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An update on treatment of depression
Paul is 13-year-old male in seventh grade with a history of inattentive ADHD and a positive family history of depression and anxiety in his mother. He always has had a few friends, but recently they have not wanted to hang out with him; he feels like people are ignoring him. For the past 2 months, Paul’s mood has gotten very low. He feels sad and also bored because he is not enjoying anything anymore. He feels as though he is “a loser,” and as though nothing will ever get better. His grades have dropped. He has thoughts of wishing he were dead, although he has no specific plan and says he wouldn’t do it because he doesn’t want to hurt his parents. He is looking at his phone at night and gets to bed late, then doesn’t want to get up in the morning. He sleeps until noon on weekends. Appetite is increased. He doesn’t have energy to do things on the weekends.
Discussion
Paul clearly meets diagnostic criteria for depression. He feels sad and has lost pleasure in activities he used to enjoy. He has negative, hopeless thoughts, and vague thoughts of death although no specific plans. He has vegetative signs of depression with increased appetite and sleep; he likely has worse concentration than usual, given that his grades have dropped. Energy is low.
Meta-analyses have demonstrated the efficacy of SSRIs (fluoxetine, sertraline, citalopram, escitalopram) as well as venlafaxine, mirtazapine, and nefazodone with small to very small effect sizes.1 A large placebo effect is seen in many of these studies, correlating with the number of study sites – a feature of many industry-sponsored studies.
John Walkup, MD, a leading researcher on both medication and psychotherapeutic interventions in children’s mood disorders, has pointed out that the quality of industry-sponsored studies (vs. National Institute of Mental Health–sponsored studies) is likely lower, with more pressure to get in large numbers of patients in a short period of time, less trained investigators leading to less clear-cut diagnoses, and other sources of bias.2 This raises the question of whether we should weight NIMH-sponsored studies more heavily in meta-analyses.
A second factor to consider is the risk of harm, and a significant issue here is the question of whether suicidal ideation is increased among those patients taking SSRIs. Meta-analyses from the late 2000s, which balanced the number needed to treat vs. the number needed to harm, judged that for children under age 13 years, fluoxetine was the only antidepressant that was worth the cost-benefit ratio. However, in the past several years there has been a major improvement in the assessment of suicidal ideation in the form of the Columbia Suicide Severity Rating Scale, a standardized method of assessing the presence and significance of suicidal thoughts and behaviors. Studies that have used this assessment have found no significant increase in suicidal ideation with SSRIs vs. placebo.
The takeaway here is that the SSRIs can work, with fluoxetine, sertraline, and escitalopram leading the evidence, and that with refinements of the assessment they do not appear to increase the risk of suicidal ideation.3 Of course, it remains important to discuss this issue with families.
Psychotherapy is the other major treatment for depression. Cognitive behavioral therapy (CBT) and Interpersonal therapy (IPT) for adolescents show effectiveness in teens.4 Recent meta-analyses have gotten stronger through the use of stringent quality criteria and the inclusion of negative studies; these therapies continue to be considered well established. It is worthwhile to talk to therapists in your community to understand what type of treatment they offer. If you are hiring therapists to be embedded in your practice, look for people who have been trained in CBT or IPT. It is particularly helpful to know whether therapists have seen patients using CBT or IPT while getting supervision in these modalities.
CBT and IPT are different. CBT puts an emphasis on the thought-feeling-behavior triangle while IPT focuses more on relationships. Someone who has tried one and has not benefited nevertheless may benefit from the other.
Working with your patients to choose what type of psychotherapy modality for depression they would like is particularly effective.
Finally, be aware of how the environment may be affecting your patient. School issues related to peers, learning style or disabilities, and organization have a major effect on teens. In this case, Paul is looking at his phone nightly, which may be affecting both his sleep and self-esteem. Family issues continue to play a key role.
Paul was referred for CBT therapy, which was moderately helpful. After a few months, sertraline was added with further improvement. A key element in fully resolving Paul’s depression was his becoming involved in the drama club, which gave him the chance to meet a group of peers who shared his interests.
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures. Email her at [email protected].
References
1. JAMA. 2007 Apr 18;297(15):1683-96.
2. Am J Psychiatry. 2017 May 1;174(5):430-7.
3. J Child Adolesc Psychopharmacol. 2018. doi: 10.1089/cap.2017.0174.
4. J Clin Child Adolesc Psychol. 2017 Jan-Feb;46(1):11-43.
Paul is 13-year-old male in seventh grade with a history of inattentive ADHD and a positive family history of depression and anxiety in his mother. He always has had a few friends, but recently they have not wanted to hang out with him; he feels like people are ignoring him. For the past 2 months, Paul’s mood has gotten very low. He feels sad and also bored because he is not enjoying anything anymore. He feels as though he is “a loser,” and as though nothing will ever get better. His grades have dropped. He has thoughts of wishing he were dead, although he has no specific plan and says he wouldn’t do it because he doesn’t want to hurt his parents. He is looking at his phone at night and gets to bed late, then doesn’t want to get up in the morning. He sleeps until noon on weekends. Appetite is increased. He doesn’t have energy to do things on the weekends.
Discussion
Paul clearly meets diagnostic criteria for depression. He feels sad and has lost pleasure in activities he used to enjoy. He has negative, hopeless thoughts, and vague thoughts of death although no specific plans. He has vegetative signs of depression with increased appetite and sleep; he likely has worse concentration than usual, given that his grades have dropped. Energy is low.
Meta-analyses have demonstrated the efficacy of SSRIs (fluoxetine, sertraline, citalopram, escitalopram) as well as venlafaxine, mirtazapine, and nefazodone with small to very small effect sizes.1 A large placebo effect is seen in many of these studies, correlating with the number of study sites – a feature of many industry-sponsored studies.
John Walkup, MD, a leading researcher on both medication and psychotherapeutic interventions in children’s mood disorders, has pointed out that the quality of industry-sponsored studies (vs. National Institute of Mental Health–sponsored studies) is likely lower, with more pressure to get in large numbers of patients in a short period of time, less trained investigators leading to less clear-cut diagnoses, and other sources of bias.2 This raises the question of whether we should weight NIMH-sponsored studies more heavily in meta-analyses.
A second factor to consider is the risk of harm, and a significant issue here is the question of whether suicidal ideation is increased among those patients taking SSRIs. Meta-analyses from the late 2000s, which balanced the number needed to treat vs. the number needed to harm, judged that for children under age 13 years, fluoxetine was the only antidepressant that was worth the cost-benefit ratio. However, in the past several years there has been a major improvement in the assessment of suicidal ideation in the form of the Columbia Suicide Severity Rating Scale, a standardized method of assessing the presence and significance of suicidal thoughts and behaviors. Studies that have used this assessment have found no significant increase in suicidal ideation with SSRIs vs. placebo.
The takeaway here is that the SSRIs can work, with fluoxetine, sertraline, and escitalopram leading the evidence, and that with refinements of the assessment they do not appear to increase the risk of suicidal ideation.3 Of course, it remains important to discuss this issue with families.
Psychotherapy is the other major treatment for depression. Cognitive behavioral therapy (CBT) and Interpersonal therapy (IPT) for adolescents show effectiveness in teens.4 Recent meta-analyses have gotten stronger through the use of stringent quality criteria and the inclusion of negative studies; these therapies continue to be considered well established. It is worthwhile to talk to therapists in your community to understand what type of treatment they offer. If you are hiring therapists to be embedded in your practice, look for people who have been trained in CBT or IPT. It is particularly helpful to know whether therapists have seen patients using CBT or IPT while getting supervision in these modalities.
CBT and IPT are different. CBT puts an emphasis on the thought-feeling-behavior triangle while IPT focuses more on relationships. Someone who has tried one and has not benefited nevertheless may benefit from the other.
Working with your patients to choose what type of psychotherapy modality for depression they would like is particularly effective.
Finally, be aware of how the environment may be affecting your patient. School issues related to peers, learning style or disabilities, and organization have a major effect on teens. In this case, Paul is looking at his phone nightly, which may be affecting both his sleep and self-esteem. Family issues continue to play a key role.
Paul was referred for CBT therapy, which was moderately helpful. After a few months, sertraline was added with further improvement. A key element in fully resolving Paul’s depression was his becoming involved in the drama club, which gave him the chance to meet a group of peers who shared his interests.
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures. Email her at [email protected].
References
1. JAMA. 2007 Apr 18;297(15):1683-96.
2. Am J Psychiatry. 2017 May 1;174(5):430-7.
3. J Child Adolesc Psychopharmacol. 2018. doi: 10.1089/cap.2017.0174.
4. J Clin Child Adolesc Psychol. 2017 Jan-Feb;46(1):11-43.
Paul is 13-year-old male in seventh grade with a history of inattentive ADHD and a positive family history of depression and anxiety in his mother. He always has had a few friends, but recently they have not wanted to hang out with him; he feels like people are ignoring him. For the past 2 months, Paul’s mood has gotten very low. He feels sad and also bored because he is not enjoying anything anymore. He feels as though he is “a loser,” and as though nothing will ever get better. His grades have dropped. He has thoughts of wishing he were dead, although he has no specific plan and says he wouldn’t do it because he doesn’t want to hurt his parents. He is looking at his phone at night and gets to bed late, then doesn’t want to get up in the morning. He sleeps until noon on weekends. Appetite is increased. He doesn’t have energy to do things on the weekends.
Discussion
Paul clearly meets diagnostic criteria for depression. He feels sad and has lost pleasure in activities he used to enjoy. He has negative, hopeless thoughts, and vague thoughts of death although no specific plans. He has vegetative signs of depression with increased appetite and sleep; he likely has worse concentration than usual, given that his grades have dropped. Energy is low.
Meta-analyses have demonstrated the efficacy of SSRIs (fluoxetine, sertraline, citalopram, escitalopram) as well as venlafaxine, mirtazapine, and nefazodone with small to very small effect sizes.1 A large placebo effect is seen in many of these studies, correlating with the number of study sites – a feature of many industry-sponsored studies.
John Walkup, MD, a leading researcher on both medication and psychotherapeutic interventions in children’s mood disorders, has pointed out that the quality of industry-sponsored studies (vs. National Institute of Mental Health–sponsored studies) is likely lower, with more pressure to get in large numbers of patients in a short period of time, less trained investigators leading to less clear-cut diagnoses, and other sources of bias.2 This raises the question of whether we should weight NIMH-sponsored studies more heavily in meta-analyses.
A second factor to consider is the risk of harm, and a significant issue here is the question of whether suicidal ideation is increased among those patients taking SSRIs. Meta-analyses from the late 2000s, which balanced the number needed to treat vs. the number needed to harm, judged that for children under age 13 years, fluoxetine was the only antidepressant that was worth the cost-benefit ratio. However, in the past several years there has been a major improvement in the assessment of suicidal ideation in the form of the Columbia Suicide Severity Rating Scale, a standardized method of assessing the presence and significance of suicidal thoughts and behaviors. Studies that have used this assessment have found no significant increase in suicidal ideation with SSRIs vs. placebo.
The takeaway here is that the SSRIs can work, with fluoxetine, sertraline, and escitalopram leading the evidence, and that with refinements of the assessment they do not appear to increase the risk of suicidal ideation.3 Of course, it remains important to discuss this issue with families.
Psychotherapy is the other major treatment for depression. Cognitive behavioral therapy (CBT) and Interpersonal therapy (IPT) for adolescents show effectiveness in teens.4 Recent meta-analyses have gotten stronger through the use of stringent quality criteria and the inclusion of negative studies; these therapies continue to be considered well established. It is worthwhile to talk to therapists in your community to understand what type of treatment they offer. If you are hiring therapists to be embedded in your practice, look for people who have been trained in CBT or IPT. It is particularly helpful to know whether therapists have seen patients using CBT or IPT while getting supervision in these modalities.
