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Autism Screening – What Will Happen with the New M-CHAT?

Posted: February 17th, 2014 by David Rettew

When it comes to autism screening for toddlers, the Modified Checklist for Autism (M-CHAT) is one of the most widely used and studied instruments available (and it’s free and dowloadable). While it’s been shown to have both good sensitivity and specificity, there is always room for improvement. Thus was born the M-CHAT Revised with Follow-up (M-CHAT-R/F).

What makes the new scale different is not just some changes in the wording of some of the questions but, perhaps more importantly, how the M-CHAT is scored and categorized. Now, based on what parents write down on the M-CHAT-R/F, the total score is placed into one of three categories – low, medium, and high risk. What to do for the low and high risk toddlers is pretty straightforward. Those at high risk should be sent for a more in-depth autism evaluation right away and those at low risk don’t need further action, other than a repeat M-CHAT-R/F if they are not yet 24 months old.

The middle risk kids are a bit trickier. Now, the instructions are that primary care clinicians are supposed to go through a series of scripted questions that delve into more detail about those items that are raising a red flag for autism. Such a process could take about 15 minutes or so and potentially could be done by someone other than the physician. Based on those questions, another score is generated and if that score is also above the cut-off then the full evaluation is recommended.

A recent study of over 16,000 toddlers who presented for well-child checks at 18 and 24 months of age demonstrated the utility of the new instrument. Nearly 93% of the initial M-CHAT-R scores were negative, defined as a score of less than 3. Of those screening positive, 63% of them no longer screened positive with the follow-up assessment. After establishing an optimal cutoff point of three for the M-CHAT-R and then at least 2 for the follow-up, those who remained positive were found to have a 47.3% chance of being diagnosed with autism, with only 5% of the remaining sample assessed to be developing typically. This detection rate of autism was found to be superior to that of the original M-CHAT.

The million dollar question in my mind, however, is will this new step for immediate risk really happen in a busy primary care office, and what will occur if it doesn’t?

In the published study, it is important to point out that they didn’t ask the PCPs to do that follow-up piece: the research staff did. This leaves the open question of how feasible it is to ask the primary care community to do these. Interviews containing scripted questions to help make a diagnosis of various psychiatric disorders have been around for decades and are considered “gold standard” measures that are required in research studies. However, they are uncommonly used in everyday practice by psychiatrists and even more rarely used in primary care settings. Consequently, it seems quite likely that many primary care clinics will struggle with this new recommended step. Am I wrong here?

I was so curious about this aspect that I sent an email to the lead author of the M-CHAT, Diana Robins PhD, at George State University. She replied quickly and acknowledged that this is looking like a real problem. In fact, she’s is having trouble finding PCPs willing even to participate in a study about putting the new M-CHAT into practice.

If primary care clinicians decide not to adopt this new follow-up procedure, the instrument could lose some of its discriminative power. If that happens, a number of things could occur.

Primary care clinicians could just stick to the old M-CHAT (with the loss of the improved instrument resulting in less accurate autism detection)
They could plan to do the follow-up step but often not actually get to it (resulting in a delay of the screening process)
They could group the medium risk kids into the low risk group (which potentially could result in some autistic kids not being formally evaluated until they are older)
They could group the medium risk kids into the high risk group (which could lead to more evaluations and longer waits for kids who would not end up being diagnosed with autism but require formal evaluations to verify this)

None of these options seems ideal and my guess at this point is that the incorporation of the new M-CHAT will be quite slow, especially with this new step in place. Public health officials interested in autism screening might begin to look for a system that will work without making it too arduous for those who need to implement it.

If you are a primary care clinician that does autism screening, please feel free to comment on what you do now and what you plan to do about the new M-CHAT, if anything. This one might be worth some follow-up dialogue on how we best should do things around here.

Reference

Robins, DL, et al. Validation of the Modified Checklist for Autism in Toddlers, Revised With Follow-up (M-CHAT-R/F). Pediatrics 2014;133:37–45

Tags: asperger's, autism, m-chat, mchat
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Child Mental Health Now Versus the Past

Posted: February 3rd, 2014 by David Rettew

Of note, this post is adapted from a similar one that appeared last week in my Psychology Today blog.

