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Home – Child Mental Health Blog

Finger Length Ratios Related to Child Aggression and Attention Problems

Posted: September 4th, 2012 by David Rettew

A proxy for the level of exposure to prenatal androgens is the length of the second finger digit relative to the length of the forth finger (although not all studies support this link). Lower ratios are generally associated with more male typical behaviors.

A new study published in the journal Development and Psychopathology examines a group of 239 fifth grade children from southeastern China.  Aggressive behavior and attention problems were assessed using a Chinese version of the Child Behavior Checklist and Teacher Report Form.  Finger lengths were measured directly by study investigators.

Results showed higher levels of both aggression and attention problems to be significantly associated with lower ratios of the length of the second finger relative to the forth for boys but not in girls and for the left but not right hand.  The significant effects persisted after controlling for other factors such as early adversity. The effect size was found to be somewhat higher than previous studies in adults.

The authors concluded that exposure to prenatal androgens contributes to aggressive and attention problems in boys.

For those wanting to impress their friends at the next barbeque, it is worth mentioning that the average second to forth finger length ratio was around 0.96 with a standard deviation of only around .03 which may be difficult to assess informally.  In addition, the study only examined the digit link with attention problems and aggression, raising the question of specificity and other types of associations that might have been found if the authors had included them in their analyses.

PROGRAM NOTE:  For those interested in hearing more about the general topic, the senior author of this study will be presenting at the Department of Psychiatry’s Grand Rounds on Friday September 21 from 10:30-11:45 in the Davis Auditorium across from the UVM Dana Medical Library. 

Reference

Liu J, Portnoy J, Raine A.  Association between a marker for prenatal testosterone exposure and externalizing behavior problems in children. Development and Psychopathology 2012; 24:771-782.

Childhood Toe-Walking: Prevalence and Links to Developmental Problems

Posted: August 27th, 2012 by David Rettew

Idiopathic Toe-walking refers to children who habitually walk on their toes rather than using a typical gait and for whom no specific cause has been found.  It has been a traditional red flag to clinicians and parents alike for developmental problems including autism.  There is little systematic study, however, of the phenomenon and its predictive associations with neurodevelopmental disorders. 

A new study from Sweden examined a group of 1436 children presenting for their health check at around age 5 and a half.  A history of past and present toe-walking was obtained and data was also collected among those who were receiving services for special needs (n=35). 

The rate of current toe-walking was 2.0% with males to females at a two to one ratio.  An additional 2.8% previously walked on their toes but no longer did. Among children with developmental or psychiatric problems, the rate of lifetime toe-walking was 41.2%.  A family history of toe-walking was common.

The authors concluded that idiopathic toe-walking is relatively common and spontaneously remits in most children by age 6.  It is more common among children with neurodevelopmental problems.

Strangely, the authors do not frame their data in a way that might be most useful for clinicians who see children with toe-walking and are trying to predict neurodevelopmental problems.  Doing the math, it appears that (7/70) or 10% of toe-walking children had a neurodevelopmental disorder such as autism or ADHD.  Thus, toe walking was not a particularly strong test for conditions such as autism in this study. 

Reference

Engstrom P, Tedroff K. The prevalence and course of idiopathic toe-walking in 5 year old children.  Pediatrics 2012; 130(2):279-284

Cardiac Warnings Out for Citalopram and Escitalopram

Posted: August 21st, 2012 by David Rettew

Last year’s warnings from the FDA about dose-dependent QTc elongation and cardiac arrhythmias including Torsade De Pointes among patients taking citalopram at higher doses have been supplemented by warnings issued by HealthCanada on escitalopram (Lexapro), the S-isomer of racemic citalopram.  The FDA’s 2012 guidelines exclude escitalopram but hedge on concluding that the QT effects are limited to the D isomer.

The risk may be heightened in those with pre-existing cardiac problems or patients with abnormal electrolyte levels such as low potassium or magnesium.  Of note, this population could include those with bulimia who are actively purging and for whom SSRIs are frequently used.   In addition, there may be increased risk among patients who are taking other medications that can potentially cause QTc elongation such as the antipsychotic medication ziprasidone (Geodon). 