CBT and IPT are different. CBT puts an emphasis on the thought-feeling-behavior triangle while IPT focuses more on relationships. Someone who has tried one and has not benefited nevertheless may benefit from the other.
Working with your patients to choose what type of psychotherapy modality for depression they would like is particularly effective.
Finally, be aware of how the environment may be affecting your patient. School issues related to peers, learning style or disabilities, and organization have a major effect on teens. In this case, Paul is looking at his phone nightly, which may be affecting both his sleep and self-esteem. Family issues continue to play a key role.
Paul was referred for CBT therapy, which was moderately helpful. After a few months, sertraline was added with further improvement. A key element in fully resolving Paul’s depression was his becoming involved in the drama club, which gave him the chance to meet a group of peers who shared his interests.
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures. Email her at [email protected].
References
1. JAMA. 2007 Apr 18;297(15):1683-96.
2. Am J Psychiatry. 2017 May 1;174(5):430-7.
3. J Child Adolesc Psychopharmacol. 2018. doi: 10.1089/cap.2017.0174.
4. J Clin Child Adolesc Psychol. 2017 Jan-Feb;46(1):11-43.
Mindfulness skill can help in parenting
Behavioral parent management training (PMT), which teaches parents concrete skills to increase their attention to positive behavior and to plan for their response to undesired behavior, has abundant evidence for success for many challenging child behaviors. But sometimes parents have a hard time managing their own emotional responses in the often highly triggering situation of family conflict. Mindfulness has the potential to provide a complement to the PMT skills. Studies are beginning to explore these possibilities.
Case summary
Zoe is a bright 5-year-old who has been “strong willed” and shown intense emotional responses since early in life. The usual 2-year-old temper tantrums increased over time. She has outbursts of yelling, kicking, and hitting, especially with transitions. Her parents tried behavioral parent training, but found it frustrating. If Zoe has been yelling and hitting earlier in the day, her mother feels hurt and angry and can’t bring herself to pay warm attention when Zoe is doing better. When Zoe refuses to pick up her room, her father is flooded with thoughts about his own father hitting him for the slightest disrespect. He thinks that he is a bad, weak father, and sometimes “sees red” and ends up yelling at Zoe instead of putting into place a calm consequence.
Discussion
Mindfulness is defined by Jon Kabat-Zinn as “paying attention in a particular way – on purpose, in the present moment, and nonjudgmentally.” A central feature of mindfulness is strengthening the ability to focus our attention. We learn to pay attention to aspects of the present moment, be that breathing, the sensations in our body, or the experiences of our senses. Often the first skill in behavioral training methods is getting parents to pay attention to their children by participating in child-led play or spending attentive time with older children. This means attending to what the child is doing or talking about rather than jumping in and taking over with suggestions, instructions, or judgments. This meshes very well with this central aspect of mindfulness.
As we practice paying attention, we observe that the mind naturally jumps around from what we mean to be attending to, to a host of distractions, worries, plans, memories, thoughts, and emotions. Mindfulness encourages practitioners to notice these thoughts, to avoid criticizing or judging oneself for becoming involved with these, but instead gently lead the mind back to what you had intended to focus on. This observation of the mind’s activity gives the mindfulness practitioner a bit of space from the thought or emotion itself. We are encouraged to name the thought or emotional processes we notice: “I am worrying, I am planning, I am remembering.”
In the heat of a difficult moment with the child, parents often are flooded with intense emotions (such as anger, fear, anxiety, panic, despair) and thoughts (such as “If my child keeps acting this way he is going to go to jail when he grows up,” “I am a terrible parent,” “Why is my child doing this to me?” or “He is just like his father”). These emotions and thoughts can drive intense, impulsive responses from the parents. As they practice mindfulness, they can gain the ability to observe themselves having these thoughts; observe harsh judgments of themselves or their children or their partners; have some space from them; and realize they may change in a few minutes or realize they may be painful but don’t necessarily have to spur impulsive action. In that moment, parents can give themselves time and space to think through possible actions, and then choose one.
From a behavioral parenting standpoint, we know that parents and humans often react intensely to negative behaviors and inadvertently make them worse with intense emotional reactivity. We want parents to have a plan about how they will respond, to remain calm in the moment, and then put the plan in place. Mindfulness may enhance parents’ ability to notice their own responses and have the space to remember what the plan was and then put it into place. It also can give them space to consider what the child might be experiencing and respond in light of this awareness. This ability does require a significant amount of mindfulness practice.
The combination of mindfulness and parenting is just beginning to be studied in research trials using a range of study designs. Some of these programs have looked at the effect of mindfulness courses, especially mindfulness-based stress reduction without any specific parenting content or indices of parent stress and child behavior. Others have looked at programs which add mindfulness to standard behavioral parenting programs, and still others are specific mindfulness/parenting programs. So far, many of these studies are quasi-experimental in nature. A recent systematic review by Townshend et al. found seven randomized controlled trials of low to moderate quality with some suggestion of ability to decrease parental stress and ADHD symptoms (JBI Database System Rev Implement Rep. 2016 Mar;14[3]:139-80). There is a clear need for randomized controlled trials with larger sample sizes.
While we may not have specific, highly evidence-based mindful parenting programs available, individuals with experience in yoga, meditation, mindfulness, dialectical behavioral therapy, and acceptance and commitment therapy can be encouraged to bring these skills to bear as parents.
Zoe’s parents had pursued outside mindfulness programs. Mindfulness concepts were brought into a standard parenting program. Her parents were encouraged to engage in child-led play with Zoe in a mindful way, fully attending to her actions and experience. Zoe’s parents also were encouraged to observe their own emotional reactions and thoughts in stressful moments and to take a breathing space before taking action.
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures. Email her at [email protected].
Resources
“Mindful Parenting” (New York: Norton & Co., 2015).
“Integrating mindfulness with parent training: Effects of the mindfulness-enhanced strengthening families program” (Dev Psychol. 2015;51[1]:26-35).
“Everyday blessings: The inner work of mindful parenting,” (New York: Hyperion, 1997).
Behavioral parent management training (PMT), which teaches parents concrete skills to increase their attention to positive behavior and to plan for their response to undesired behavior, has abundant evidence for success for many challenging child behaviors. But sometimes parents have a hard time managing their own emotional responses in the often highly triggering situation of family conflict. Mindfulness has the potential to provide a complement to the PMT skills. Studies are beginning to explore these possibilities.
Case summary
Zoe is a bright 5-year-old who has been “strong willed” and shown intense emotional responses since early in life. The usual 2-year-old temper tantrums increased over time. She has outbursts of yelling, kicking, and hitting, especially with transitions. Her parents tried behavioral parent training, but found it frustrating. If Zoe has been yelling and hitting earlier in the day, her mother feels hurt and angry and can’t bring herself to pay warm attention when Zoe is doing better. When Zoe refuses to pick up her room, her father is flooded with thoughts about his own father hitting him for the slightest disrespect. He thinks that he is a bad, weak father, and sometimes “sees red” and ends up yelling at Zoe instead of putting into place a calm consequence.
Discussion
Mindfulness is defined by Jon Kabat-Zinn as “paying attention in a particular way – on purpose, in the present moment, and nonjudgmentally.” A central feature of mindfulness is strengthening the ability to focus our attention. We learn to pay attention to aspects of the present moment, be that breathing, the sensations in our body, or the experiences of our senses. Often the first skill in behavioral training methods is getting parents to pay attention to their children by participating in child-led play or spending attentive time with older children. This means attending to what the child is doing or talking about rather than jumping in and taking over with suggestions, instructions, or judgments. This meshes very well with this central aspect of mindfulness.
As we practice paying attention, we observe that the mind naturally jumps around from what we mean to be attending to, to a host of distractions, worries, plans, memories, thoughts, and emotions. Mindfulness encourages practitioners to notice these thoughts, to avoid criticizing or judging oneself for becoming involved with these, but instead gently lead the mind back to what you had intended to focus on. This observation of the mind’s activity gives the mindfulness practitioner a bit of space from the thought or emotion itself. We are encouraged to name the thought or emotional processes we notice: “I am worrying, I am planning, I am remembering.”
In the heat of a difficult moment with the child, parents often are flooded with intense emotions (such as anger, fear, anxiety, panic, despair) and thoughts (such as “If my child keeps acting this way he is going to go to jail when he grows up,” “I am a terrible parent,” “Why is my child doing this to me?” or “He is just like his father”). These emotions and thoughts can drive intense, impulsive responses from the parents. As they practice mindfulness, they can gain the ability to observe themselves having these thoughts; observe harsh judgments of themselves or their children or their partners; have some space from them; and realize they may change in a few minutes or realize they may be painful but don’t necessarily have to spur impulsive action. In that moment, parents can give themselves time and space to think through possible actions, and then choose one.
From a behavioral parenting standpoint, we know that parents and humans often react intensely to negative behaviors and inadvertently make them worse with intense emotional reactivity. We want parents to have a plan about how they will respond, to remain calm in the moment, and then put the plan in place. Mindfulness may enhance parents’ ability to notice their own responses and have the space to remember what the plan was and then put it into place. It also can give them space to consider what the child might be experiencing and respond in light of this awareness. This ability does require a significant amount of mindfulness practice.
The combination of mindfulness and parenting is just beginning to be studied in research trials using a range of study designs. Some of these programs have looked at the effect of mindfulness courses, especially mindfulness-based stress reduction without any specific parenting content or indices of parent stress and child behavior. Others have looked at programs which add mindfulness to standard behavioral parenting programs, and still others are specific mindfulness/parenting programs. So far, many of these studies are quasi-experimental in nature. A recent systematic review by Townshend et al. found seven randomized controlled trials of low to moderate quality with some suggestion of ability to decrease parental stress and ADHD symptoms (JBI Database System Rev Implement Rep. 2016 Mar;14[3]:139-80). There is a clear need for randomized controlled trials with larger sample sizes.
While we may not have specific, highly evidence-based mindful parenting programs available, individuals with experience in yoga, meditation, mindfulness, dialectical behavioral therapy, and acceptance and commitment therapy can be encouraged to bring these skills to bear as parents.
Zoe’s parents had pursued outside mindfulness programs. Mindfulness concepts were brought into a standard parenting program. Her parents were encouraged to engage in child-led play with Zoe in a mindful way, fully attending to her actions and experience. Zoe’s parents also were encouraged to observe their own emotional reactions and thoughts in stressful moments and to take a breathing space before taking action.
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures. Email her at [email protected].
Resources
“Mindful Parenting” (New York: Norton & Co., 2015).
“Integrating mindfulness with parent training: Effects of the mindfulness-enhanced strengthening families program” (Dev Psychol. 2015;51[1]:26-35).
“Everyday blessings: The inner work of mindful parenting,” (New York: Hyperion, 1997).
Behavioral parent management training (PMT), which teaches parents concrete skills to increase their attention to positive behavior and to plan for their response to undesired behavior, has abundant evidence for success for many challenging child behaviors. But sometimes parents have a hard time managing their own emotional responses in the often highly triggering situation of family conflict. Mindfulness has the potential to provide a complement to the PMT skills. Studies are beginning to explore these possibilities.
Case summary
Zoe is a bright 5-year-old who has been “strong willed” and shown intense emotional responses since early in life. The usual 2-year-old temper tantrums increased over time. She has outbursts of yelling, kicking, and hitting, especially with transitions. Her parents tried behavioral parent training, but found it frustrating. If Zoe has been yelling and hitting earlier in the day, her mother feels hurt and angry and can’t bring herself to pay warm attention when Zoe is doing better. When Zoe refuses to pick up her room, her father is flooded with thoughts about his own father hitting him for the slightest disrespect. He thinks that he is a bad, weak father, and sometimes “sees red” and ends up yelling at Zoe instead of putting into place a calm consequence.