From many headlines today, it is easy to get the impression that children and adolescents are struggling more than ever these days. At the same time, the mental health system designed to help our kids and their families has been under intense criticism for being either completely inaccessible or for being too accessible when it comes to medication treatment.

Image courtesy of John Churchman and www.brickhousestudios.com

Few would argue that there are serious issues to confront right now. However, it may also be useful to take a step back and look at how levels of problems now compare to the past. While good statistics in many areas have not been available for that long, what trends are evident for many important metrics of youth mental health may be surprising. Here are some examples.

Suicide. The rate of completed youth suicides (we now try to stay away from the phrase “successful” suicide for obvious reasons) has been steadily declining. The incidence rose steeply, especially for males, from the 1960s until the early 1990s and has been coming down ever since, according to the Center for Disease Control (CDC).

Teen Pregnancy Rates. According to the government’s Office of Adolescent Health, the teen pregnancy rate among adolescent females has been cut in half from 1990 to 2012, across many different ethnic groups.

Delinquency. The number of youth who are incarcerated have dropped from a high of 381 per 100,000 in 1995 to 225 per 100,000 in 2010 according to a report by the Annie E. Casey Foundation.

Substance Use. The rate of smoking in teens is at an all-time low, according to the Monitoring the Future study that has surveyed substance use for decades. Cannabis use is also down from peaks in the 1970s, although has been trending up. Alcohol use in teens is also at historic lows, according to the National Institute of Drug Abuse.

Psychiatric Disorders. As has been well covered in many venues, there have been significant increases in the rates of many psychiatric disorders, including ADHD, autism, and bipolar disorder. What is less clear, however, is the degree to which these numbers reflect an actual increase in behavior versus other factors such as an improved detection rates or a lowering of the diagnostic threshold. A study by Achenbach and coworkers several years ago that looked at quantitative levels of child behavior problems using the same instrument over a 23 year time span found some increases in overall levels from the 1970s to the early 1990s which then began to fall by the end of the millennium.

Child Abuse and Bullying. Reports from the Crimes Against Children Research Center shows a steady decline in the rate of child abuse since the early 1990s, particularly physical and sexual abuse as well as violent victimization at school. The reports utilize government data from the National Child Abuse and Neglect Data System.

When it comes to Vermont, many of these metrics look even better in weighing our place relative to other states, especially when it comes to teen pregnancy and youth incarceration. One notable exception, however, is adolescent cannabis use.

There are still many things to work on to help children and their families thrive when it comes of behavioral wellness. At the same time, however, we also need to recognize that compared to other time periods (particularly the early 1990s for some strange reason), kids today are really not behaving that terribly and now doesn’t look like a terrible time to be a kid.

Reference

Achenbach, T.M., Dumenci, L., & Rescorla, L.A. (2003). Are American children’s problems still getting worse? A 23-year comparison. Journal of Abnormal Child Psychology, 31, 1-11.

Tags: child mental health, substance use, suicide, teen pregnancy
Access to care, Diagnosis, Drugs and Alcohol, General Family Based Appraoch, Public Policy, Suicide | No Comments »

Child Psychiatry Phone/Email Consult Service Underused: Help Us Understand Why?

Posted: January 28th, 2014 by David Rettew

For the past year, child psychiatry clinicians at the Vermont Center for Children, Youth, and Families (VCCYF) have been assigned to primary care practices across the state to be available for questions made through phone or email (or this blog). The program is supported by the Vermont Child Health Improvement Program (VCHIP) and comes at no cost to the primary care practices.

Many practices have signed up. However, the number of questions submitted have remained small. This past quarter, only 19 questions were submitted from 12 primary care clinicians (with only 5 from the previous quarter). At the same time, the number of requests for in-person consultation has remained relatively constant, reflecting continued need for child psychiatry services.

Those of us at VCHIP and the VCCYF would like to understand why the service is underutilized in order to try and make any improvements. Please help us if you are a primary care clinician in Vermont by completing this ONE QUESTION survey by clicking here.

If you would like to enroll of find out more about this program, please contact our project coordinator Eliza Pillard at eliza.pillard@vtmednet.org.

