Showing posts with label psychology. Show all posts
Showing posts with label psychology. Show all posts

Monday, May 4, 2015

Vulnerability, Hair Cortisol and Pediatric Practice

By: Lydia Furman, MD,  Assistant Editor

Only in Scandinavia! A study by Jerker et al. (doi:10.1542/peds.2014-2561) brings us follow-ups to ten years of age from the prenatal period in a racially, socially, economically and ethnically homogenous population with near 100% subject retention. The authors appear to have nailed down a primary etiologic biomarker and in turn mechanism of the much discussed but less well understood “toxic stress” response (Garner AS, Shonkoff JP. Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health. Pediatr. 2012;129:e224-3)—using hair cortisol levels.
     High-sensitivity C-reactive protein (hs-CRP) has become an oft used measure of cumulative inflammation and cardiovascular risk in the world of internal medicine (Koenig W. High-sensitivity C-reactive protein and atherosclerotic disease: from improved risk prediction to risk-guided therapy. Int J Cardiol. 2013;168:5126-34, and others).Will hair cortisol become our all-encompassing pediatric counterpart to hs-CRP? As a “novel biomarker,” hair cortisol appears to measure prolonged or frequent activation of the HPA (hypothalamic pituitary axis) and thus can serve as a proxy for accumulated stress over time. Its correlation with a scaled measure of psychosocial vulnerability is intriguing. You may agree or disagree with the authors’ composite of 11 Likert scaled items that are used to measure psychosocial risk, but the impact of this well done study is difficult to disregard. 
      Where to from here? For primary care physicians, serving children from diverse backgrounds, none of us can afford to be skeptical about the potential impact of psychosocial adversity on our patients, and on their long term mental and physical health. While we won’t likely be measuring hair cortisol at one year of age in the near future, we need to consider a more focused approach to antecedents of health. Some might counter that pediatric clinicians do not want to always have to take on the role of  social worker as well, and  spend precious well care visit minutes delving into the family’s personal life. I respectfully and vociferously disagree with you. The 11 elements of psychosocial vulnerability and risk measured in this study are hardly obscure or excessively personal questions- if we don’t know the answers, honestly, we don’t know our families; and if you don’t know the family in front of you, how in the world are you planning to help the child, your patient? This terrific article opens up a world of possibility for each of us in our everyday practice- please read it and consider if you now see your practice with new eyes.

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Tuesday, April 7, 2015

An Assault Injury May Lead to Subsequent Firearm Violence

By: Lewis First, MD, MS; Editor-in-Chief 
     Our heart goes out to teens who are victims of physical assault injuries that present to emergency departments for further evaluation and treatment.  But what happens after the assault compared to teens who are not assaulted?  Carter et al. (doi: 10.1542/peds.2014-3572) performed a prospective cohort study involving drug-using assaulted teens who presented to an urban Level 1 emergency department and compared them to a similar group of drug using teens who had not been assaulted and then followed both groups over the next two years  (collecting data on their well-being every 6 months).   
      Sadly there was a 40% increase in firearm violence in the assaulted group compared to the non-assaulted group—most having a firearm violent event within 6 months of the initial assault incident.  The authors take this finding further and identify risk factors that can further predict firearm violence in the assaulted group.
     What can we learn from this study?  We might want to do more than simply deal with the assault injuries themselves in the ED or in follow-up in a primary care setting—but instead try to intervene with more supportive services to these troubled youth in regard to helping  them with their substance abuse, mental health needs, need for revenge and /or desire to possess a firearm.  Obviously the goal is to do even more prevention work on firearm violence with teens even before this type of assault injury occurs—and Drs. Judith Schaechter and Eliot Nelson, experts on injury prevention from firearms share some important thoughts on this topic in an accompanying commentary (doi: 10.1542/peds.2015-0693). In this era of advocating for pediatrician inquiry into firearm access in homes with children and teens, this study and commentary are well worth your time and attention.

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Tuesday, March 3, 2015

Antipsychotic medications and foster children- what does the Vermont story teach us?