Discussion
Mindfulness is defined by Jon Kabat-Zinn as “paying attention in a particular way – on purpose, in the present moment, and nonjudgmentally.” A central feature of mindfulness is strengthening the ability to focus our attention. We learn to pay attention to aspects of the present moment, be that breathing, the sensations in our body, or the experiences of our senses. Often the first skill in behavioral training methods is getting parents to pay attention to their children by participating in child-led play or spending attentive time with older children. This means attending to what the child is doing or talking about rather than jumping in and taking over with suggestions, instructions, or judgments. This meshes very well with this central aspect of mindfulness.
As we practice paying attention, we observe that the mind naturally jumps around from what we mean to be attending to, to a host of distractions, worries, plans, memories, thoughts, and emotions. Mindfulness encourages practitioners to notice these thoughts, to avoid criticizing or judging oneself for becoming involved with these, but instead gently lead the mind back to what you had intended to focus on. This observation of the mind’s activity gives the mindfulness practitioner a bit of space from the thought or emotion itself. We are encouraged to name the thought or emotional processes we notice: “I am worrying, I am planning, I am remembering.”
In the heat of a difficult moment with the child, parents often are flooded with intense emotions (such as anger, fear, anxiety, panic, despair) and thoughts (such as “If my child keeps acting this way he is going to go to jail when he grows up,” “I am a terrible parent,” “Why is my child doing this to me?” or “He is just like his father”). These emotions and thoughts can drive intense, impulsive responses from the parents. As they practice mindfulness, they can gain the ability to observe themselves having these thoughts; observe harsh judgments of themselves or their children or their partners; have some space from them; and realize they may change in a few minutes or realize they may be painful but don’t necessarily have to spur impulsive action. In that moment, parents can give themselves time and space to think through possible actions, and then choose one.
From a behavioral parenting standpoint, we know that parents and humans often react intensely to negative behaviors and inadvertently make them worse with intense emotional reactivity. We want parents to have a plan about how they will respond, to remain calm in the moment, and then put the plan in place. Mindfulness may enhance parents’ ability to notice their own responses and have the space to remember what the plan was and then put it into place. It also can give them space to consider what the child might be experiencing and respond in light of this awareness. This ability does require a significant amount of mindfulness practice.
The combination of mindfulness and parenting is just beginning to be studied in research trials using a range of study designs. Some of these programs have looked at the effect of mindfulness courses, especially mindfulness-based stress reduction without any specific parenting content or indices of parent stress and child behavior. Others have looked at programs which add mindfulness to standard behavioral parenting programs, and still others are specific mindfulness/parenting programs. So far, many of these studies are quasi-experimental in nature. A recent systematic review by Townshend et al. found seven randomized controlled trials of low to moderate quality with some suggestion of ability to decrease parental stress and ADHD symptoms (JBI Database System Rev Implement Rep. 2016 Mar;14[3]:139-80). There is a clear need for randomized controlled trials with larger sample sizes.
While we may not have specific, highly evidence-based mindful parenting programs available, individuals with experience in yoga, meditation, mindfulness, dialectical behavioral therapy, and acceptance and commitment therapy can be encouraged to bring these skills to bear as parents.
Zoe’s parents had pursued outside mindfulness programs. Mindfulness concepts were brought into a standard parenting program. Her parents were encouraged to engage in child-led play with Zoe in a mindful way, fully attending to her actions and experience. Zoe’s parents also were encouraged to observe their own emotional reactions and thoughts in stressful moments and to take a breathing space before taking action.
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures. Email her at [email protected].
Resources
“Mindful Parenting” (New York: Norton & Co., 2015).
“Integrating mindfulness with parent training: Effects of the mindfulness-enhanced strengthening families program” (Dev Psychol. 2015;51[1]:26-35).
“Everyday blessings: The inner work of mindful parenting,” (New York: Hyperion, 1997).
ADHD and the role of wellness
ADHD is a very common disorder with several medication treatment options. There also are wellness and parenting strategies that can address aspects of the challenges of ADHD that are not perfectly covered by medication, such as excess symptoms, times of day that are not covered, or oppositional behavior that often develops secondarily.
Case summary
James is a 6-year-old boy who has been an active, high-energy child since preschool. He has had difficulty with wiggling around in kindergarten and preschool, talking excessively, and being unable to follow directions and pay attention. He is impulsive, disruptive, and frequently doesn’t listen to what his parents tell him to do. Parents and teachers rank him in the clinical range for hyperactivity, impulsivity, and attention problems on standardized rating scales.
Discussion
When we first discuss a new diagnosis with a family, we have the opportunity to shape the family’s expectations about that diagnosis and how it should be addressed. When I discuss ADHD with a new family, I want them to understand the symptoms of inattention, hyperactivity, and impulsiveness, and that these symptoms are not the child’s fault, but rather related to the way his brain is connected. At the same time, I also emphasize that these connections are not entirely fixed, that they mature over time, and that they are affected by experiences in life. In particular, I stress that positive experiences and wellness activities can influence the brain in a positive way. While, of course, I discuss the range of medications that can address these issues, I also deal with wellness in the treatment plan.
Exercise
Studies in humans and animals have provided background evidence that exercise increases the release of neurotransmitters such as dopamine and norepinephrine that are important in the pathophysiology of ADHD. Cerillo-Urbina et al. did a meta-analysis in 2015 of randomized controlled trials and found medium to large effect sizes for a variety of physical activity programs with respect to attention, hyperactivity, and impulsivity, although the study quality was generally low.1 Clearly we need additional more rigorous studies, but given the positive direction of outcomes, the lack of side effects, and the many other positive effects of exercise, it does not seem too soon to add exercise as a prescription for our patients with ADHD. I review this evidence with families, ask them about physical activity they like, and ask if they are willing to work toward an hour of exercise a day.
Sleep
Many children with ADHD have problems with sleep even before they start on stimulant medications, which can further affect sleep. Addressing sleep early on can improve ADHD symptoms, as well as help parents change or avoid patterns like having children fall asleep to the sound of a television. Brief sleep hygiene and cognitive-behavioral therapy interventions over three visits were demonstrated in a randomized controlled trial by Hisock et al. to improve ADHD symptoms and behavioral function.2 These psychosocial interventions clearly are the first line in addressing sleep problems in ADHD, and can benefit even sleep problems connected to medication.
Parent training
Treatment plan
1. Have the child exercise 1 hour every day. Have fun!
2. Establish a nightly bedtime routine, with a bath at 7:30 p.m., brushing of teeth, a story, and lights out at 8 with no TV in the room.
3. Check out the CHADD website for Parent to Parent.
4. Start a trial of stimulant medication.
5. Return in 2 weeks to monitor these interventions, adjust goals, and adjust medications.
When to refer
Many parents will be able to put such a plan in motion with your support and that of other parents. If they are struggling, therapists, psychologists, and psychiatrists trained in motivational and behavioral methods can provide more individualized parent training. Also consider whether the parents themselves may have ADHD and could use referral and treatment.
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures.
References
1. Child Care Health Dev. 2015 Nov;41(6):779-88.
2. BMJ. 2015. doi: 10.1136/bmj.h68.
ADHD is a very common disorder with several medication treatment options. There also are wellness and parenting strategies that can address aspects of the challenges of ADHD that are not perfectly covered by medication, such as excess symptoms, times of day that are not covered, or oppositional behavior that often develops secondarily.
Case summary
James is a 6-year-old boy who has been an active, high-energy child since preschool. He has had difficulty with wiggling around in kindergarten and preschool, talking excessively, and being unable to follow directions and pay attention. He is impulsive, disruptive, and frequently doesn’t listen to what his parents tell him to do. Parents and teachers rank him in the clinical range for hyperactivity, impulsivity, and attention problems on standardized rating scales.
Discussion
When we first discuss a new diagnosis with a family, we have the opportunity to shape the family’s expectations about that diagnosis and how it should be addressed. When I discuss ADHD with a new family, I want them to understand the symptoms of inattention, hyperactivity, and impulsiveness, and that these symptoms are not the child’s fault, but rather related to the way his brain is connected. At the same time, I also emphasize that these connections are not entirely fixed, that they mature over time, and that they are affected by experiences in life. In particular, I stress that positive experiences and wellness activities can influence the brain in a positive way. While, of course, I discuss the range of medications that can address these issues, I also deal with wellness in the treatment plan.
Exercise
Studies in humans and animals have provided background evidence that exercise increases the release of neurotransmitters such as dopamine and norepinephrine that are important in the pathophysiology of ADHD. Cerillo-Urbina et al. did a meta-analysis in 2015 of randomized controlled trials and found medium to large effect sizes for a variety of physical activity programs with respect to attention, hyperactivity, and impulsivity, although the study quality was generally low.1 Clearly we need additional more rigorous studies, but given the positive direction of outcomes, the lack of side effects, and the many other positive effects of exercise, it does not seem too soon to add exercise as a prescription for our patients with ADHD. I review this evidence with families, ask them about physical activity they like, and ask if they are willing to work toward an hour of exercise a day.
Sleep
Many children with ADHD have problems with sleep even before they start on stimulant medications, which can further affect sleep. Addressing sleep early on can improve ADHD symptoms, as well as help parents change or avoid patterns like having children fall asleep to the sound of a television. Brief sleep hygiene and cognitive-behavioral therapy interventions over three visits were demonstrated in a randomized controlled trial by Hisock et al. to improve ADHD symptoms and behavioral function.2 These psychosocial interventions clearly are the first line in addressing sleep problems in ADHD, and can benefit even sleep problems connected to medication.
Parent training
Treatment plan
1. Have the child exercise 1 hour every day. Have fun!
2. Establish a nightly bedtime routine, with a bath at 7:30 p.m., brushing of teeth, a story, and lights out at 8 with no TV in the room.
3. Check out the CHADD website for Parent to Parent.
4. Start a trial of stimulant medication.
5. Return in 2 weeks to monitor these interventions, adjust goals, and adjust medications.
When to refer
Many parents will be able to put such a plan in motion with your support and that of other parents. If they are struggling, therapists, psychologists, and psychiatrists trained in motivational and behavioral methods can provide more individualized parent training. Also consider whether the parents themselves may have ADHD and could use referral and treatment.
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures.
References
1. Child Care Health Dev. 2015 Nov;41(6):779-88.
2. BMJ. 2015. doi: 10.1136/bmj.h68.
ADHD is a very common disorder with several medication treatment options. There also are wellness and parenting strategies that can address aspects of the challenges of ADHD that are not perfectly covered by medication, such as excess symptoms, times of day that are not covered, or oppositional behavior that often develops secondarily.
Case summary
James is a 6-year-old boy who has been an active, high-energy child since preschool. He has had difficulty with wiggling around in kindergarten and preschool, talking excessively, and being unable to follow directions and pay attention. He is impulsive, disruptive, and frequently doesn’t listen to what his parents tell him to do. Parents and teachers rank him in the clinical range for hyperactivity, impulsivity, and attention problems on standardized rating scales.
Discussion
When we first discuss a new diagnosis with a family, we have the opportunity to shape the family’s expectations about that diagnosis and how it should be addressed. When I discuss ADHD with a new family, I want them to understand the symptoms of inattention, hyperactivity, and impulsiveness, and that these symptoms are not the child’s fault, but rather related to the way his brain is connected. At the same time, I also emphasize that these connections are not entirely fixed, that they mature over time, and that they are affected by experiences in life. In particular, I stress that positive experiences and wellness activities can influence the brain in a positive way. While, of course, I discuss the range of medications that can address these issues, I also deal with wellness in the treatment plan.
Exercise
Studies in humans and animals have provided background evidence that exercise increases the release of neurotransmitters such as dopamine and norepinephrine that are important in the pathophysiology of ADHD. Cerillo-Urbina et al. did a meta-analysis in 2015 of randomized controlled trials and found medium to large effect sizes for a variety of physical activity programs with respect to attention, hyperactivity, and impulsivity, although the study quality was generally low.1 Clearly we need additional more rigorous studies, but given the positive direction of outcomes, the lack of side effects, and the many other positive effects of exercise, it does not seem too soon to add exercise as a prescription for our patients with ADHD. I review this evidence with families, ask them about physical activity they like, and ask if they are willing to work toward an hour of exercise a day.