Access to care | No Comments »

Next Child Psychiatry in Primary Care Conference Friday, May 30

Posted: January 13th, 2014 by David Rettew

Please mark your calendars to attend the 8th annual Child Psychiatry in Primary Care conference to be held Friday May 30, 2014 at the Doubletree Hotel in South Burlington, Vermont. It promises to be another captivating and practically useful event for primary care clinicians, mental health professionals, and educators.

We plan to have our usual mix of lectures, breakout sessions, and the opportunity to ask case-based questions to a panel of experts.

More information will be coming soon and you can check back at this site and the UVM Continuing Medical Education page.

If there are specific suggestions for topics, please use the comment function here or you can email me at david.rettew@med.uvm.edu.

Tags: child mental health, child psychiatry, conference
Uncategorized | No Comments »

Vermont 34th in Rate of Stimulant Treatment

Posted: January 5th, 2014 by David Rettew

The popular press has been abuzz with articles on ADHD, with many suggesting that the diagnosis is much overused and that medication treatment is basically a way that affluent parents give their children an academic advantage. In the midst of all this controversy comes a recent and interesting study in the journal Psychiatric Methods, which compared the rates of stimulant treatment in children and adults across regions, states and counties.

Using an IMS Health database, a total of 24.1 million prescriptions were analyzed, all issued in 2008 and representing over three-quarters of all U.S. pharmacies. Prevalence rates were calculated using weighted statistics based on U.S. census numbers and regression models were applied to examine potential factors that might be related to the variable rates between different areas. Of note, the authors looked at sustained stimulant treatment and did not count prescriptions that were filled only briefly.

Overall, a total of 2.5% of children were being treated with stimulant medications nationally with the rate being higher in boys (3.5%) than girls (1.5%). In addition, 0.7% of adults over age 17 were also receiving these medications. For children, the lowest stimulant rate was in Alaska (0.4%) while the highest was in Delaware (5.1%). Vermont came in at 34th at about 2%, while neighboring New Hampshire was 14th which was right after Massachusetts. Regional differences (South, Midwest) were smaller than between neighboring states and counties. About one-third of the treatment came from psychiatrists. Higher rates of treatment was related in children to an increased supply of pediatricians, lower socioeconomic status of the population, and more funding for special education.

In the discussion, the authors perspective was mainly about access to treatment. They noted that the prevalence of ADHD is generally cited as between 5-10% which would suggest a large number of children not being diagnosed and treated, especially in particular states and counties. However, the authors also acknowledged that their data could not directly address the question of under or over-diagnosis. The finding of stimulants generally being related to families with lower socioeconomic status, however, does suggest that they are not being used simply as a study drug for well-to-do kids. It is also important to note that nonstimulant medications such as atomoxetine as well as nonpharmacological treatment were not included in these analyses.

What to make of Vermont as being towards the bottom of the pack? I must admit that this result was a bit surprising to me and does not quite square up with data from the Department of Vermont Health Access which found much higher rates, at least among kids with Medicaid. Furthermore, whether this 2% rate found in this study reflects good and careful prescribing, statewide under-recognition of ADHD, or a mixture of both is difficult to say. There are wide fluctuations even within our small state related to the density of primary care physicians. At least in rural areas where access to pediatric care is more difficult, these data would suggest that many struggling children have yet to have their ADHD symptoms diagnosed and treated.

Reference

McDonald DC, Jalbert SK. Geographic Variation and Disparity in Stimulant Treatment of Adults and Children in the United States in 2008. Psych Services 2013;64(11):1079-1086.

ADHD, Medications | No Comments »

Psychotic Symptoms in Adolescence Common and Appear Dimensionsal

Posted: December 10th, 2013 by David Rettew

While there has been increased appreciation that most symptoms in psychiatry exist along a spectrum or continuum, certain domains have continued to be viewed by many as more binary in nature, meaning that a person generally has the symptom or not. Psychotic symptoms have generally been one of those areas. A recent study by Ronald and coworkers that appeared as an advance article from the journal Schizophrenia Bulletin, however, challenges that assertion.