Current guidelines include the following…

  • Among healthy patients with no other medications that could affect cardiac conduction, using no more than 40 mg of citalopram and no more than 20 mg of escitalopram per day
  • A “not recommended” classification for use in patients with congenital QT interval prolongation (one step below contraindicated)
  • ECG and electrolyte monitoring among higher-risk patients who continue to use the medications

The guidelines don’t give additional information regarding pediatric use, unfortunatley.  Escitalopram does have an FDA indication to treat depression in adolescents at least 12 years of age.

Parental Levels of Anxiety Predict Child Adjustment after Illness and Injury

Posted: August 16th, 2012 by David Rettew

by John Koutras, MD

The risk factors for children developing post-traumatic stress symptoms (PTSS) or post-traumatic stress disorder (PTSD) following a medical trauma are complex and include medical and family factors, among others.  A concept of “relational PTSD” has been proposed which suggests that parent and child symptoms mutually influence each other.  A new study is the first to include independent assessments of mothers, fathers and children while controlling for the severity of the child’s medical condition. 

John Koutras, MD

Families from four German children’s hospitals were recruited within 2 weeks of the child’s admission for either a new diagnosis of cancer or type I diabetes mellitus (n=149), or occurrence of an unintentional injury (n=138).  Child PTSS were assessed by the Child PTSD Reaction Index (RI).  Parental PTSS was assessed by the Post-traumatic Diagnostic Scale (PDS).  The authors used a proxy variable of number of days of the child’s hospital stay, in an attempt to operationalize the severity of medical stressors. 

The incidence of moderate to severe PTSS in children was between 4 % and 17 % at 5-6 weeks, and between 2% and 17% at 1 year.  At both time points, children with diabetes showed the lowest rates and children with injuries had the highest rates.  At 5-6 weeks, PTSS rates among parents were higher than children.  Specifically, parents of children with cancer and diabetes were affected significantly more than their children.  Although parental symptoms decreased over time, PTSD in the cancer group was still remarkably high at 1 year (mothers 25 %; fathers 18%).  In contrast, only 5% of the children with cancer had clinically relevant PTSS.  PTSS were found to be quite stable over time in both adults and children, i.e. levels of PTSS at 5-6 weeks were found to be highly predictive of levels at 1 year.  Initially high levels of PTSS in mothers and fathers were longitudinally related to poorer recovery of PTSS in the child.

Thus, there appears to be a longitudinal influence of parental PTSS on child PTSS in injured children.  One postulated mechanism for this relationship is that parents’ own symptoms prevent them from adequately addressing the child’s needs following the trauma.  Therefore, the child does not receive the psychological buffering of an optimal caregiving relationship. 

When working with hurt and hospitalized children, some focus on the parents’ well-being and their own reaction to the event may pay dividends for the entire family down the road.

Reference

Markus A,Ystrom E et al.  The mutual prospective influence of child and parental post-truamatic stress symptoms in pediatric patients.  J Child Psychology Psychiatry 2012: 53 July: 767-774.

 

Trends in Antipsychotic Medication Use 1993-2009

Posted: August 13th, 2012 by David Rettew

A new study in the Archives of General Psychiatry reports on the increasing use of antipsychotic medications in youth.  The study analyzed nearly half a million medical visits over a 17 year span (1993 through 2009). 

Results showed that the number of medical visits that included an antipsychotic medication per 100 persons rose in children (defined as 13 years old and less) from 0.24 to 1.83.  The rate increased from 0.78 to 3.76 for adolescents and from 3.25 to 6.18 for adults. Disruptive behavior disorders, including ADHD,  are now the most common diagnoses associated with antipsychotic use in youth, accounting for 63% and 34% of the visits for children and adolescents, respectively, while there was also a sharp increase in their use for bipolar disorder in youth.  Nearly 90% of antipsychotic use was off-label in children and adolescents.  Risperidone was the most commonly prescribed antipsychotic medication.  A large percentage of medical visits with non-psychiatrists that included antipsychotic medication had no psychiatric diagnosis attached to it at all.

The authors speculated that the increase use is likely due to many factors including the release of new medications during the study period, rise in autism and bipolar disorder diagnoses, reduced stigma for mental health conditions, and insurance limitations for psychotherapy.  The authors expressed concern over these trends and advocated for reevaluation of current practice standards and additional education about medication risks.