Sleep
Many children with ADHD have problems with sleep even before they start on stimulant medications, which can further affect sleep. Addressing sleep early on can improve ADHD symptoms, as well as help parents change or avoid patterns like having children fall asleep to the sound of a television. Brief sleep hygiene and cognitive-behavioral therapy interventions over three visits were demonstrated in a randomized controlled trial by Hisock et al. to improve ADHD symptoms and behavioral function.2 These psychosocial interventions clearly are the first line in addressing sleep problems in ADHD, and can benefit even sleep problems connected to medication.
Parent training
Treatment plan
1. Have the child exercise 1 hour every day. Have fun!
2. Establish a nightly bedtime routine, with a bath at 7:30 p.m., brushing of teeth, a story, and lights out at 8 with no TV in the room.
3. Check out the CHADD website for Parent to Parent.
4. Start a trial of stimulant medication.
5. Return in 2 weeks to monitor these interventions, adjust goals, and adjust medications.
When to refer
Many parents will be able to put such a plan in motion with your support and that of other parents. If they are struggling, therapists, psychologists, and psychiatrists trained in motivational and behavioral methods can provide more individualized parent training. Also consider whether the parents themselves may have ADHD and could use referral and treatment.
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures.
References
1. Child Care Health Dev. 2015 Nov;41(6):779-88.
2. BMJ. 2015. doi: 10.1136/bmj.h68.
Dealing with stealing
A 7-year-old boy, Jacob, with a history of ADHD and frequent impulsive behavior, takes a calculator from another child’s desk. About 3 months before, he had come home after taking another child’s action figure. His parents have been working on parent training for ADHD, but don’t know how to respond to this behavior and are very upset at their son.
Discussion
Stealing is an issue of serious concern to parents. To understand how common this is in younger children, researchers need to rely on the reports of parents and teachers, which may be underestimates of the problem because stealing is usually a hidden or covert behavior. Research on older youth can include anonymous self-reports.
Stealing and dishonesty are such disappointing behaviors to adults that it is tempting to resort to harsh punishments, long lectures, or harshly disparaging words. But these kinds of punishments backfire. The goal is an overall positive relationship and a calm consistent response to undesired behaviors. Parents often need support in how to be positive with a child who is frustrating them. Taking 15 minutes a day to do some activity a child likes – playing catch, playing a board game, cooking together, or doing crafts – all while noticing the positive things a child is doing rather than teaching, criticizing, or grilling a child on what happened in school sets a happier tone to the relationship, which is a background for any discipline. Jacob’s parents had already been working on this through their parent training class, but it helped to encourage them to keep doing this.
Because of the covert nature of stealing, it is sometimes hard to know where an item has come from, and children are likely to lie about this, saying that a friend gave it to them or they found it. To avoid this, when working with a child who has been stealing, the expectation should be made clear in advance that it is the child’s responsibility to avoid suspicion by having nothing in his possession that is not known to the adult. It is important to avoid back and forth arguments. The adult’s decision is final. With frequent stealing, it is helpful to make an inventory of the child’s possessions as a baseline.
When it comes to consequences, the important thing is to be sure that they are consistent and predictable. Returning an item to the owner and apologizing are logical. Another excellent type of consequence for behaviors that happen rarely is an extra work chore of about half an hour.
So a parent might say something like, “Jacob, we know that a stealing monster has been getting you, and we want to fight against him. I have made up a list of everything you have right now, and it is going to be your responsibility to make sure you don’t bring home anything else. So that means even if you find something or someone gives you something, you shouldn’t take it. If I find anything that isn’t on the list, you are going to have to return it to the person it belongs to and apologize, and then do an extra work chore for half an hour. A habit can be hard to change, but I know we can do it together. Let’s go play catch.” Then when the child is found with something in his possession, the adult should remain calm, avoid a lecture, and just say something like, “Jacob, this is something that doesn’t belong to you. You need to return it to the person it belongs to, and you have an extra half hour of raking leaves. No TV until the leaves are done.” The parent also should be alert to opportunities to attend to or praise behaviors like the child saving money to spend on things he wants, or asking to borrow things from other family members rather than just taking them.
Stealing can be a tough problem and often goes along with other rule-breaking behavior. If a parent is struggling to stay calm and find the positive, referral to group or individual parent training through programs like the Incredible Years or Triple P can give a parent the chance to learn and practice skills step by step.
As children enter their teen years, stealing becomes much more common, and can be reinforced by peers as well as by the action itself. The same principles of finding positive activities, continuing positive interactions with parents, and predictable and consistent – rather than harsh – consequences continue to apply, but may require additional supports. Larger programs such as Multisystemic Therapy, which works with families, peers, and communities, have been demonstrated to be effective for young people with juvenile delinquency.
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures.
Resource
Stealing, in “Children’s needs III: Development, prevention, and intervention,” (Washington: National Association of School Psychologists, 2006, pp. 171-83).
A 7-year-old boy, Jacob, with a history of ADHD and frequent impulsive behavior, takes a calculator from another child’s desk. About 3 months before, he had come home after taking another child’s action figure. His parents have been working on parent training for ADHD, but don’t know how to respond to this behavior and are very upset at their son.
Discussion
Stealing is an issue of serious concern to parents. To understand how common this is in younger children, researchers need to rely on the reports of parents and teachers, which may be underestimates of the problem because stealing is usually a hidden or covert behavior. Research on older youth can include anonymous self-reports.
Stealing and dishonesty are such disappointing behaviors to adults that it is tempting to resort to harsh punishments, long lectures, or harshly disparaging words. But these kinds of punishments backfire. The goal is an overall positive relationship and a calm consistent response to undesired behaviors. Parents often need support in how to be positive with a child who is frustrating them. Taking 15 minutes a day to do some activity a child likes – playing catch, playing a board game, cooking together, or doing crafts – all while noticing the positive things a child is doing rather than teaching, criticizing, or grilling a child on what happened in school sets a happier tone to the relationship, which is a background for any discipline. Jacob’s parents had already been working on this through their parent training class, but it helped to encourage them to keep doing this.
Because of the covert nature of stealing, it is sometimes hard to know where an item has come from, and children are likely to lie about this, saying that a friend gave it to them or they found it. To avoid this, when working with a child who has been stealing, the expectation should be made clear in advance that it is the child’s responsibility to avoid suspicion by having nothing in his possession that is not known to the adult. It is important to avoid back and forth arguments. The adult’s decision is final. With frequent stealing, it is helpful to make an inventory of the child’s possessions as a baseline.
When it comes to consequences, the important thing is to be sure that they are consistent and predictable. Returning an item to the owner and apologizing are logical. Another excellent type of consequence for behaviors that happen rarely is an extra work chore of about half an hour.
So a parent might say something like, “Jacob, we know that a stealing monster has been getting you, and we want to fight against him. I have made up a list of everything you have right now, and it is going to be your responsibility to make sure you don’t bring home anything else. So that means even if you find something or someone gives you something, you shouldn’t take it. If I find anything that isn’t on the list, you are going to have to return it to the person it belongs to and apologize, and then do an extra work chore for half an hour. A habit can be hard to change, but I know we can do it together. Let’s go play catch.” Then when the child is found with something in his possession, the adult should remain calm, avoid a lecture, and just say something like, “Jacob, this is something that doesn’t belong to you. You need to return it to the person it belongs to, and you have an extra half hour of raking leaves. No TV until the leaves are done.” The parent also should be alert to opportunities to attend to or praise behaviors like the child saving money to spend on things he wants, or asking to borrow things from other family members rather than just taking them.
Stealing can be a tough problem and often goes along with other rule-breaking behavior. If a parent is struggling to stay calm and find the positive, referral to group or individual parent training through programs like the Incredible Years or Triple P can give a parent the chance to learn and practice skills step by step.
As children enter their teen years, stealing becomes much more common, and can be reinforced by peers as well as by the action itself. The same principles of finding positive activities, continuing positive interactions with parents, and predictable and consistent – rather than harsh – consequences continue to apply, but may require additional supports. Larger programs such as Multisystemic Therapy, which works with families, peers, and communities, have been demonstrated to be effective for young people with juvenile delinquency.
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures.
Resource
Stealing, in “Children’s needs III: Development, prevention, and intervention,” (Washington: National Association of School Psychologists, 2006, pp. 171-83).
A 7-year-old boy, Jacob, with a history of ADHD and frequent impulsive behavior, takes a calculator from another child’s desk. About 3 months before, he had come home after taking another child’s action figure. His parents have been working on parent training for ADHD, but don’t know how to respond to this behavior and are very upset at their son.
Discussion
Stealing is an issue of serious concern to parents. To understand how common this is in younger children, researchers need to rely on the reports of parents and teachers, which may be underestimates of the problem because stealing is usually a hidden or covert behavior. Research on older youth can include anonymous self-reports.
Stealing and dishonesty are such disappointing behaviors to adults that it is tempting to resort to harsh punishments, long lectures, or harshly disparaging words. But these kinds of punishments backfire. The goal is an overall positive relationship and a calm consistent response to undesired behaviors. Parents often need support in how to be positive with a child who is frustrating them. Taking 15 minutes a day to do some activity a child likes – playing catch, playing a board game, cooking together, or doing crafts – all while noticing the positive things a child is doing rather than teaching, criticizing, or grilling a child on what happened in school sets a happier tone to the relationship, which is a background for any discipline. Jacob’s parents had already been working on this through their parent training class, but it helped to encourage them to keep doing this.
Because of the covert nature of stealing, it is sometimes hard to know where an item has come from, and children are likely to lie about this, saying that a friend gave it to them or they found it. To avoid this, when working with a child who has been stealing, the expectation should be made clear in advance that it is the child’s responsibility to avoid suspicion by having nothing in his possession that is not known to the adult. It is important to avoid back and forth arguments. The adult’s decision is final. With frequent stealing, it is helpful to make an inventory of the child’s possessions as a baseline.
When it comes to consequences, the important thing is to be sure that they are consistent and predictable. Returning an item to the owner and apologizing are logical. Another excellent type of consequence for behaviors that happen rarely is an extra work chore of about half an hour.
So a parent might say something like, “Jacob, we know that a stealing monster has been getting you, and we want to fight against him. I have made up a list of everything you have right now, and it is going to be your responsibility to make sure you don’t bring home anything else. So that means even if you find something or someone gives you something, you shouldn’t take it. If I find anything that isn’t on the list, you are going to have to return it to the person it belongs to and apologize, and then do an extra work chore for half an hour. A habit can be hard to change, but I know we can do it together. Let’s go play catch.” Then when the child is found with something in his possession, the adult should remain calm, avoid a lecture, and just say something like, “Jacob, this is something that doesn’t belong to you. You need to return it to the person it belongs to, and you have an extra half hour of raking leaves. No TV until the leaves are done.” The parent also should be alert to opportunities to attend to or praise behaviors like the child saving money to spend on things he wants, or asking to borrow things from other family members rather than just taking them.
Stealing can be a tough problem and often goes along with other rule-breaking behavior. If a parent is struggling to stay calm and find the positive, referral to group or individual parent training through programs like the Incredible Years or Triple P can give a parent the chance to learn and practice skills step by step.
As children enter their teen years, stealing becomes much more common, and can be reinforced by peers as well as by the action itself. The same principles of finding positive activities, continuing positive interactions with parents, and predictable and consistent – rather than harsh – consequences continue to apply, but may require additional supports. Larger programs such as Multisystemic Therapy, which works with families, peers, and communities, have been demonstrated to be effective for young people with juvenile delinquency.
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures.
