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Overtreatment of Adolescent Depression? A New SAMHSA Report Says Otherwise

Posted: January 24th, 2012 by David Rettew

The Substance Abuse and Mental Health Services Administration (SAMHA) recently issued a report based on new survey results. One area of focus was major depression among adolescents.

Service Utilization Among Depressed Adolescents

Major findings from the survey included the following:

1.9 million youth (8% of the population) between the ages 12-17 experienced a major depressive episode in 2010, a rate in line with recent years and slightly less than rates of around 9% in 2004. The rate increased with age from 3.3% among 12 year olds and 10.9% among 16 year olds.
Major depression was more common in females (11.8% versus 4.4%)
Only 37.8% of youth with depression sought out a professional (defined as seeing or talking to a doctor or other professional)
16.3% of depressed youth were treated with medications (with or without other types of treatment), while the remaining 21.4% saw or spoke to a doctor or other professional without using medication
Only 3% of depressed youth were treated with medications only without seeing a medical or mental health professional

While the accuracy of survey data can be questioned, the rate of 8% found here is actually below the rate of 11% found in a more rigorously diagnosed group in the National Comorbidity Study of Adolescents.

These data cannot be used to examine the question of whether teens who are not depressed are receiving diagnoses and treatment inappropriately. Nonetheless, the results do suggest that most depressed adolescents, even those with significant impairment, are receiving no treatment at all of any kind.

Questions related to the overdiagnosis of mental illness and overuse of medications are important ones, but we shouldn’t lose sight of findings like these that indicate that most depressed teens who need our help are not getting it.

The report can be found at http://www.samhsa.gov/data/NSDUH/2k10MH_Findings/2k10MHResults.htm

Tags: depression, medications
Depression, Medications | 1 Comment »

New NEJM Study Shows No Increased Cardiovascular Risk with ADHD Medications

Posted: January 17th, 2012 by David Rettew

by John Koutras, MD

The use of ADHD drugs was not associated with an increased risk of serious cardiovascular events in children and young adults.

John Koutras, M.D.

This was the overall finding of a new study published in the New England Journal of Medicine. ADHD medications are prescribed for more than 2.7 million children in the US each year, and are generally considered safe. However, reports of adverse events from Canada and the United States have included cases of sudden death, myocardial infarction, and stroke, in conjunction with the use of these medications have intermittently raised concerns regarding their safety. The authors of this study used data from four large, geographically and demographically diverse US health plans to conduct a retrospective cohort study of the use of ADHD medications and the risk of serious adverse cardiovascular events in children and young adults, with review of medical records to validate study end points.

Data was obtained from four health plans: 2 state Medicaid plans, 1 large Californian private insurance plan, and 1 national health insurance plan. In total, the plans covered 22.4 million people. For each patient receiving an ADHD medication, the authors randomly selected up to two nonuser control subjects, matched on age and gender. The primary study endpoint was a serious cardiovascular event, which was defined as sudden cardiac death, myocardial infarction, or stroke. Cases were excluded if the documentation suggested a cause other than a cardiovascular cause.

The point estimate of the relative risk provided no evidence that the use of ADHD drugs increased the risk of serious cardiovascular risk. In the study population, which excluded children with possibly life-threatening illness, the incidence of serious cardiovascular events was 3.1 per 100,000 person years.

The findings of this study are consistent with the results of several reports that have appeared since the FDA safety review of adverse-event data for ADHD drugs. Although the point estimates of relative risk for ADHD drugs did not indicate increased risk, the upper limit of the 95% confidence interval suggested that a doubling in the risk could not be ruled out. Inexplicably, this study did not include any data from patients exposed to alpha-2 agonists, such as guanfacine and clonidine. It would be extremely helpful to have an analysis of alpha-2 agonists, alone and in combination with stimulants, in the treatment of ADHD. However, the study establishes, perhaps conclusively, that the absolute magnitude of any increased risk would be extremely low, as it could not even be demonstrated in such a large population sample. In my opinion, the prevailing wisdom that any sudden deaths, which occur on or off of these medications, are mostly due to undetected cardiac issues, particularly conduction irregularities, has been reaffirmed by this study.

References

Cooper W, Habel L, et al. ADHD drugs and serious cardiovascular events in children and young adults. NEJM 2011: 365 Nov 1: 1896-1904.

Tags: add, adhd
ADHD, Medications | No Comments »

Genetic Sensitivities to Negative AND Positive Parenting

Posted: January 10th, 2012 by David Rettew

Traditional models of child emotional-behavioral problems often posit the presence of genetic “vulnerabilities” that can be realized in the presence of specific environmental triggers. A series of new studies, however, suggest that some genes may make children more sensitive to both negative and positive environments.