Participants for the study came from the Twins Early Development Study (TEDS) which has been following a community sample from England and Wales. Over 5000 16-year-old twins and their parents participated. Psychotic symptoms were assessed quantitatively using the self-report Specific Psychotic Experiences Questionnaire (SPEQ) at baseline and, for a subsample, again 9 months later. The responses from the SPEQ were then analyzed pschometrically to try and identify key dimensions of psychosis.

In terms of results, psychotic symptoms were found to be quite common. For example, 15% of the sample reporting hearing voices that commented on what the person was doing or thinking. Six principle dimensions of psychosis were found namely: paranoia, hallucinations, cognitive disorganization, grandiosity, anhedonia, and negative symptoms. These domains were found to be relatively distinct with only small to moderate correlations between them. All of these subscales with the exception of grandiosity were found to correlate significantly with levels of anxiety, depression as well as with personality traits such as neuroticism. Some sex differences were also found such as boys reporting more grandiosity and girls reporting more hallucinations. The level of psychotic symptoms showed a wide range of variation, with characteristics more like a quantitative trait rather than a discrete “yes or no” presence.

The authors concluded that psychotic symptoms in adolescence are quite heterogeneous and relatively common, with many adolescents endorsing them without high degrees of distress.

It is important to note that this sample was community based and thus, one cannot conclude that similar properties would occur within a clinical sample of youth with psychotic disorders. The endorsement of psychotic symptoms seemed quite high and may have been due to the main use of a self-report questionnaire. Specific associations with drug use were not explored.

Reference

Ronald A, et al. Characterization of Psychotic Experiences in Adolescence Using the Specific Psychotic Experiences Questionnaire: Findings From a Study of 5000 16-Year-Old Twins. Shiz Bulletin 2013; Epub ahead of print.

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AAP Releases New Child Media Guidelines

Posted: November 20th, 2013 by David Rettew

The American Academy of Pediatrics (AAP) recently published an updated policy statement paper on recommended limits for media usage in kids. The new report is designed to incorporate the increase of “new media” devices such as mobile phones and computers that are making up an increasingly larger portion of the total time. The trends necessitate that primary care clinicians adapt in the way that they ask about media usage and make recommendations to families.

Photo courtesy of ImageryMajestic / freedigitialphotos.net

The paper cites data from previous studies, chronicling an astonishing amount of media use among youth. Total time per day using media for entertainment purposes rises from about 8 hours per day in 8-10 year old to a stunning 11 hours or more in teens (it is hard to figure out the math for that one while still leaving time for school). Over 70% of youth reportedly have a television in their room, not to mention a phone or tablet connected to the internet. As many parents of teens already know, texting 50 to 100 times per day is now commonplace and ironically, teens are now one of the demographic groups least likely to use phones for voice communication. Teens also report that they typically have no clear rules about media use from their parents, although parents tend to give a slightly different story. These concerns are balanced by evidence that the some forms of media can be positive and enhance learning and social interactions.

The guidelines recommend that pediatricians ask two specific questions about media usage with parents namely 1) How much recreational screen time does your child or teenager consume daily? and 2) Is there a TV set or an Internet connected electronic device in the child’s or teenager’s bedroom? Specific recommendations about media use include the following:

Total media use should be less than 2 hours per day
Children under age 2 should be discouraged from any media use
TVs and internet connected devices should not be in youth’s bedroom
Media use should be monitored and discussed
Family rules about media use, such as no usage during meals, should be made (and modeled by parents)

Getting less press attention but also contained in the article are also recommendations that primary care clinicians become more actively involved in educational and political groups to advocate for specific policies and laws, such as trying to ban alcohol advertising on television similar to cigarettes.

Following the release of these guidelines, many parents on the internet responded with some skepticism that such limits are realistic. Indeed, a potential danger is that parents will dismiss the guidelines altogether rather than try to enforce attainable limits even if they fall somewhat short of the specified numbers. The authors have commented themselves that the recommendations are not meant to be rigidly followed each day but are rather benchmarks that can be flexibly applied. There is also a bit of a “one size fits all” approach to the guidelines in that no differentiation is given between, for example, a 3- and a 17-year-old. Public health messages tend to be made as simple as possible to avoid confusion, and often there is a tacit understanding that some degree of customization will be necessary. If these quite remarkable statistics are true, however, any concerted effort to bring media use into greater balance is a welcome enterprise, with primary care clinicians needed to support children and the families to make healthier choices.