Resource
Stealing, in “Children’s needs III: Development, prevention, and intervention,” (Washington: National Association of School Psychologists, 2006, pp. 171-83).
Postelection anxiety
Introduction
Since the election, many of the psychiatrists and psychologists in our office have reported a wave of anxiety among our patients. These fears have sometimes come from watching television commercials that highlight the faults of the other party or from watching the debates themselves. Children have reported fears of a nuclear war, of being taken away from family, or of being harmed or killed because of racial, religious, immigration, disability, gender, or sexual orientation status. In addition, some children are reporting remarks by peers.
Case summary
Discussion
How can we support our patients and their parents in responding to this surge in anxiety? First, we can reiterate the central importance of family. What the family models in values, behavior, and coping is central to how children respond to stress and winning and losing. Parents who manage their own emotions model how to cope with both victory and defeat, demonstrating appropriate celebration as well as grief and anger. Coping strategies for parents can include reaching out to supports from family and friends, using relaxation strategies, and then planning practical next steps to take.
Parents should reassure their children that they are there to keep their children safe. Modeling self-care and keeping the family routine as stable as possible is a powerful source of this sense of safety. As always, parents should think about what their children are consuming in the way of electronics.
In talking to children, listening is a first step. Help children find the words for what they are feeling. Consider your own words and the rhetoric of the election. Withering scorn of the other side has become increasingly common and not only damages our ability to understand other points of view and resolve conflicts but is also leading to intense anxiety in our children. The extreme nature of some of these words has led some children to believe that complete disaster is imminent should the other side win. Try to avoid using words that intensify fear. Acknowledge the feelings that children have, but provide reassurance of safety and hope.
Using the principles of cognitive-behavioral therapy, a therapist or parent can help a child think through how their thoughts are connected with feelings and behavior. When we are fearful, we often think that the absolute worst is going to happen, or we imagine that we definitely know the future. Sometimes an extreme thought can magnify feelings to the point that constructive behavior is blocked. A therapist might acknowledge feelings, but also help enlarge the child’s perspective. There are many reasons why people voted for or against candidates, and we don’t know everything about them just because of how they chose to vote. Discussing the three branches of government and the system of checks and balances that bring many people together to think over a problem can help a child see that the government is more than just one person. Parents or therapists can talk about protections in the Constitution such as freedom of the press, which allows us to be informed of what is going on. Parents might want to talk about the reality that we are one country, and that the vast majority of people on both sides share many, if not all, values.
Helping a child consider other perspectives isn’t saying that there are no reasons at all for anxiety, but that there are many possibilities for the future, and that a family can think together about what behaviors they want to engage in. There may be specific actions a child or family might want to take to have a voice in how the country moves forward.
Treatment plan for Jane
• Psychotherapy. Continue cognitive-behavioral therapy with a focus on identifying thoughts tied to anxiety that are overgeneralizations or exaggerations. Discuss alternative thoughts with greater perspective.
• Parents. Discuss supporting the child through listening, reassurance of safety, reestablishment of family routine, and family discussion about what actions to take to promote values.
• Health promotion. Discuss using exercise, pleasant activities, mindfulness, and minimizing of screen time as ways to cope with stress.
• Medications. There is no need to use medications for the child’s acute stress response.
Resources
1. Psychological First Aid: Field Operations Manual , 2nd ed. (National Child Traumatic Stress Network, National Center for PTSD, 2006).
2. Cognitive Behavioral Therapy for Anxious Children: Therapist Manual, 3rd edition. (Ardmore, Pa.: Workbook Publishing, 2006).
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures.
Introduction
Since the election, many of the psychiatrists and psychologists in our office have reported a wave of anxiety among our patients. These fears have sometimes come from watching television commercials that highlight the faults of the other party or from watching the debates themselves. Children have reported fears of a nuclear war, of being taken away from family, or of being harmed or killed because of racial, religious, immigration, disability, gender, or sexual orientation status. In addition, some children are reporting remarks by peers.
Case summary
Discussion
How can we support our patients and their parents in responding to this surge in anxiety? First, we can reiterate the central importance of family. What the family models in values, behavior, and coping is central to how children respond to stress and winning and losing. Parents who manage their own emotions model how to cope with both victory and defeat, demonstrating appropriate celebration as well as grief and anger. Coping strategies for parents can include reaching out to supports from family and friends, using relaxation strategies, and then planning practical next steps to take.
Parents should reassure their children that they are there to keep their children safe. Modeling self-care and keeping the family routine as stable as possible is a powerful source of this sense of safety. As always, parents should think about what their children are consuming in the way of electronics.
In talking to children, listening is a first step. Help children find the words for what they are feeling. Consider your own words and the rhetoric of the election. Withering scorn of the other side has become increasingly common and not only damages our ability to understand other points of view and resolve conflicts but is also leading to intense anxiety in our children. The extreme nature of some of these words has led some children to believe that complete disaster is imminent should the other side win. Try to avoid using words that intensify fear. Acknowledge the feelings that children have, but provide reassurance of safety and hope.
Using the principles of cognitive-behavioral therapy, a therapist or parent can help a child think through how their thoughts are connected with feelings and behavior. When we are fearful, we often think that the absolute worst is going to happen, or we imagine that we definitely know the future. Sometimes an extreme thought can magnify feelings to the point that constructive behavior is blocked. A therapist might acknowledge feelings, but also help enlarge the child’s perspective. There are many reasons why people voted for or against candidates, and we don’t know everything about them just because of how they chose to vote. Discussing the three branches of government and the system of checks and balances that bring many people together to think over a problem can help a child see that the government is more than just one person. Parents or therapists can talk about protections in the Constitution such as freedom of the press, which allows us to be informed of what is going on. Parents might want to talk about the reality that we are one country, and that the vast majority of people on both sides share many, if not all, values.
Helping a child consider other perspectives isn’t saying that there are no reasons at all for anxiety, but that there are many possibilities for the future, and that a family can think together about what behaviors they want to engage in. There may be specific actions a child or family might want to take to have a voice in how the country moves forward.
Treatment plan for Jane
• Psychotherapy. Continue cognitive-behavioral therapy with a focus on identifying thoughts tied to anxiety that are overgeneralizations or exaggerations. Discuss alternative thoughts with greater perspective.
• Parents. Discuss supporting the child through listening, reassurance of safety, reestablishment of family routine, and family discussion about what actions to take to promote values.
• Health promotion. Discuss using exercise, pleasant activities, mindfulness, and minimizing of screen time as ways to cope with stress.
• Medications. There is no need to use medications for the child’s acute stress response.
Resources
1. Psychological First Aid: Field Operations Manual , 2nd ed. (National Child Traumatic Stress Network, National Center for PTSD, 2006).
2. Cognitive Behavioral Therapy for Anxious Children: Therapist Manual, 3rd edition. (Ardmore, Pa.: Workbook Publishing, 2006).
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures.
Introduction
Since the election, many of the psychiatrists and psychologists in our office have reported a wave of anxiety among our patients. These fears have sometimes come from watching television commercials that highlight the faults of the other party or from watching the debates themselves. Children have reported fears of a nuclear war, of being taken away from family, or of being harmed or killed because of racial, religious, immigration, disability, gender, or sexual orientation status. In addition, some children are reporting remarks by peers.
Case summary
Discussion
How can we support our patients and their parents in responding to this surge in anxiety? First, we can reiterate the central importance of family. What the family models in values, behavior, and coping is central to how children respond to stress and winning and losing. Parents who manage their own emotions model how to cope with both victory and defeat, demonstrating appropriate celebration as well as grief and anger. Coping strategies for parents can include reaching out to supports from family and friends, using relaxation strategies, and then planning practical next steps to take.
Parents should reassure their children that they are there to keep their children safe. Modeling self-care and keeping the family routine as stable as possible is a powerful source of this sense of safety. As always, parents should think about what their children are consuming in the way of electronics.
In talking to children, listening is a first step. Help children find the words for what they are feeling. Consider your own words and the rhetoric of the election. Withering scorn of the other side has become increasingly common and not only damages our ability to understand other points of view and resolve conflicts but is also leading to intense anxiety in our children. The extreme nature of some of these words has led some children to believe that complete disaster is imminent should the other side win. Try to avoid using words that intensify fear. Acknowledge the feelings that children have, but provide reassurance of safety and hope.
Using the principles of cognitive-behavioral therapy, a therapist or parent can help a child think through how their thoughts are connected with feelings and behavior. When we are fearful, we often think that the absolute worst is going to happen, or we imagine that we definitely know the future. Sometimes an extreme thought can magnify feelings to the point that constructive behavior is blocked. A therapist might acknowledge feelings, but also help enlarge the child’s perspective. There are many reasons why people voted for or against candidates, and we don’t know everything about them just because of how they chose to vote. Discussing the three branches of government and the system of checks and balances that bring many people together to think over a problem can help a child see that the government is more than just one person. Parents or therapists can talk about protections in the Constitution such as freedom of the press, which allows us to be informed of what is going on. Parents might want to talk about the reality that we are one country, and that the vast majority of people on both sides share many, if not all, values.
Helping a child consider other perspectives isn’t saying that there are no reasons at all for anxiety, but that there are many possibilities for the future, and that a family can think together about what behaviors they want to engage in. There may be specific actions a child or family might want to take to have a voice in how the country moves forward.
Treatment plan for Jane
• Psychotherapy. Continue cognitive-behavioral therapy with a focus on identifying thoughts tied to anxiety that are overgeneralizations or exaggerations. Discuss alternative thoughts with greater perspective.
• Parents. Discuss supporting the child through listening, reassurance of safety, reestablishment of family routine, and family discussion about what actions to take to promote values.
• Health promotion. Discuss using exercise, pleasant activities, mindfulness, and minimizing of screen time as ways to cope with stress.
• Medications. There is no need to use medications for the child’s acute stress response.
Resources
1. Psychological First Aid: Field Operations Manual , 2nd ed. (National Child Traumatic Stress Network, National Center for PTSD, 2006).
2. Cognitive Behavioral Therapy for Anxious Children: Therapist Manual, 3rd edition. (Ardmore, Pa.: Workbook Publishing, 2006).
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures.
Treatment of posttraumatic stress disorder
Traumatic events are extremely common, with as many as 60% of children experiencing some trauma by age 18 years. About 15% of these children will develop posttraumatic stress disorder (PTSD).
Case summary
Jane is a 13-year-old girl who presented because of steadily escalating angry outbursts with her mother, irritable mood, and anxiety since her father went to jail 2 years previously. Prior to the father’s departure from the family, he drank heavily and had been physically violent to Jane’s mother through most of Jane’s life.
Since these events, Jane has been extremely angry and irritable, often fighting extensively with her younger sister. She has severe difficulty separating from her mother, often following her around or demanding to know everything that her mother is doing. Jane herself reports that she feels worried, irritable, and sad much of the time. She is especially angry when thinking about anything related to her father. Jane won’t talk about her father to anyone, except occasionally her mother and one friend. She has difficulty falling asleep and has nightmares. She never thinks about the future, and instead just lives day to day. Images from the past come vividly into her mind. She has highly negative, hopeless views of the world, and doesn’t trust people, so she is unwilling to consider any therapy. Jane’s mother also is highly irritable and snaps at Jane over small things while in the office.
Discussion
The DSM-5 diagnostic criteria for PTSD require that an individual has been exposed to a severe stressor that threatens death, serious injury, or sexual violence through direct experience, witnessing the event happening to others, or learning that the event happened to a close family member or friend. Not all people who experience such events will develop PTSD, however. Additional symptoms are grouped into four areas (rather than three as in the DSM-IV), and a diagnosis requires one or two symptoms in each area:
• Intrusive symptoms including intrusive distressing memories, recurrent dreams with content related to the event, dissociative reactions such as flashbacks, intense distress at exposure to triggers that remind individuals of the event, or marked physiologic reactions to triggers.