Three separate studies that were published together examine the interaction between parenting, mood, and the famous 5-HTTLPR gene which codes for the serotonin transporter promoter and has been linked previously to depression and anxiety.

While the methodologies of each study varied slightly, each assessed gene status of the children, parenting quality, and the child’s overall affect. Overall, youth with two copies of the short allele (shown as S/S in the figure) tended to have more negative affect when there was more negative parenting but also had more positive emotions in the presence of more positive parenting. The results strongly suggested evidence for what has been called a genetic environmental interaction (G X E).

The authors concluded that genes like 5-HTTLPR may be better conceptualized as an environmental responsivity gene more than a vulnerability gene.

One limitation of these studies were their naturalistic and associative design which somewhat limits the degree to which cause and effect can be determined. Nevertheless, these new studies illustrate the possibility that in many cases, children don’t have “bad” genes but rather genetic influences that with the right environment can lead to very positive outcomes.

Reference

Hankin BL, Nederof E, Oppenheimer CW, et al. Differential susceptibility in youth: Evidence that 5-HTTLPR x positive parenting is associated with positive affect ‘for better and worse.’ Trans Psychiatry, e44, 1-7.

Depression, Parenting | No Comments »

Misbehavior at School? Don’t Pull Recess and Sports

Posted: December 28th, 2011 by David Rettew

by Robert Althoff, MD PhD

Rob Althoff, MD PhD

For many child and adolescent psychiatric diagnoses, problem behaviors occur in more than one setting – often home and also at school. Problem behavior, particularly externalizing or disruptive behavior, is a common reason for children to be sent to the principal’s office or the “opportunity room”. Sometimes these “opportunities” are coupled with a punishment that includes limitation of the enjoyable activities of the day such as lunch with friends or recess.

So, where is the evidence that keeping a child in the classroom or benching him at recess results in better behavior? There aren’t any. In fact, the data are in the opposite direction. In the largest study to date on the issue Barros, Silver, and Stein (2009) looked at data from about 10,000 children in the Early Childhood Longitudinal Study. Teacher ratings of classroom behavior were better for those who had daily recess for at least 15 minutes than for those with no or minimal break. In children with Attention-Deficit/Hyperactivity Disorder, the current literature suggests that moderate physical activity reduces ADHD symptoms both acutely and chronically (Gapin, Labban, & Etnier, 2011)

Perhaps worse than keeping kids in at recess, are school policies that remove children from sports participation for being disruptive in the classroom. Sports participation is protective for behavior problems in children and adolescents. Removing protective factors from the most vulnerable children is a recipe for disaster.

At the VCCYF, we support school policies that keep kids on teams and allow all children access to daily exercise regardless of behavior. Disruptive behavior should have consequences, but don’t take away recess and sports from our kids. You may be making the situation worse.

Barros RM, Silver EJ, Stein EK. (2009). School recess and group classroom behavior. Pediatrics. 123 (2):431-436.

Gappin JI, Labban JD, Etnier JL. (2011). The effects of physical activity on attention deficit hyperactivity disorder symptoms: The evidence. Preventive Medicine. 52: S70-S74.

ADHD, ODD, School | No Comments »

Reinforcing Holiday Traditions

Posted: December 23rd, 2011 by David Rettew

Family traditions during the holidays repeated year after year can be a wonderful part of the season. These rituals small and large can take all forms including…

Holiday services
Getting and decorating the tree
Preparing holiday cookies
Charity work
Special foods
Reading particular stories or singing carols
Making gifts or decorations

Of course, holiday traditions won’t by themselves heal troubled families, but they can contribute to a child’s sense of belonging and stability. Furthermore, they can open the door to further efforts parents can do to build the amount of structure and stability into daily family life.

Many physicians around now often start off patient conversations with a quick question about the holidays. Consider asking about family traditions, encourage the practice, and provide examples to those who need it.

From all of us at the VCCYF, Happy Holidays!

Parenting | No Comments »

Defiant Behavior: Discussing the Full Array of Treatment Options with Families

Posted: December 20th, 2011 by David Rettew

by Allison Hall, MD

Alisson Hall, MD

Behavioral and emotional problems, like some other health conditions such as diabetes, are often best treated with a package of interventions. Because families may sometimes expect a quick fix, it is helpful to have a strategy

to discuss the importance of several treatment features. Russell Barkley, a psychologist who is one of the leading experts in ADHD and behavioral problems, has a model concerning defiant behavior which is helpful in discussing many child psychiatric problems.

Dr. Barkley describes four contributors to child defiance. These include

1) Child characteristics. These are genetically influenced aspects of the child including temperament (such as being prone to irritability or a very high activity level) and also cognitive factors (such as language disability) which affect how a child interacts with the world,

2) Parent characteristics. These are similar temperamental and cognitive factors in the parent and include mental health problems, such as depression, substance misuse or ADHD, which affect how the parent responds to situations and the child.

