of Justice Office of Juvenile Justice and Delinquency Prevention. The 2010 national rate of 225 youth per 100,000 is the lowest in 35 years.

The drop has not been associated with an increase in youth crime (which has actually fallen as well). The most recent 2010 data show that, on a given day, approximately 70,000 youth across the country are detained in juvenile or adult retention facilities or mandated residential placement. About 70% of these placements are for more than 90 days, and the majority of offenses that resulted in the placement were nonviolent. Of note, the report states that, despite the drop, the U.S. still incarcerates a higher percentage of youth than most every other developed nation.

There were marked differences in these rates according to race with Asian youth rates lower than their white peers and African American, Latino, and American Indian rates higher. There was also large variability between states that ranged from a high in South Dakota (575 per 100,000 youth) to Vermont (53 per 100,000 youth). After Vermont, the next lowest state was Hawaii (90 per 100,000 youth).

The reason for the decline is unclear but was not due to a targeted national strategy. Changes in state policy, lawsuits, and cost concerns all likely are playing a role in this decline. These data are not able to determine whether the drop in incarceration rate is also a function of lower levels of youth behavior problems.

The Foundation urges additional efforts to find alternatives to incarceration when appropriate and to provide adequate treatment in these settings.

Aggression, Conduct Problems, Drugs and Alcohol | No Comments »

The Family Dinner

Posted: February 26th, 2013 by David Rettew

(Editor’s note: I am very pleased to present a new posting written by one of our third year psychiatry residents, Dr. David DeVellis. – DR)

by David DeVellis, MD

David DeVellis, MD
Resident in Psychiatry

How often do you find yourself saying “I’d do fill in the blank if I only had more time”? Exercise, sleep, and eating well–all vital for mental and physical health–are often among the casualties of a jam-packed 24-hour day. But time spent with family, particularly around the dinner table, is perhaps one of the greatest losses in a fast-paced society. Creating the family dinner is an emotional issue for many parents who struggle to carve out time among the competing demands and schedules of their families.

Dinner: A Love Story (DALS) is a blog and cookbook written by Jenny Rosenstrach with contributions from her husband Andy Ward and their 2 young daughters (disclosure: they are friends of mine). DALS celebrates the family dinner as “an emotional anchor” to our day and aims to inspire readers to approach and embrace it as such. The benefits of the family dinner have been well studied. Among the potential benefits is that parents will know much more about what their children are doing and eating–or in the case of restrictive eating disorders–not eating, if family meals are part of the daily routine.

However, you won’t find scientific research cited on DALS. What makes DALS so readable and enjoyable is the empathy, support, and encouragement it provides its time-starved readers. There are no unrealistic or unachievable goals to meet: our challenges as working parents are their challenges, and there is no shame in not preparing gourmet meals each night. Their earnest conviction that dinner is an opportunity for families to “put down our Blackberries and Polly Pockets Shimmer and Splash Adventure dolls” and share our experiences and reconnect with each other amidst the chaos of everyday life is downright inspiring. Changing our thoughts about dinnertime and making family dinner feel like an indispensable part of our day can lead to changes in our approach to and execution of dinner. Come to think of it, the website is really a fun form of cognitive behavioral therapy. DALS provides practical strategies that can make preparing for family dinner less daunting. And, of course, they have lots of recipes for flavorful meals that are designed to be relatively quick and made with ingredients you likely already have at home. In addition, as well-read professional editors with daughters who love to read, Jenny and Andy provide many great recommendations for children’s books.

Although “family” is not explicitly in the DALS title, it is understood, and I believe, wherein lies the love story. We espouse the family-based approach to psychiatric treatment here in Vermont, and the family dinner (or any meal really) is a good place to start. To learn more, go to http://www.dinneralovestory.com/ .

Parenting, Uncategorized | No Comments »

Medication Storage Safety – Not a Glamorous Conversation, but Important

Posted: February 21st, 2013 by David Rettew

We all know how important the right medications can be to health, but when they are not stored properly, these same medications can become dangerous instruments of misuse. Diversion, suicide attempts, and accidental overdose can all result from the unsecured storage of medications. A conversation with parents about safe medications storage can sometimes be the difference between a curious or depressed teen being in the emergency department or not from medications you, as primary care clinicians, prescribe.

Locking up medications does not need to be complicated or expensive. If the designated medication cabinet does not have a locking mechanism, medications can be moved to a lockbox or even a closet or other storage area where a simple padlock can be applied. Other points that can help keep medications safe are as follows.

Keep medications in their original containers so that there is no confusion about what they are, who they are for, and when they were prescribed
For parents of adolescents who are prescribed medications and who are learning to be responsible for taking them, put them in charge of weekly pillboxes rather than giving over the entire prescription
Old medications should be disposed of properly, options include:
1. Take medications to an identified community drug “take-back” site, often the local police station.
2. Take no longer needed medications out of their original containers and mix them with an undesirable substance, such as used coffee grounds or kitty litter. The medication will be less appealing to children and pets, and unrecognizable to people who may intentionally go through your trash. See this FDA site for more information.
Use similar safety precautions for other items such as alcohol and, of course, firearms.

For more information, or to print out a flyer to give to parents, you can download a PDF from Safe Guard My Meds.