By: Lydia Furman, MD Assistant Editor 

       In a sobering article, Rettew et al. (doi:10.1542/peds.2014-2260) examine the prescribing of antipsychotic medications to foster children on Medicaid insurance in Vermont. They surveyed prescribers, and were able to achieve a near 80% return rate in part because continued authorization of the medication was linked to survey completion. While acknowledging the inherent shortcomings of the survey approach, including potential differences between those who did and did not reply, possible social desirability bias in responses, and the self-forgiving nature of self-report, the authors were able to extract important information.  Did prescribers follow FDA guidelines and best practice guidelines? Although a small number of respondents (8.8%) were responsible for the majority (52.7%) of prescriptions, and 84.6% of these were child psychiatrists, the survey results are still highly relevant to non-psychiatrists.  Child psychiatrists not surprisingly did better than non-psychiatrists, but the results are still humbling. 
       Nationally, antipsychotic medication prescribing for children has increased with little standardized oversight or monitoring (Harrison et al J Pediatr Health Care 2012), and in many cases without appropriate or recognized indications (41.3% did not have a diagnosis for which such treatment was supported; Pathak et al Psychiatr Serv 2010). Among the most vulnerable, children in foster care with mental health problems have been previously documented to experience antipsychotic prescribing at 3x the rate of Medicaid-insured children not in foster care (Zito et al, Pediatr 2008); although this worrisome data is now 5 years old, the problem shows no evidence of abating.  Recent work shows that, “In the absence of any co-morbid conditions, ADHD-diagnosed foster care youth had more than threefold greater adjusted odds of atypical antipsychotic use than did youth enrolled in income-eligible Medicaid categories,” (Burcu et al J Child Adolesc Psychopharmacol. 2014).  This problem is even more concerning among very young children in foster care who are experiencing prolonged treatment with way “off label” psychotropic medications: 12% of foster children age 6 years and under in foster care for 1 year or more had received a psychotropic medication (either an ADHD or antipsychotic medication) and the prevalence of medication use and duration increased significantly (Psychiatr Serv 2014). Reducing overuse of second generation antipsychotics among Medicaid-enrolled children is a national priority (Saloner et al Psychiatr Serv 2014).
      Are these results generalizable and what can primary care pediatricians take home? There is good reason to act on the information here. Almost half (42.4%) of the respondents did not actually start the medication they were prescribing. This suggests that there is a huge role for personal accountability among this group of prescribers, including not continuing medications without full review of the diagnostic evaluation and re-evaluation as appropriate, engaging in discussion and ongoing monitoring in collaboration with a child psychiatrist, and strong consideration of whether continuing the medication is in the best interest of the child.  Interestingly in this survey, only 2.1% of respondents said they were unable to access psychotherapy or counselling services, effectively removing the all-too-oft heard excuse of lack of mental health care availability as a reason for medication prescribing. Most children in foster care have been exposed to abuse, neglect, interpersonal violence and other horrific conditions- medication treatment alone or as a “quick fix” is unlikely to provide the sustained help the child needs for personality development to proceed.       
      Harrison et al note that, “Many of the causes of children’s aggressive or disruptive behaviors are linked to family relationships and stressful, unpredictable home environments, which also may be violent and aggressive (National Research Council and the Institute of Medicine, 2009). Under these situations, antipsychotic medication is not an appropriate course of treatment because it does not address the underlying cause of the problem.”  (J Pediatr Health Care 2012, available at ).   By taking the time to reevaluate rather than just refill, those of us on the front line have the potential to make a difference for the individual child. 


Monday, August 4, 2014

Video Games and Psychosocial Adjustment

Pediatrics Editorial Board Member Terrill Bravender MD, MPH, shares his expert perspective on a new article from our September issue. To learn more about Dr. Bravender and his work in adolescent medicine, check out his bio on our Contributors page.

By: Terrill Bravender, MD, MPH

Photo by OakleyOriginals via Flickr
The effects of video games on child development and behavior have been topics of intense debate since "Pac Man" first hit the arcades. These days, though, adolescents no longer need a pocket full of quarters, and "Call of Duty: Black Ops" is certainly not "Donkey Kong".

With more than 97 percent of adolescents reporting video game use, “gaming” is the new normal. In the September issue of Pediatrics, Dr. Andrew Przybylski (doi: 10.1542/peds.2013-4021) presents a fascinating population-based study of the effects of self-reported daily video game use on measures of psychosocial adjustment. No matter how you feel about video games, you will likely be intrigued.

While moderate levels of game play (defined as one to three hours daily) had no effect on adjustment indicators, those teens who reported playing for more than three hours daily indicated higher levels of internalizing and externalizing problems as well as lower levels of prosocial behavior. This is unlikely to surprise any parent who has tried to get an online teenager to turn away from the video screen, disconnect the headphone and microphone, and go outside to try to experience something IRL (“in real life” for the uninitiated).

However, the news is not all bad for the adolescents who use video games in moderation: Those teens who reported playing for less than one hour daily had higher levels of prosocial behavior than those teens who said they never played. These low-level players also reported lower levels of internalizing and externalizing problems.

The author contends that low-level playing might help children work through social and cognitive challenges online without taking too much time away from their offline lives. Although the results are fascinating and statistically significant, the reader must keep in mind that the effects are small, with video games only accounting for 0.3 to 1.5 percent of the variability in their measures. Even so, these small effects are broad, and may help create a more nuanced understanding of the behavioral and developmental effects of video games.

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Monday, September 30, 2013

Psychotropic Medication Use in Very Young Children: Is It Getting Better or Worse?

We all probably hesitate in considering whether or not to use psychotropic medication in very young children, given the limited evidence available on their benefits versus their risks.  Yet they are being used—and the question is: are they being used more and more on children between the ages of 2 and 5 years of age?  Chirdkiatgumchai et al. (doi: 10.1542/peds.2013-1546) studied this question using data from national surveys obtained on more than 43000 very young children between 1994 and 2009 looking at 4 year time intervals to sample.  The trend analysis is very interesting and shows some ups and downs that are worth reading about. In addition, the authors provide an epidemiologic profile of demographic variables that are associated with use of these drugs that identifies some sociodemographic disparities in who is and is not receiving these medications.  While it is not clear what might be causing these disparities, the authors offer some thoughts as they discuss their findings.

While needing to put a young child on a psychotropic medication is a bitter pill to swallow, this study will provide you with a healthy dose of data to better understand just who is receiving these medications so you can better assess whether or not you need to prescribe them for very young patients in your own practice.