In my view, the sharp increase in childhood antipsychotic use is alarming but not because of it being off-label.  Aggression, likely the major reason for these medications, is a serious problem that spans multiple diagnoses.  Targeting it for treatment  is certainly appropriate, and it seems less important if its treatment is under a diagnosis of bipolar disorder or something else like conduct disorder or ODD.  What is more concerning to me is how quickly antipsychotics seems to be appearing in the treatment algorithm ahead of other less risky medications and ahead of intensive psychotherapy directed both at the children and at the home environment, which can be chaotic and hostile.  Further, the lack of any psychiatric diagnosis on so many outpatient visits with primary care clinicians suggests a continued discomfort with managing psychopathology and a disconnect with the patient’s mental health team.  It is also interesting to note that this national trend of increased antipsychotic use seems less evident in Vermont (see previous blog posting “Vermont Youth are Taking Fewer Medications“).

Reference

Olfsen M, Blanco C, et al. National Trends in the Office-Based Treatment of Children, Adolescents, and Adults With Antipsychotics.  Archives of General Psychiatry, online first.

Why “Just” is Such a Dangerous Word in Mental Health

Posted: July 31st, 2012 by David Rettew

How many times have you heard a psychiatric diagnosis questioned based on the possibility that the behaviors are JUST something else.  You know the drill: “C’mon doc, are you sure this ADHD thing isn’t a fancy label for kids who are JUST (insert lazy, bad, spoiled, etc.)?” Another common one is “Can’t a kid JUST be sad without being called depressed?”

There is a very legitimate question in there, but it is not the one most people are asking.  Indeed, we are called upon every day to try and make a call as to whether particular behaviors fall beyond developmental expectations and are thus deserving of a diagnosis.  The problem, though, lies with the alternative and specifically in the assumptions behind that word:  JUST.  The implications are that if a set of behaviors are a JUST then the following must also be true.

a)    Their origin differs from the origin of “real” symptoms and aren’t particularly interesting

b)    Nothing can be done about it

c)    We can and should be blaming the child, parents, or both rather than framing the issue as something to do with brain function

All of these assumptions are likely wrong, although much more research is needed to address them more fully.  For now, however, there is overwhelming evidence that nearly everything we assess in child mental health (mood, attention span, aggression, autistic traits) exists, at least on the surface, as a quantitative continuum rather than in binary yes/no disease form.  As such, making a diagnosis of ADHD is a bit like officially calling somebody “tall” or “smart.”  What is much less well understood, however, is whether or not the mechanisms that underlie JUST traits or personality are shared, but perhaps amplified, when it comes to full-fledged disorders, or whether there may be lurking more discrete etiologies for at least some of those with the more extreme behaviors that qualify for a diagnosis. 

In the meantime, the word JUST simply doesn’t make sense.  Child behavior at all levels is complex, derived from a large array of mutually interacting genetic and environmental, and amenable to change with the proper approach.

Bath Salts and Designer Drugs an Increasing Problem

Posted: July 27th, 2012 by David Rettew

 Despite recent efforts to clamp down on “bath salts” and other designer drugs, their use (both legal and illegal) continues with many individuals winding up needing emergency treatment. 

A previous law last December making many of the designer drugs illegal in Vermont was strengthened this month by new federal and state legislation. By slightly changing the content of the compounds, however, new products continue to be tweaked and, at least for a time, be sold legally. 

Bath salts can contain mephedrone, methylone or methylenedioxypyrovalerone (MDPV), among other things.  Similar to MDMA (Ecstasy) and methamphetamines, they bind to monoamine containing neurons and cause rapid increases in serotonin, norepinephrine, and dopamine. They are generally sold as a powder in smoke shops, often under a variety of odd sounding names such as “Mr Nice Guy” or “Vanilla Sky” and can be swallowed, injected, or inhaled. Use of the drugs can cause a number of symptoms and problems including psychosis (hallucinations and paranoia), aggressive and disorganized behavior, kidney failure, tachycardia, hypertension, hyperthermia, and seizures.  Central Valley Medical Center in Barre has been especially busy with patients who present with bath salt toxicity.   Treatment is largely supportive and can consist of IV benzodiazepines to control extreme agitation and lower seizure risk.   The drugs often do not show up on routine drug screens. 

We all need to be on the lookout for patients who are using and experimenting with these dangerous compounds.  Adolescents when being interviewed can suddenly become remarkably skilled at very subtle language.   If you ask, for example, if he or she uses any “other illicit drugs,” the answer from someone using bath salts might be a straight “no” based on a concrete response to your question.  It can be worthwhile to examine about how we phrase our questions so that we minimize any wiggle room in the answers.