Tags: medication storage
Medications | No Comments »

Prenatal Folic Acid Linked to Lower Rate of Autism

Posted: February 14th, 2013 by David Rettew

(NOTE: This study has received a lot of press and coverage today but read on to gain new insights into important details of the study that may have influenced the results and interpretation)

The usefulness of folic acid supplication to reduce the risk of neural tube defects is well known. A new study from Norway published in JAMA, however, now suggests that autistic spectrum disorders (ASDs) may be another group of neurodevelopmental conditions whose risk can be reduced with folic acid, if taken at the right time. Since 1998, the Norwegian government has recommended that women planning on becoming pregnant take 400 micrograms of folic acid supplement prior to conception and through the first trimester of pregnancy.

Data for this study comes from the Mother and Child Cohort Study that examined over 85,000 children born between 2002 and 2008. The Children were between ages 3 and 10 at the time of the study. Folic acid use between 4 weeks prior to conception to 8 weeks into pregnancy was assessed through questionnaires mother competed at 18 and 22 weeks of pregnancy. Mothers were not asked about specific doses but were asked to provide the specific names of their supplements. The specific time period focused upon in this study was due to the authors’ hypothesis based on available information about nervous system development. Mothers were placed in the folic acid group if they had taken the supplement all or part of the interval. A diagnosis of autism was determined through questionnaires, referral information, and a patient registry, and half were assessed directly in a related study. The study divided autistic spectrum disorders into autistic disorder, Asperger syndrome, and PDD NOS, and the authors did not group them together for their analyses. Reduction in autism risk was calculated using odds ratios and logistic regressions that controlled for a few other variables such as maternal education, parity, and year of birth (all of which were found to be significant in the odds ratio calculations).

Nearly 72% (check) of mothers took folic acid supplements around their pregnancy. The overall rate of any autistic spectrum disorder was found to be 0.32%. The rate of specific autistic disorder among women who took folic acid was 0.1% and significant lower than the 0.2% found in offspring whose mothers did not take folic acid. The adjusted odds ratio for autistic disorder related to folic acid use was 0.6 representing a 40% reduction in risk. This significant reduction was not found for taking folic acid later in pregnancy or for Asperger syndrome and PDD-NOS. The authors also examined fish oil supplements and did not find a significant decrease in risk.

The authors concluded that folic acid supplementation before conception and during early pregnancy was significantly related to a lower risk of autistic disorder in children.

While promising, some potentially important difficulties with the study need to be mentioned. The overall rate of an autistic spectrum disorder was 0.3% which is well below approximate 1% rate often quoted these days. The authors noted that some of this difference may be due to mothers of more severely affected children not participating in the study. In addition, it is puzzling why the association with folic acid was not found for Asperger syndrome or PDD-NOS. The authors commented about a lack of power, yet they chose not to combine the ASD diagnoses which would have maximized their power (but perhaps given them a different overall conclusion?). It is also possible the folic acid is a proxy for other unmeasured variables that may have decreased autism risk. Some of these potential confounds were examined, however, and the lack of association with fish oil or for folic acid taken later in pregnancy lessen this concern somewhat. The way positive folic acid use was “counted” also leaves quite a bit of uncertainty regarding the dose and timing needed to produce maximum benefit. Despite these questions and limitations, the study offers some important data about a relatively simple step that can be taken that may reduce the rate of autism.

Reference:

Suren P, et al. Association Between Maternal Useof Folic Acid Supplements and Risk of Autism Spectrum Disorders in Children. JAMA 2013; 309:570-577.

Anxiety, Infants | No Comments »

Can Reviewing Potential Side Effects Increase their Chance of Being Reported?

Posted: February 5th, 2013 by David Rettew

It is standard (and required practice) to give informed consent prior to beginning a new medication during which possible side effects are discussed. While few would argue with this practice, clinicians have wondered about the possibility that the very discussion of potential side effects might actually create an expectation that they will occur and thus increase the likelihood of certain individuals to report them. A recent study from the Journal of Psychopharmacology experimentally tested this hypothesis using college undergraduates with complaints of sleeping difficulty.

The participants were 82 undergraduates at a university in Australia who had difficulty sleeping and believed they were participating in a trial of a new hypnotic medication. The sample was randomly divided into three groups- one that was given a written and verbal warning for the potential for a single side effect (appetite increase or decrease), another that was given warnings about four potential side effects, while a third group was told that they were controls and thus given no side effect warnings. The first two groups received a placebo pill in a red capsule, cleverly labeled SX3752. Subjects returned a week later to complete questionnaires about their sleep as well as any potential adverse effects.

The two groups that took placebo reported an improvement in their sleep by about 47 minutes compared to controls (a finding that has been reported previously). With regard to side effects, the group warned about a single side effect often reported just that. Approximately 25% of the group warned about either an increase or decrease in appetite reported a change in that direction, while no subjects reported a change in appetite in the direction opposite of their warning (i.e. you were warned about appetite increase but reported appetite decrease). An increased reporting of appetite side effects for the group told of only one potential side effect versus four was found, but only at the trend level, and approximately 25% of the control group also reported some appetite change.

The authors concluded that there is modest evidence to support the conclusion that the warning about fewer side effects increases the possibility of them being reported by patients through a placebo effect. This phenomenon likely operates because a smaller number of potential side effects are easier to remember. The authors state that such effects should be considered especially when reviewing side effect data computed in clinical trials.

Thus, it seems somewhat ironic that these data suggest that a more exhaustive informed consent that covers many potential side effects may actually reduce the likelihood of any individual effect being reported. This study is certainly intriguing, although it is not clear exactly how a clinician should use these findings in everyday practice.

Tags: placebo effect, side effects
Medications | No Comments »

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