Reference

Strasburger VC, et al. Children, Adolescents, and the Media. JAMA Pediatrics. 2013;132(5):958-61

Tags: media use, screen time, texting, video game usage
Parenting, Public Policy, Uncategorized | No Comments »

Is Cannabis Really A Gateway Drug?

Posted: November 12th, 2013 by David Rettew

Across the country, there have been several initiatives to decriminalize and even legalize marijuana, including efforts here in Vermont. A common sentiment behind these movements is that cannabis in not really addictive or harmful. These efforts have reignited the debate about the potential dangers associated with cannabis use, particularly among adolescents. A recent review paper by Hurd and colleagues in the journal Neuropharmacology examined the literature on the link between early cannabis use and later addiction and provides some practical conclusions that can be useful in discussions with patients.

Adolescence is a period during which there is a lot of brain plasticity, thus rendering the stage as potentially susceptible to the influence of substances such as cannabis. Cannabaniod receptors are highly expressed in the brain, particularly in regions such as the prefrontal cortex, cerebellum, amygdala, and hippocampus that are critical for cognitive and emotional functioning.

Regarding the “gateway hypothesis,” which states that early cannabis use increases the risk of addiction for other drugs, there is good evidence from multiple studies that the intensity of cannabis exposure is directly related to the use of ‘heavy’ drugs. Further, early cannabis use has been linked to poorer outcomes in a number of areas including educational achievement, employment, rule-breaking behaviors, and assuming more adult roles. Human studies of cannabis often have methodological flaws that make it difficult to demonstrate a clear causal action of cannabis use on later outcomes. In other words, it can be quite difficult to determine if cannabis is truly the problem itself or if a common genetic or environmental factor drives both cannabis use and psychopathology (Harder et al., 2008). Animal studies, however, are often free of these complications and have demonstrated a direct relation between cannabis exposure and increased intake of opiates. Animal studies also show links between THC exposure and later behavioral changes (although the study about pot smoking rats being less likely to attend college is inconclusive). In humans, behavioral effects tend to be seen in a subset of cannabis abusing adolescents and include negative affect, decreased goal directed behavior, aggression, and less frequently psychosis.

Overall, then, the available evidence does point to cannabis use in adolescents being related to increased vulnerability to future addiction and poorer outcomes; however, there is much that remains to be learned about how cannabis interacts with other factors in development. The article provides a great deal of useful information about the risks associated with cannabis use while not glossing over the significant gaps in knowledge that need to be addressed.

Reference

Harder VS, et al. Adolescent cannabis problems and young adult depression: Male-female stratified propensity score analyses. Am J Epidemiol 2008; 168:592-601.

Hurd YL, et al. Trajectory of adolescent cannabis use on addiction vulnerability. Neurophrarmacology 2013. Epub ahead of print.

Tags: cannabis, gateway drug, marijuana
Drugs and Alcohol | No Comments »

Parent Training Rated as First Line Treatment for Preschool ADHD

Posted: October 29th, 2013 by David Rettew

Recent practice guideline from the American Academy of Pediatrics now include a recommendation for assessment and intervention for ADHD before they begin elementary school, but many clinicians are unsure about exactly what treatment to recommend. A recent paper sponsored by the US Agency for Healthcare Research and Quality and published in the the journal JAMA Pediatrics attempts to perform a meta-analysis of ADHD treatment studies in preschoolers in order to provide a more specific evidence base. Stimulants are not approved for children below the age of 6, although medication treatment of preschool age children is not uncommon.

The authors identified treatment studies of children with disruptive behavior symptoms below the age of 6. The overall strength of evidence was rated as good, moderate, low, or insufficient based on previously published guidelines that incorporated many aspects of the studies that assessed that intervention. While the study authors had planned to provide quantitative analyses of multiple types of treatment, only Parent Behavioral Training (PBT) had enough studies to allow for the use of meta-analysis techniques while methylphenidate treatment and combined home and school/day care interventions needed to be summarized descriptively. A total of 55 studies were found (34 for parent behavioral training and 15 for pharmacotherapy).