Physical Punishment Linked to Increased Long-Term Mental Health Disorders

Posted: July 24th, 2012 by David Rettew

David Harari, UVM Medical Student

by David Harari

(Editor Note – I am very pleased to have one of our UVM medical students, David Harari, contribute this well written piece on an important topic.  For those interested in learning more about corporal punishment, however, I suggest not doing an internet search on “spanking.”  You were warned – DCR)

While it is well established that overt child maltreatment  is associated with an array of mental disorders, less is known about the link between harsh physical punishment (i.e., pushing, grabbing, shoving, slapping, hitting)—in the absence of more severe child maltreatment—and psychiatric disorders.

A new study, however, found that children who experienced harsh physical punishment in the absence of severe maltreatment were also more likely to develop long-term psychiatric problems including depression, anxiety, mania, drug and alcohol abuse/dependence, and various personality disorders.

The study, recently published in the August 2012 journal Pediatrics (published online on July 2, 2012), surveyed between 2004 and 2005 a nationally representative sample of 34,653 individuals involved with the National Epidemiologic Survey on Alcohol and Related Conditions. Researchers found that approximately 6% of respondents reported harsh physical punishment in the absence of frank abuse before the age of 18.

Even after adjusting for sociodemographic variables and a family history of dysfunction, a significant link emerged between harsh physical punishment and long-term psychiatric disorders. Approximately 2% to 5% of Axis I disorders and 4% to 7% of Axis II disorders were attributable to harsh physical punishment. Among the mental health disorders most associated with physical harsh punishment in childhood were schizotypal personality disorders (7.2% more likely), antisocial personality disorder (5.5% more likely), mania (5.2% more likely), narcissistic personality disorder (4.7% more likely), borderline personality disorder (4.6% more likely), alcohol abuse or dependence (3.4% more likely), and drug use or dependence (3% more likely).

The parent or caregiver’s right to use physical punishment as a means of discipline remains a matter of dispute. Indeed, the right to use physical punishment has been abolished in 32 countries. With the continued use of physical discipline in this country, the authors argue that their findings should stimulate a stronger position by health care professionals against the practice. While the American Academy of Pediatrics has already opposed the striking of a child for any reason, the authors suggest that a more explicit position statement (physical punishment of any sort should not be used with children of any age) might prove beneficial. In addition, improvement is needed in developing more widespread education and resources that encourage more positive approaches and strategies to disciplining children. From a public health perspective, the authors conclude, “reducing physical punishment may help to decrease the prevalence of mental disorders in the general population.”

Reference

Afifi, TO, Mota NP, et al. Physical punishment and mental disorders: Results from a nationally representative US sample.  Pediatrics 2012;130:1-9.

What about Intermittent Explosive Disorder?

Posted: July 15th, 2012 by David Rettew

Primary care clinicians are becoming increasingly comfortable with diagnoses such as ADHD, OCD, and even depression but what about Intermittent explosive disorder (IED, not to be confused with improvised explosive device)?   IED refers to individuals who experience recurrent episodes of aggression that is disproportionate to the precipitating trigger and that the person finds unable to control.  The diagnostic criteria are vague, even for the DSM, any many child psychiatrists (including most of us here) tend to avoid the diagnosis due to its lack of research evidence or approved treatments, and the fact that it seems most everyone meets criteria for at least something that is better defined

A recent study on IED, however, was published in the prestigious Archives of General Psychiatry that comes from the National Comorbidity Survey Replication Adolescent Supplement: one of the most comprehensive and rigorous epidemiologic studies to date for adolescent psychiatric disorders.  Over 6000 adolescents were interviewed to examine the rate of IED and subjects were excluded from the analysis if they had a history of bipolar disorder, ADHD, oppositional defiant disorder, or conduct disorder. Both more broadly and more narrowly defined IED were investigated.

Results revealed that the rate of lifetime anger episodes was extremely high with 63.3% of subjects reporting at least one episode of an anger “attack” that included acts such as destroying property, verbal threats, or actual physical violence or aggression.  The estimated lifetime prevalence of more narrowly defined IED was 5.3% while an additional 2.5% met criteria for broadly defined IED.  Comorbidity with other disorders was high, and only 6.5% of IED adolescents were receiving treatment specifically for anger.