• Avoidance of stimuli associated with the event, either memories or thoughts or external reminders.
• Negative cognitions manifesting as changes in thoughts and mood beginning or worsening after the event. These are an inability to remember the event, persistent negative beliefs about oneself or the world, distorted thoughts about the cause or results of the event, persistent negative emotional states such as anger or guilt, decreased participation in activities, feelings of estrangement from others, or an inability to experience positive emotions.
• Changes in arousal and reactivity as shown by irritable behavior, reckless behavior, hypervigilance, an exaggerated startle response, concentration problems, or sleep disturbance.
There are several screening instruments for the presence of a history of traumatic events as well as for symptoms of PTSD. The Child PTSD Symptom Scale (CPSS) is one example of a simple, readily available screening tool. More extensive assessment is an important part of treatment by mental health clinicians.
Treatment
Psychotherapy interventions are the core of treatment for PTSD in young people. Interventions based on cognitive-behavioral therapy (CBT) are the most extensively researched, with trauma-focused CBT (TF-CBT) being the specific intervention with the most research (13 randomized controlled trials showing efficacy) for children and adolescents. There are several other approaches that have evidence of efficacy through randomized controlled trials, and have been specifically studied for different ages, cultural groups, and focus of intervention (group, family, classroom). Child-parent psychotherapy focuses on traumatized 3-to 5-year-olds and works with both parent and child. Eye movement desensitization and preprocessing therapy (EMDR), extensively studied for adults, has some randomized controlled trials in children. The National Child Traumatic Stress Network (NCTSN) has a website listing evidence-based interventions with descriptions of the extent of the evidence for these and other interventions, including the population for which the intervention was designed and information on training and dissemination.
A recent meta-analysis by Morina et al. identified 39 randomized controlled trials with psychological interventions targeting PTSD in children and youth and found a large (0.83) overall effect size vs. wait list control, and a moderate (0.41) effect size vs. an active control such as supportive therapy. There were enough randomized controlled trials to analyze the TF-CBT–based interventions as a group, and these had even larger effect sizes: 1.44 vs. wait list and 0.66 vs. active control. The non-CBT approaches did not have enough studies to be evaluated separately (Clin Psychol Rev. 2016 Jul;47:41-54).
It is important to know which available therapists are trained in specific interventions such as TF-CBT and review the evidence behind other interventions that therapists are using. Advocacy for the training of local therapists, particularly therapists who are affiliated with your practice, can increase these resources.
The evidence for pharmacologic treatment for PTSD in children and adolescents, in contrast to adults, is very thin. In adults, SSRIs have shown a significant benefit, but there have been three randomized controlled trials examining this question in young people with no significant difference shown for the SSRI. One of these compared TF-CBT alone to TF-CBT plus sertraline, with no added benefit for sertraline. A second compared sertraline to placebo and showed no difference, and the third was an extremely brief trial of 1 week of fluoxetine for children with burns, with no effect. There are open label studies of citalopram that have shown some benefit.
Prazosin is an alpha-1 antagonist that decreases the effect of peripheral norepinephrine, which has been shown to decrease reactivity in adults through two randomized controlled trials, but there are case reports in adolescents only. Guanfacine, an alpha-2 agonist that acts centrally to decrease norepinephrine release, has one open label study of the extended-release form in adolescents showing benefit, but there are two negative randomized controlled trials in adults. Other agents such as second-generation antipsychotics and mood stabilizers (specifically carbamazepine and valproic acid) have open label studies in children only and have the potential for significant side effects.
Psychotherapy is clearly the treatment of choice for children and adolescents with PTSD; the difficulty is that avoidance and difficulty trusting people are core symptoms of PTSD, and can lead patients to be extremely reluctant to try therapy. As a pediatrician, you likely already have a trusting relationship with your patient and parent(s), which can provide an opening for discussion.
Psychoeducation about trauma and the specific trauma a child has experienced is a core component and often the first step of PTSD treatment. The NCTSN website provides a goldmine of information about specific types of trauma (found under the tab labeled trauma types), including common symptoms at different developmental stages and specific resources. By providing information to families in a sensitive way, clinicians can help people understand that they are not alone, that their struggles are common reactions to the type of trauma they have experienced, and that people can recover with therapy so that the trauma does not have to go on negatively affecting their lives.
Finally, noting a parent’s possible trauma, and encouraging that parent to get his or her own treatment in order to help the child, can be a crucial first step.
General references
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures.
Traumatic events are extremely common, with as many as 60% of children experiencing some trauma by age 18 years. About 15% of these children will develop posttraumatic stress disorder (PTSD).
Case summary
Jane is a 13-year-old girl who presented because of steadily escalating angry outbursts with her mother, irritable mood, and anxiety since her father went to jail 2 years previously. Prior to the father’s departure from the family, he drank heavily and had been physically violent to Jane’s mother through most of Jane’s life.
Since these events, Jane has been extremely angry and irritable, often fighting extensively with her younger sister. She has severe difficulty separating from her mother, often following her around or demanding to know everything that her mother is doing. Jane herself reports that she feels worried, irritable, and sad much of the time. She is especially angry when thinking about anything related to her father. Jane won’t talk about her father to anyone, except occasionally her mother and one friend. She has difficulty falling asleep and has nightmares. She never thinks about the future, and instead just lives day to day. Images from the past come vividly into her mind. She has highly negative, hopeless views of the world, and doesn’t trust people, so she is unwilling to consider any therapy. Jane’s mother also is highly irritable and snaps at Jane over small things while in the office.
Discussion
The DSM-5 diagnostic criteria for PTSD require that an individual has been exposed to a severe stressor that threatens death, serious injury, or sexual violence through direct experience, witnessing the event happening to others, or learning that the event happened to a close family member or friend. Not all people who experience such events will develop PTSD, however. Additional symptoms are grouped into four areas (rather than three as in the DSM-IV), and a diagnosis requires one or two symptoms in each area:
• Intrusive symptoms including intrusive distressing memories, recurrent dreams with content related to the event, dissociative reactions such as flashbacks, intense distress at exposure to triggers that remind individuals of the event, or marked physiologic reactions to triggers.
• Avoidance of stimuli associated with the event, either memories or thoughts or external reminders.
• Negative cognitions manifesting as changes in thoughts and mood beginning or worsening after the event. These are an inability to remember the event, persistent negative beliefs about oneself or the world, distorted thoughts about the cause or results of the event, persistent negative emotional states such as anger or guilt, decreased participation in activities, feelings of estrangement from others, or an inability to experience positive emotions.
• Changes in arousal and reactivity as shown by irritable behavior, reckless behavior, hypervigilance, an exaggerated startle response, concentration problems, or sleep disturbance.
There are several screening instruments for the presence of a history of traumatic events as well as for symptoms of PTSD. The Child PTSD Symptom Scale (CPSS) is one example of a simple, readily available screening tool. More extensive assessment is an important part of treatment by mental health clinicians.
Treatment
Psychotherapy interventions are the core of treatment for PTSD in young people. Interventions based on cognitive-behavioral therapy (CBT) are the most extensively researched, with trauma-focused CBT (TF-CBT) being the specific intervention with the most research (13 randomized controlled trials showing efficacy) for children and adolescents. There are several other approaches that have evidence of efficacy through randomized controlled trials, and have been specifically studied for different ages, cultural groups, and focus of intervention (group, family, classroom). Child-parent psychotherapy focuses on traumatized 3-to 5-year-olds and works with both parent and child. Eye movement desensitization and preprocessing therapy (EMDR), extensively studied for adults, has some randomized controlled trials in children. The National Child Traumatic Stress Network (NCTSN) has a website listing evidence-based interventions with descriptions of the extent of the evidence for these and other interventions, including the population for which the intervention was designed and information on training and dissemination.
A recent meta-analysis by Morina et al. identified 39 randomized controlled trials with psychological interventions targeting PTSD in children and youth and found a large (0.83) overall effect size vs. wait list control, and a moderate (0.41) effect size vs. an active control such as supportive therapy. There were enough randomized controlled trials to analyze the TF-CBT–based interventions as a group, and these had even larger effect sizes: 1.44 vs. wait list and 0.66 vs. active control. The non-CBT approaches did not have enough studies to be evaluated separately (Clin Psychol Rev. 2016 Jul;47:41-54).
It is important to know which available therapists are trained in specific interventions such as TF-CBT and review the evidence behind other interventions that therapists are using. Advocacy for the training of local therapists, particularly therapists who are affiliated with your practice, can increase these resources.
The evidence for pharmacologic treatment for PTSD in children and adolescents, in contrast to adults, is very thin. In adults, SSRIs have shown a significant benefit, but there have been three randomized controlled trials examining this question in young people with no significant difference shown for the SSRI. One of these compared TF-CBT alone to TF-CBT plus sertraline, with no added benefit for sertraline. A second compared sertraline to placebo and showed no difference, and the third was an extremely brief trial of 1 week of fluoxetine for children with burns, with no effect. There are open label studies of citalopram that have shown some benefit.
Prazosin is an alpha-1 antagonist that decreases the effect of peripheral norepinephrine, which has been shown to decrease reactivity in adults through two randomized controlled trials, but there are case reports in adolescents only. Guanfacine, an alpha-2 agonist that acts centrally to decrease norepinephrine release, has one open label study of the extended-release form in adolescents showing benefit, but there are two negative randomized controlled trials in adults. Other agents such as second-generation antipsychotics and mood stabilizers (specifically carbamazepine and valproic acid) have open label studies in children only and have the potential for significant side effects.
Psychotherapy is clearly the treatment of choice for children and adolescents with PTSD; the difficulty is that avoidance and difficulty trusting people are core symptoms of PTSD, and can lead patients to be extremely reluctant to try therapy. As a pediatrician, you likely already have a trusting relationship with your patient and parent(s), which can provide an opening for discussion.
Psychoeducation about trauma and the specific trauma a child has experienced is a core component and often the first step of PTSD treatment. The NCTSN website provides a goldmine of information about specific types of trauma (found under the tab labeled trauma types), including common symptoms at different developmental stages and specific resources. By providing information to families in a sensitive way, clinicians can help people understand that they are not alone, that their struggles are common reactions to the type of trauma they have experienced, and that people can recover with therapy so that the trauma does not have to go on negatively affecting their lives.
Finally, noting a parent’s possible trauma, and encouraging that parent to get his or her own treatment in order to help the child, can be a crucial first step.
General references
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures.
Traumatic events are extremely common, with as many as 60% of children experiencing some trauma by age 18 years. About 15% of these children will develop posttraumatic stress disorder (PTSD).
Case summary
Jane is a 13-year-old girl who presented because of steadily escalating angry outbursts with her mother, irritable mood, and anxiety since her father went to jail 2 years previously. Prior to the father’s departure from the family, he drank heavily and had been physically violent to Jane’s mother through most of Jane’s life.
Since these events, Jane has been extremely angry and irritable, often fighting extensively with her younger sister. She has severe difficulty separating from her mother, often following her around or demanding to know everything that her mother is doing. Jane herself reports that she feels worried, irritable, and sad much of the time. She is especially angry when thinking about anything related to her father. Jane won’t talk about her father to anyone, except occasionally her mother and one friend. She has difficulty falling asleep and has nightmares. She never thinks about the future, and instead just lives day to day. Images from the past come vividly into her mind. She has highly negative, hopeless views of the world, and doesn’t trust people, so she is unwilling to consider any therapy. Jane’s mother also is highly irritable and snaps at Jane over small things while in the office.
Discussion
The DSM-5 diagnostic criteria for PTSD require that an individual has been exposed to a severe stressor that threatens death, serious injury, or sexual violence through direct experience, witnessing the event happening to others, or learning that the event happened to a close family member or friend. Not all people who experience such events will develop PTSD, however. Additional symptoms are grouped into four areas (rather than three as in the DSM-IV), and a diagnosis requires one or two symptoms in each area:
• Intrusive symptoms including intrusive distressing memories, recurrent dreams with content related to the event, dissociative reactions such as flashbacks, intense distress at exposure to triggers that remind individuals of the event, or marked physiologic reactions to triggers.