3) The parent child relationship which includes parenting style with issues such as the degree of attention, permissiveness, monitoring limit setting.

4) And finally contextual factors such as the couple’s relationship, trauma, the neighborhood environment and similar issues.

When one looks at a behavioral or emotional problem in this way, one can see that there are several levels on which to intervene. By treating the child with medication or individual therapy one may be able to modify child characteristics. But it may also be important to treat a parent individually to address the parent characteristics. One might recommend a parent training intervention to address the parent child relationship and one might address contextual factors by making recommendations for the school or by accessing neighborhood and larger social resources such as The Boys and Girls Club.

A conversation concerning this model can help parents understand the opportunities to address a problem in a variety of ways. It also encourages families to become aware of their own strengths and resources.

ODD, Parenting | No Comments »

Getting Parents Involved in Their Child’s Education

Posted: December 14th, 2011 by David Rettew

Compared to the media attention given to what teachers and schools can and should do to improve education, parents have sometimes seemed like an afterthought. Maybe no more, as a New York Times article highlights a couple reports recently published about how parents can help their children succeed at school.

The article summarizes findings from the Program for International Student Association (PISA) and their assessment of the parenting practices of 5,000 15 year old adolescents from 14 countries as well as a recent report from the Center for Public Education called Back to School: How Parent Involvement Affects Student Achievement.

Summarizing, improved school performance performance was found to be related to the following:

1) Whether or not parents regularly read with their children when they were in elementary school. This finding held even when controlling for socioeconomic background

2) Having regular discussions with your child about current events and activities (politics, art, social issues, colleges)

3) Monitoring and reinforcing things like homework, school attendance, and good performance

One important take home message here that primary care clinicians can convey to parents is that relatively simple measures demonstrating that a parent cares about their child’s school day can have a measurable effect. Thus, even when we are completely useless in our ability to help our kids with their trigonometry homework, we can still promote academic success.

Education, Parenting, Uncategorized | No Comments »

Psychiatric Medications and Foster Care: The New GAO Report

Posted: December 3rd, 2011 by David Rettew

The Government Accountability Office (GAO) has been investigating the rates of foster care children taking psychiatric medications in several states (not Vermont). A Senate hearing was held on Thursday December 1 about the issue which was picked up by a number of media outlets.

You can see CNN’s report for yourself. In their typical manner, they paint the issue in the most inflammatory language possible in describing children like “zombies” using “mild-altering medications.” At the same time, the report itself outlines some disturbing practices. Key findings include the following.

Children in foster care were 2.7 to 4.5 times more likely to be taking psychiatric medications than non-foster care children in the Medicaid system (20-39% of kids in foster care were taking psychiatric medications with Massachusetts having the highest rate). OF NOTE, however, this same report cites data that up to 57% of children in foster care have been diagnosed with a psychiatric disorder with other studies showing rates that are even higher.
Up to 2.1% (in Florida) of children under the age of one were taking a psychiatric medication. OF NOTE, however, the “vast majority” of the medications were antihistamines or benzodiazepines that were likely used for nonpsychiatric purposes, such as allergies and medical procedures.
Up to 1.3% (in Massachusetts) of children in foster care were taking 5 or more psychiatric medications. OF NOTE, however, the report looked at all prescriptions in 2008 and uses the term “concomitant” without the ability to differentiate between a child truly taking multiple medications at the same time and stopping one medication for another within the same calendar year.

The report compared medication usage to the best practice guidelines from the American Academy of Child and Adolescent Psychiatry (AACAP) along four principles including 1) obtaining informed consent, 2) oversight procedures, 3) consultation with a child psychiatrist, and 4) information sharing. Most states were lacking in at least some of these areas. The report recommends that although states now are tasked with developing their own protocols for monitoring psychiatric medication in foster care children, nationwide guidelines may be useful. AACAP issued a statement supporting GAO’s recommendation that there be formal guidelines issued to state welfare agencies on best practices for using psychiatric medications in this population. The statement further noted that “medication alone is rarely an adequate or appropriate intervention for children and adolescents with complex psychiatric disorders, including those in the foster care system.

What should we make of this? Well, first is READ THE FINE PRINT before going on television and making sweeping and provocative conclusions. While it is alarming that any infant is taking a psychiatric medication, it is likely that about 80% of those prescriptions were for non-psychiatric reasons. More importantly, however, the report does indicate some gaps in taking care of some of our most vulnerable children. Medications are sometimes used as a shortcut when other useful interventions aren’t available. One measure that could definitely help cut down the number of medications children in foster care receive, for example, would be to ensure that all of them have ready access to intensive evidence-based psychotherapy. These kids deserve our protection and our advocacy.