Interestingly, anger is one of the core negative human emotions that is not well captured by a specific diagnostic category.  Rather, irritability and aggression is found across of number of diagnoses. Unfortunately, the decision to exclude from this study adolescents with conditions such as bipolar disorder and ODD make this paper less useful towards resolving some of the diagnostic controversy between these diagnoses.  At the same time, these data suggest that explosive anger can exist fairly commonly even in the absence of these other disorders.

Is this a “real” disorder or just another way to pathologize normal behavior? In the conclusions, the authors advocated that more research is strongly needed to understand explosive anger in order to develop effective treatment strategies and to resolve its relations with other mental disorders. What exactly is that ubiquitous “Anger Management” treatment that reporters and judges seem so fond of discussing, you might ask?  That one will have to wait for another posting.

Reference

McLaughlin KA, Green JG, Hwang I, et al.  Intermittent explosive disorder in the National Comorbidity Survey Replication Adolescent Supplement.  Archives of General Psychiatry: Online First, July 2012.

Helping Parents with Preschool Choices – Montessori, Reggio Emilia, and Waldorf

Posted: July 10th, 2012 by David Rettew

Parents have a number of options when it comes to daycare and preschool and can wind up anxious and confused trying to find the “right” one.  Primary care clinicians may be asked to weigh in on this important decision but themselves can be unfamiliar with the different approaches now available.  To help, here is a very brief primer of some of the prevailing methodologies. 

Montessori:  The Montessori approach comes from Dr. Maria Montessori: one of Italy’s first female physicians.  Her initial school opened in 1907.  The general approach emphasizes self-motivated learning rather than listening to teacher lessons.  The curriculum includes practical life skills and sensory education in addition to language. More unique components include multi-age classrooms and “self-correcting” learning materials (that can be used one way).  There may be more children per teacher than in a Reggio program to facilitate peer learning and there typically is less emphasis on imaginative or symbolic play. 

Reggio:  The term Reggio Emilia comes from a small town in northern Italy that was noted to have particularly excellent schools.  Its worldwide appeal is more recent than other models, gaining popularity since the 1990s. The approach emphasizes relationships, community, collaboration, and self-inspired learning designed to harness a child’s inner potential.  There again is less priority on teacher driven lessons.  The environment is thought of as a “third teacher” and may resemble Montessori schools somewhat with more natural products and less typical plastic toys.  Relatively unique components include the practice of “documentation” by teachers to help them capture interactions between teachers and children, few students per teacher (who often stay with the group of children as they age), and a strong encouragement of parental participation. 

Waldorf:  The Waldorf method was founded by Rudolf Steiner, an Austrian scientist in the early 1900s.  It is rooted in anthroposophy which is the idea that the universe can be understood by first understanding humanity. In contrast to Montessori and Reggio, there is greater priority given to imaginative and artistic play.  Activities, furthermore, tend to be more teacher driven at first rather than trying to follow the child’s lead.  The environment is built to be homelike and very predictable.  There is also greater attention paid to the seasons, festivals, and holidays in comparison a Reggio school.  

Traditional:  While a “traditional” program is more a catch-all for a large number of programs not adhering to a named school of thought, some generalizations may be appropriate.  More classic “academics,” using things such as flashcards, are likely to be introduced than would be present certainly in the other types. In addition, the “thinking” or “planning” chair is likely to be more heavily utilized as a discipline technique.  The environment typically includes more mainstream toy options, and the use of technology such as computers and even the occasional movie may be more present in preschools that do not follow a Reggio, Waldorf, or Montessori model.  

Which approach is best?  Obviously it depends on the child.  There does exist some research showing that children from Montessori/Reggio/Waldorf programs do somewhat better than their peers later in school but the results are not uniform and often suffer from confounding problems (that is, other factors such as increased parental involvement that may be driving the perceived differences).  One noted study published in Science, however, showed positive gains for a Montessori school in an inner-city population.  In the end, something like fingerpainting, whether it is done in the context of an overarching curriculum promoting sensory-motor integration or just because it’s fun, is still fingerpainting.  Common elements such as safety, warmth, enthusiasm, and structure may be critical elements of all good early educational programs, regardless of their historical background.   

Lillard A, Else-Quest N.  Evaluating Montessori education.  Science 313:1893-1894, 2006.

 

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