• Avoidance of stimuli associated with the event, either memories or thoughts or external reminders.
• Negative cognitions manifesting as changes in thoughts and mood beginning or worsening after the event. These are an inability to remember the event, persistent negative beliefs about oneself or the world, distorted thoughts about the cause or results of the event, persistent negative emotional states such as anger or guilt, decreased participation in activities, feelings of estrangement from others, or an inability to experience positive emotions.
• Changes in arousal and reactivity as shown by irritable behavior, reckless behavior, hypervigilance, an exaggerated startle response, concentration problems, or sleep disturbance.
There are several screening instruments for the presence of a history of traumatic events as well as for symptoms of PTSD. The Child PTSD Symptom Scale (CPSS) is one example of a simple, readily available screening tool. More extensive assessment is an important part of treatment by mental health clinicians.
Treatment
Psychotherapy interventions are the core of treatment for PTSD in young people. Interventions based on cognitive-behavioral therapy (CBT) are the most extensively researched, with trauma-focused CBT (TF-CBT) being the specific intervention with the most research (13 randomized controlled trials showing efficacy) for children and adolescents. There are several other approaches that have evidence of efficacy through randomized controlled trials, and have been specifically studied for different ages, cultural groups, and focus of intervention (group, family, classroom). Child-parent psychotherapy focuses on traumatized 3-to 5-year-olds and works with both parent and child. Eye movement desensitization and preprocessing therapy (EMDR), extensively studied for adults, has some randomized controlled trials in children. The National Child Traumatic Stress Network (NCTSN) has a website listing evidence-based interventions with descriptions of the extent of the evidence for these and other interventions, including the population for which the intervention was designed and information on training and dissemination.
A recent meta-analysis by Morina et al. identified 39 randomized controlled trials with psychological interventions targeting PTSD in children and youth and found a large (0.83) overall effect size vs. wait list control, and a moderate (0.41) effect size vs. an active control such as supportive therapy. There were enough randomized controlled trials to analyze the TF-CBT–based interventions as a group, and these had even larger effect sizes: 1.44 vs. wait list and 0.66 vs. active control. The non-CBT approaches did not have enough studies to be evaluated separately (Clin Psychol Rev. 2016 Jul;47:41-54).
It is important to know which available therapists are trained in specific interventions such as TF-CBT and review the evidence behind other interventions that therapists are using. Advocacy for the training of local therapists, particularly therapists who are affiliated with your practice, can increase these resources.
The evidence for pharmacologic treatment for PTSD in children and adolescents, in contrast to adults, is very thin. In adults, SSRIs have shown a significant benefit, but there have been three randomized controlled trials examining this question in young people with no significant difference shown for the SSRI. One of these compared TF-CBT alone to TF-CBT plus sertraline, with no added benefit for sertraline. A second compared sertraline to placebo and showed no difference, and the third was an extremely brief trial of 1 week of fluoxetine for children with burns, with no effect. There are open label studies of citalopram that have shown some benefit.
Prazosin is an alpha-1 antagonist that decreases the effect of peripheral norepinephrine, which has been shown to decrease reactivity in adults through two randomized controlled trials, but there are case reports in adolescents only. Guanfacine, an alpha-2 agonist that acts centrally to decrease norepinephrine release, has one open label study of the extended-release form in adolescents showing benefit, but there are two negative randomized controlled trials in adults. Other agents such as second-generation antipsychotics and mood stabilizers (specifically carbamazepine and valproic acid) have open label studies in children only and have the potential for significant side effects.
Psychotherapy is clearly the treatment of choice for children and adolescents with PTSD; the difficulty is that avoidance and difficulty trusting people are core symptoms of PTSD, and can lead patients to be extremely reluctant to try therapy. As a pediatrician, you likely already have a trusting relationship with your patient and parent(s), which can provide an opening for discussion.
Psychoeducation about trauma and the specific trauma a child has experienced is a core component and often the first step of PTSD treatment. The NCTSN website provides a goldmine of information about specific types of trauma (found under the tab labeled trauma types), including common symptoms at different developmental stages and specific resources. By providing information to families in a sensitive way, clinicians can help people understand that they are not alone, that their struggles are common reactions to the type of trauma they have experienced, and that people can recover with therapy so that the trauma does not have to go on negatively affecting their lives.
Finally, noting a parent’s possible trauma, and encouraging that parent to get his or her own treatment in order to help the child, can be a crucial first step.
General references
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures.
Medication compliance
Introduction
Stimulant medications are an important part of attention-deficit/hyperactivity disorder (ADHD) treatment for most affected children and teens. But studies suggest that children and teens may not take their prescribed medication anywhere from 13% to as much as 64% of the time. As teenagers develop an appropriate increased desire for autonomy, they wish to have greater participation in their medication decisions, sometimes to the dismay of their parents.
Case
Will is an engaging young man who has been on stimulants for many years. However, he is frequently in conflict with his parents over an array of issues, including being annoyed at being reminded to take his medications. Although he is willing to take medication some of the time, he often forgets. He commonly fails to complete his homework, a further source of conflict.
Discussion
Parents can get frustrated with their teens and drawn into a control struggle over medication and other issues. Teenagers want to have more control of their lives, and sometimes this takes the form of not wanting to take medication. The No. 1 goal is to help the family move away from digging themselves further into conflict, and instead to have a genuine discussion about the pros and cons of medication.
This starts with listening seriously to the teenager. It helps to reassure teens that you are not going to get mad at them for not taking medication, but that instead you really value the information about how often they are taking it and, if they are skipping some doses or not taking it at all, the reason for that.
It is crucial to find out the real reason why someone is not taking his medication. Sometimes teens are genuinely forgetting. Here it can be helpful to be sure that the medication has to be taken as few times a day as possible, and then to set some kind of alarm reminder. This is one area where the omnipresence of cell phones is very useful. Help parents and teens negotiate about whether the parent will remind the teen, as repeated reminders can be irritating. Divided pill containers help both the parent and teen know whether the medication has been taken or not. If you formulate a plan with the family, write it down so that you can ask next time how it worked out, because if you are asking someone to make a behavior change, it is important to pay attention to whether they did it or not.
Other times it is clear that the teen doesn’t want to take the medication. In this situation, it is important to get the specifics. It is key to convey that the teen’s point of view is very important.
Reasons for not wanting to take a medication include some type of side effect, embarrassment about having to take the medication in school, inconvenience, or a general feeling that the teen doesn’t want to be on medication.
A genuinely collaborative attitude is the best approach. Restate what you have heard from the teen about his or her viewpoint. Help the parents state their concerns (for instance, about school success, driving safety, or the potential for impulsive behavior) in a noncritical manner. Then outline options and discuss the possible pros and cons of the different choices, including going off the medication as one option. By considering this as an option, you will have an opportunity to discuss what the drawbacks, as well as the advantages, might be.
When it comes to ADHD, there are many choices. These can include trying a different stimulant or using a nonstimulant such as atomoxetine or an alpha-adrenergic agonist. Because these medications have very different side effect profiles, they may be more acceptable to the teenager, although they also may have different efficacy. There are also psychotherapeutic options such as organizational skills training. By discussing a variety of choices and listening to the teen’s concerns and hopes, the teenager is engaged in taking responsibility for his own choices.
Once a choice is decided upon, it is important to follow up and review how well the plan is working and revise if necessary.
When to consult
If parents and teens are unable to participate in discussion and come up with a plan, family therapy to improve communication and address parenting issues can be recommended.
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Hall said that she had no relevant financial disclosures. To comment, e-mail her at [email protected].
Introduction
Stimulant medications are an important part of attention-deficit/hyperactivity disorder (ADHD) treatment for most affected children and teens. But studies suggest that children and teens may not take their prescribed medication anywhere from 13% to as much as 64% of the time. As teenagers develop an appropriate increased desire for autonomy, they wish to have greater participation in their medication decisions, sometimes to the dismay of their parents.
Case
Will is an engaging young man who has been on stimulants for many years. However, he is frequently in conflict with his parents over an array of issues, including being annoyed at being reminded to take his medications. Although he is willing to take medication some of the time, he often forgets. He commonly fails to complete his homework, a further source of conflict.
Discussion
Parents can get frustrated with their teens and drawn into a control struggle over medication and other issues. Teenagers want to have more control of their lives, and sometimes this takes the form of not wanting to take medication. The No. 1 goal is to help the family move away from digging themselves further into conflict, and instead to have a genuine discussion about the pros and cons of medication.
This starts with listening seriously to the teenager. It helps to reassure teens that you are not going to get mad at them for not taking medication, but that instead you really value the information about how often they are taking it and, if they are skipping some doses or not taking it at all, the reason for that.
It is crucial to find out the real reason why someone is not taking his medication. Sometimes teens are genuinely forgetting. Here it can be helpful to be sure that the medication has to be taken as few times a day as possible, and then to set some kind of alarm reminder. This is one area where the omnipresence of cell phones is very useful. Help parents and teens negotiate about whether the parent will remind the teen, as repeated reminders can be irritating. Divided pill containers help both the parent and teen know whether the medication has been taken or not. If you formulate a plan with the family, write it down so that you can ask next time how it worked out, because if you are asking someone to make a behavior change, it is important to pay attention to whether they did it or not.
Other times it is clear that the teen doesn’t want to take the medication. In this situation, it is important to get the specifics. It is key to convey that the teen’s point of view is very important.
Reasons for not wanting to take a medication include some type of side effect, embarrassment about having to take the medication in school, inconvenience, or a general feeling that the teen doesn’t want to be on medication.
A genuinely collaborative attitude is the best approach. Restate what you have heard from the teen about his or her viewpoint. Help the parents state their concerns (for instance, about school success, driving safety, or the potential for impulsive behavior) in a noncritical manner. Then outline options and discuss the possible pros and cons of the different choices, including going off the medication as one option. By considering this as an option, you will have an opportunity to discuss what the drawbacks, as well as the advantages, might be.
When it comes to ADHD, there are many choices. These can include trying a different stimulant or using a nonstimulant such as atomoxetine or an alpha-adrenergic agonist. Because these medications have very different side effect profiles, they may be more acceptable to the teenager, although they also may have different efficacy. There are also psychotherapeutic options such as organizational skills training. By discussing a variety of choices and listening to the teen’s concerns and hopes, the teenager is engaged in taking responsibility for his own choices.
Once a choice is decided upon, it is important to follow up and review how well the plan is working and revise if necessary.
When to consult
If parents and teens are unable to participate in discussion and come up with a plan, family therapy to improve communication and address parenting issues can be recommended.
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Hall said that she had no relevant financial disclosures. To comment, e-mail her at [email protected].
Introduction
Stimulant medications are an important part of attention-deficit/hyperactivity disorder (ADHD) treatment for most affected children and teens. But studies suggest that children and teens may not take their prescribed medication anywhere from 13% to as much as 64% of the time. As teenagers develop an appropriate increased desire for autonomy, they wish to have greater participation in their medication decisions, sometimes to the dismay of their parents.
Case
Will is an engaging young man who has been on stimulants for many years. However, he is frequently in conflict with his parents over an array of issues, including being annoyed at being reminded to take his medications. Although he is willing to take medication some of the time, he often forgets. He commonly fails to complete his homework, a further source of conflict.
Discussion
Parents can get frustrated with their teens and drawn into a control struggle over medication and other issues. Teenagers want to have more control of their lives, and sometimes this takes the form of not wanting to take medication. The No. 1 goal is to help the family move away from digging themselves further into conflict, and instead to have a genuine discussion about the pros and cons of medication.