Foster Care, Medications | No Comments »

Findings from the Vermont Youth Risk Behavior Survey 2011

Posted: November 14th, 2011 by David Rettew

The Department of Health conducts a survey among high school and now middle school students in Vermont every two years to query about behaviors that are known to contribute to injury and disease. The 2011 survey has recently been recently released. Highlights for the 2011 survey in comparison to the 2009 survey include the following.

High School Survey (Grades 9-12)

Alcohol Use: the rate of ever using alcohol fell from 66% to 60%

Nicotine: the rate of ever smoking a whole cigarette fell from 31% to 24%

Cannabis: Use remains high and unchanged with 24% reporting use in the last 30 days

Sex: 41% of students report having had sex

Obesity: The rate of being obese or overweight based on BMI was 23% and statistically unchanged from 2009

Self Harm: 13% of students state that they tried to hurt themselves without intent to die in the past year

Depression: 19% of the sample reported that they felt sad and hopeless for most of the day for at least two weeks (close to the 21% rate in 2009)

Middle School Survey (Grades 6-8)

Alcohol: the rate of ever using alcohol was 23%

Nicotine: 13% of students have tried a cigarette

Cannabis: the rate of ever using cannabis was 13%

Bullying: 48% of the sample report having been bullied at school

Physical Activity: 31% of the sample state that they get an hour of physical activity per day

Screen Time: 26% and 29% of students say they spend three hours a day or more watching TV or playing video games, respectively

These data reveal some promising trends but illustrate a startling number of our youth who continue to engage in high risk behavior that can have enormous consequences. For further information or to see the questionnaire or more detailed results, click here.

Bullying, Depression, Parenting | No Comments »

Parenting Books: What to Suggest to Your Families

Posted: November 2nd, 2011 by David Rettew

written by Alisson Richards, MD

Recommending books for parents to read is an easy and effective way to initiate and encourage parents to take an active role in parenting and can also provide a guide for parents with challenging children. The books can be particularly useful for motivated parents struggling to find available cognitive-behavioral therapists.

Dr. Alisson Richards, 2nd Year Fellow

Choosing a book among the large number of choices can be overwhelming. In searching for “anxiety in children” using an on-line bookstore, 9,511 different options came up. To help narrow the search, I have outlined a few recommended choices with good feedback from families.

SOS: Help for Parents by Lynn Clark, Ph.D. This book is helpful to families who are experiencing behavioral problems with primarily younger children but it is recommended from ages 2-12. The format makes it very easy to access and it is not necessary to read the book in its entirety. There is information on how to appropriately use Time-out to extinguish behaviors and also, very importantly, on how to encourage good behaviors. There are many special situations addressed including noncompliance, not minding, strong-willed behavior, oppositional and defiant behavior, aggression, ADHD, dressing problems, sibling conflict, tantrums, attention seeking, immature behavior, avoidance of chores, homework resistance, communication problems, and managing bad behavior away from home.

The Available Parent by Dr. John Duffy. The target age group for this book is teens and tweens. The adolescent years can be particularly challenging and Dr. Duffy recommends that parents read this book, before the teenage years. Topics covered are social media (facebook, texting, etc. ), sex, rebellion and body image in addition to how to communicate and connect with your teen. Being a parent of a 16 year old, I found it very helpful in making ourselves “available” to listen and to try to understand a teen’s world in today’s society.

Straight Talk about Psychiatric Medications for Kids by Timothy E. Wilens, MD. I find this book extremely helpful as a quick and easy way to navigate psychiatric medications for the medical provider and also for parents who have questions. I will sometimes make copies of specific chapters for parents to review before initiating treatment so that they have an opportunity to become fully informed, especially if they are hesitant. It covers common disorders, information for parents and psychotropic medications including FDA approved and off-label uses.

Helping Your Anxious Child by Ronald M. Rapee, Ph.D. This is another parent guide that helps parents assist their children who struggle with worries and fears in a step-by-step process. I find it is often a useful first step for parents to begin by following the “program” that is outlined as an alternative option before starting treatment with a therapist. The approach used is similar to cognitive behavioral therapy (CBT) which has the strongest scientific evidence for being effective in treating anxiety in children. The authors also outline coping skills and relaxation techniques that parents can guide their child through.

Books for Oppositional Behavior

Below are several books that can be helpful for parents of oppositional-defiant children who have trouble regulating themselves. All three share some common elements but there are some deviations that may work better for a specific child.

The Explosive Child by Ross W. Greene

Your Defiant Child by Russell Barkley, Ph.D

Parenting the Strong-Willed Child: The Clinically Proven Five-Week Program for Parents of Two- to Six-Year-Olds by Rex Forehand, Ph.D

When looking for resources, don’t forget about “bibliotherapy” as part of your comprehensive treatment plan.

Tags: parenting
Parenting | No Comments »

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