Parent behavioral training studies were found to result in a moderate effect size that favored its use. These studies showed improvement in child disruptive behavior, ADHD symptoms, and parental skill. With regard to medication, only the Preschool ADHD Treatment Study (PATS) was deemed to be of “high” quality. The lack of additional high quality studies and amount of adverse effects with medications thus caused the overall recommendation for methylphenidate use to be low. Studies that combined PBT with school or daycare based interventions were found too conflicting to make an overall conclusion.

Based on their review of the data, the authors concluded that the research evidence suggest that parent behavioral training should be considered first line treatment for preschool ADHD.

For those less familiar with PBT, the goal of parent behavioral training is to teach parents strategies that help them manage their child’s challenging behaviors through promotion of a positive behavior and employing rewards and punishments for negative behavior. Unlike other types of child therapy, PBT tends to be quite structured and, as the name suggests, focused quite a bit on the parents. Many of these programs have individual names (Incredible Years, Parent-Child Interaction Therapy) and manuals but utilize a similar overall framework. In this study, no particular program was found to be clinically superior.

The authors acknowledged that many of the parent behavioral training studies have some methodological limitations with a sizable proportion of eligible parents not completing the course of treatment. It is also worth noting that others might quibble with their determination that only one pharmacological study is worthy of a high quality rating.

Nonetheless, it seems quite reasonable in my view to follow the recommendation that parent behavioral training be tried first for preschoolers with ADHD and other types of disruptive behavior. Finding it can be a challenge, and it may be worthwhile for clinicians to ask about it specifically or encourage parents to ask potential therapists about their experience with these techniques.

Reference

Charach et al., Interventions for preschool children at high risk for ADHD: A comparative effectiveness review. Pediatrics; 2013;131:e1584–e1604

ADHD, Medications, Parenting, Therapy, Uncategorized | No Comments »

Age 5 Behavior Linked to Maternal and Child Nutrition

Posted: October 22nd, 2013 by David Rettew

Many studies have found associations between specific nutrition deficiency states or gross malnutrition and child behavior, but lacking are more global studies that examine the link between more typical diets in general and behavioral outcomes.

The Norwegian Mother and Child Cohort Study is a prospective study that recruited mothers when they were pregnant and followed them and their children in serial assessments up until the child was 5 years old. Over 23,000 mothers and their children were assessed using mailed questionnaires. For this study, raters made a dichotomous judgment of whether a mother’s or child’s diet was high or low in both healthy foods and unhealthy foods. This variable was used to predict child internalizing and externalizing scores at age 5 using latent growth curve models. The authors attempted to control for some potential confounds including socioeconomic status and maternal smoking, among others. Unfortunately, factors such as the home environment or parenting, were not included in these models.

In terms of results, a significant link was found between a mother’s unhealthy diet during pregnancy and child level of externalizing problems. Regarding the child’s diet early in life, both higher intake of unhealthy foods and lower intake of healthy foods were associated with both internalizing and externalizing problems. The effect of diet was most evident early in a child’s life and diminished by age 5 for some types of problems.

The authors concluded that both an increased intake of unhealthy foods and a decreased intake of healthy foods was related to negative child behavior at age 5. They advocated that adhering to good dietary principles is an important factor for optimal child mental.

While the effect sizes for this study tended to be small (correlations between diet quality and child behavior less than 0.1), these data give us additional scientific backing for our recommendation to eat well during pregnancy and to provide healthy food choices early in a child’s life. In addition to factors such as parental mental health, sleep, exercise, structured activities, and screen time limits, good nutrition is an important target of intervention in a child’s overall mental health treatment and is “an important part of a good breakfast” when it comes to wellness promotion.

One nice resource for families is the USDA’s Choose My Plate website.

Reference

Jacka FN, et al. Maternal and Early Postnatal Nutrition and Mental Health of Offspring by Age 5 Years: A Prospective Cohort Study. J. Am. Acad. Child Adolesc. Psychiatry, 2013;52(10):1038–1047.

Tags: behavior, mental health, nutrition
General Family Based Appraoch, Parenting | No Comments »

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