This starts with listening seriously to the teenager. It helps to reassure teens that you are not going to get mad at them for not taking medication, but that instead you really value the information about how often they are taking it and, if they are skipping some doses or not taking it at all, the reason for that.
It is crucial to find out the real reason why someone is not taking his medication. Sometimes teens are genuinely forgetting. Here it can be helpful to be sure that the medication has to be taken as few times a day as possible, and then to set some kind of alarm reminder. This is one area where the omnipresence of cell phones is very useful. Help parents and teens negotiate about whether the parent will remind the teen, as repeated reminders can be irritating. Divided pill containers help both the parent and teen know whether the medication has been taken or not. If you formulate a plan with the family, write it down so that you can ask next time how it worked out, because if you are asking someone to make a behavior change, it is important to pay attention to whether they did it or not.
Other times it is clear that the teen doesn’t want to take the medication. In this situation, it is important to get the specifics. It is key to convey that the teen’s point of view is very important.
Reasons for not wanting to take a medication include some type of side effect, embarrassment about having to take the medication in school, inconvenience, or a general feeling that the teen doesn’t want to be on medication.
A genuinely collaborative attitude is the best approach. Restate what you have heard from the teen about his or her viewpoint. Help the parents state their concerns (for instance, about school success, driving safety, or the potential for impulsive behavior) in a noncritical manner. Then outline options and discuss the possible pros and cons of the different choices, including going off the medication as one option. By considering this as an option, you will have an opportunity to discuss what the drawbacks, as well as the advantages, might be.
When it comes to ADHD, there are many choices. These can include trying a different stimulant or using a nonstimulant such as atomoxetine or an alpha-adrenergic agonist. Because these medications have very different side effect profiles, they may be more acceptable to the teenager, although they also may have different efficacy. There are also psychotherapeutic options such as organizational skills training. By discussing a variety of choices and listening to the teen’s concerns and hopes, the teenager is engaged in taking responsibility for his own choices.
Once a choice is decided upon, it is important to follow up and review how well the plan is working and revise if necessary.
When to consult
If parents and teens are unable to participate in discussion and come up with a plan, family therapy to improve communication and address parenting issues can be recommended.
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Hall said that she had no relevant financial disclosures. To comment, e-mail her at [email protected].
Child Psychiatry Consult: Evidence-based therapies
Introduction
Parents sometimes come to clinicians with concerns about their children’s moods and behaviors, hoping for a rapid fix of the problem. Most child psychiatric issues can’t be fixed with just medication and respond better with psychotherapy or a combination of psychotherapy and medication. In the past 30 years, tremendous strides have been made in studying the effectiveness of psychotherapeutic interventions among youth.
Case Summary
Katy is a 10-year-old girl who gets into arguments with her mother every day after school because she wants to walk to her grandmother’s house not far away. She was exposed to severe domestic violence by her father against her mother when she was 5 years old, and she has nightmares that cause her to wake up often at night, a fear of men, and rapid mood shifts into sudden rage as well as oppositional behavior with her mother. Her mother also has significant fears and views the world as a very unsafe place. She is worried that Katy has bipolar disorder because of her daughter’s rapid mood changes.
Discussion
While Katy has angry outbursts at times, she does not present with clear-cut episodes of elevated mood along with other symptoms of bipolar disorder, particularly grandiosity. Instead her presentation raises the possibility of post-traumatic stress disorder (PTSD) with nightmares, a fear of men who likely trigger past memories, and sudden mood shifts. Her mother also may have some elements of PTSD, which may be complicating Katy’s presentation. No medication interventions so far have demonstrated significant benefit in youth with PTSD. If further evaluation confirms PTSD, what sort of therapy should be sought for Katy?
A large number of websites now list evidence-based treatments, although many of those require that the creators of the treatment apply for inclusion, and do not address the issue of varying levels of evidence. The American Psychological Association has a website entitled Effective Child Therapy, which discusses psychotherapeutic interventions for various diagnostic areas in youth and the varying levels of evidence for such treatments based on the types and numbers of studies that support them. The website also has an excellent video resource library.
Trauma-focused cognitive-behavioral therapy has numerous studies supporting its efficacy for a wide range of traumas and includes work with both the parent and the child to address the ways the trauma can affect their interaction. This would be an excellent choice for Katy and her mother. Other therapies that have supporting research include child-parent psychotherapy, eye movement desensitization and reprocessing therapy, resilient peer treatment, child-centered therapy, and family therapy for PTSD. Treatments have usually been designed for specific ages, so it is important to consider whether the intervention fits the age of the child.
The extent to which evidence-based treatments are available in the community is variable. However, pediatricians can play a significant role in the availability of these interventions by being aware of which ones are most strongly supported, asking the therapists to whom they refer what their experience is with such interventions, and encouraging training in their offices and communities. Therapists should be comfortable describing exactly how much training they have had in a certain area, for instance, extensive training through their professional education or one or several postgraduate trainings, preferably with follow-up consultation with an experienced practitioner while they are seeing their first cases with a particular intervention.
There is controversy about evidence-based treatment among some psychotherapists who argue that the strict requirements of the research setting make the results inapplicable to the complexity of patients seen in typical clinical settings. In fact, many of the treatments, including trauma-focused cognitive-behavioral therapy, work very well in complex families. Certainly there is much more to learn about how to help patients who don’t respond to certain types of therapy or how to engage families who are reluctant to participate in treatment, but the treatments that we know work are clearly what we should choose first.
Dr. Hall is an assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Hall said she had no relevant financial disclosures. To comment, e-mail her at [email protected].
Introduction
Parents sometimes come to clinicians with concerns about their children’s moods and behaviors, hoping for a rapid fix of the problem. Most child psychiatric issues can’t be fixed with just medication and respond better with psychotherapy or a combination of psychotherapy and medication. In the past 30 years, tremendous strides have been made in studying the effectiveness of psychotherapeutic interventions among youth.
Case Summary
Katy is a 10-year-old girl who gets into arguments with her mother every day after school because she wants to walk to her grandmother’s house not far away. She was exposed to severe domestic violence by her father against her mother when she was 5 years old, and she has nightmares that cause her to wake up often at night, a fear of men, and rapid mood shifts into sudden rage as well as oppositional behavior with her mother. Her mother also has significant fears and views the world as a very unsafe place. She is worried that Katy has bipolar disorder because of her daughter’s rapid mood changes.
Discussion
While Katy has angry outbursts at times, she does not present with clear-cut episodes of elevated mood along with other symptoms of bipolar disorder, particularly grandiosity. Instead her presentation raises the possibility of post-traumatic stress disorder (PTSD) with nightmares, a fear of men who likely trigger past memories, and sudden mood shifts. Her mother also may have some elements of PTSD, which may be complicating Katy’s presentation. No medication interventions so far have demonstrated significant benefit in youth with PTSD. If further evaluation confirms PTSD, what sort of therapy should be sought for Katy?
A large number of websites now list evidence-based treatments, although many of those require that the creators of the treatment apply for inclusion, and do not address the issue of varying levels of evidence. The American Psychological Association has a website entitled Effective Child Therapy, which discusses psychotherapeutic interventions for various diagnostic areas in youth and the varying levels of evidence for such treatments based on the types and numbers of studies that support them. The website also has an excellent video resource library.
Trauma-focused cognitive-behavioral therapy has numerous studies supporting its efficacy for a wide range of traumas and includes work with both the parent and the child to address the ways the trauma can affect their interaction. This would be an excellent choice for Katy and her mother. Other therapies that have supporting research include child-parent psychotherapy, eye movement desensitization and reprocessing therapy, resilient peer treatment, child-centered therapy, and family therapy for PTSD. Treatments have usually been designed for specific ages, so it is important to consider whether the intervention fits the age of the child.
The extent to which evidence-based treatments are available in the community is variable. However, pediatricians can play a significant role in the availability of these interventions by being aware of which ones are most strongly supported, asking the therapists to whom they refer what their experience is with such interventions, and encouraging training in their offices and communities. Therapists should be comfortable describing exactly how much training they have had in a certain area, for instance, extensive training through their professional education or one or several postgraduate trainings, preferably with follow-up consultation with an experienced practitioner while they are seeing their first cases with a particular intervention.
There is controversy about evidence-based treatment among some psychotherapists who argue that the strict requirements of the research setting make the results inapplicable to the complexity of patients seen in typical clinical settings. In fact, many of the treatments, including trauma-focused cognitive-behavioral therapy, work very well in complex families. Certainly there is much more to learn about how to help patients who don’t respond to certain types of therapy or how to engage families who are reluctant to participate in treatment, but the treatments that we know work are clearly what we should choose first.
Dr. Hall is an assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Hall said she had no relevant financial disclosures. To comment, e-mail her at [email protected].
Introduction
Parents sometimes come to clinicians with concerns about their children’s moods and behaviors, hoping for a rapid fix of the problem. Most child psychiatric issues can’t be fixed with just medication and respond better with psychotherapy or a combination of psychotherapy and medication. In the past 30 years, tremendous strides have been made in studying the effectiveness of psychotherapeutic interventions among youth.
Case Summary
Katy is a 10-year-old girl who gets into arguments with her mother every day after school because she wants to walk to her grandmother’s house not far away. She was exposed to severe domestic violence by her father against her mother when she was 5 years old, and she has nightmares that cause her to wake up often at night, a fear of men, and rapid mood shifts into sudden rage as well as oppositional behavior with her mother. Her mother also has significant fears and views the world as a very unsafe place. She is worried that Katy has bipolar disorder because of her daughter’s rapid mood changes.
Discussion
While Katy has angry outbursts at times, she does not present with clear-cut episodes of elevated mood along with other symptoms of bipolar disorder, particularly grandiosity. Instead her presentation raises the possibility of post-traumatic stress disorder (PTSD) with nightmares, a fear of men who likely trigger past memories, and sudden mood shifts. Her mother also may have some elements of PTSD, which may be complicating Katy’s presentation. No medication interventions so far have demonstrated significant benefit in youth with PTSD. If further evaluation confirms PTSD, what sort of therapy should be sought for Katy?
A large number of websites now list evidence-based treatments, although many of those require that the creators of the treatment apply for inclusion, and do not address the issue of varying levels of evidence. The American Psychological Association has a website entitled Effective Child Therapy, which discusses psychotherapeutic interventions for various diagnostic areas in youth and the varying levels of evidence for such treatments based on the types and numbers of studies that support them. The website also has an excellent video resource library.
Trauma-focused cognitive-behavioral therapy has numerous studies supporting its efficacy for a wide range of traumas and includes work with both the parent and the child to address the ways the trauma can affect their interaction. This would be an excellent choice for Katy and her mother. Other therapies that have supporting research include child-parent psychotherapy, eye movement desensitization and reprocessing therapy, resilient peer treatment, child-centered therapy, and family therapy for PTSD. Treatments have usually been designed for specific ages, so it is important to consider whether the intervention fits the age of the child.
The extent to which evidence-based treatments are available in the community is variable. However, pediatricians can play a significant role in the availability of these interventions by being aware of which ones are most strongly supported, asking the therapists to whom they refer what their experience is with such interventions, and encouraging training in their offices and communities. Therapists should be comfortable describing exactly how much training they have had in a certain area, for instance, extensive training through their professional education or one or several postgraduate trainings, preferably with follow-up consultation with an experienced practitioner while they are seeing their first cases with a particular intervention.
There is controversy about evidence-based treatment among some psychotherapists who argue that the strict requirements of the research setting make the results inapplicable to the complexity of patients seen in typical clinical settings. In fact, many of the treatments, including trauma-focused cognitive-behavioral therapy, work very well in complex families. Certainly there is much more to learn about how to help patients who don’t respond to certain types of therapy or how to engage families who are reluctant to participate in treatment, but the treatments that we know work are clearly what we should choose first.
Dr. Hall is an assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Hall said she had no relevant financial disclosures. To comment, e-mail her at [email protected].
