Linda Little

ALBUQUERQUE, N.M. – A survey of 50 psychiatrists from across the country provides insight into treatment of refractory depression in the elderly, Dr. William Apfeldorf said at a psychiatric symposium sponsored by the University of New Mexico, Albuquerque.

“Treatment guidelines can help but can't fully address the complexity of a complicated case,” said Dr. Apfeldorf of the department of psychiatry at the university.

In the survey, psychiatrists were asked to rate the appropriateness of treatments, with 9 being the treatment of choice, 7–8 being a first-line treatment, 4–6 a second-line treatment, 2–3 being a treatment rarely used, and 1 being a treatment that is never used.

For mild, nonpsychotic major depression in the elderly, the first line of treatment chosen by respondents was pharmacotherapy and psychotherapy. Pharmacotherapy alone was a close second, almost ranking as a first-line treatment.

If the first-line antidepressant failed, the psychiatrists would switch to a different antidepressant if there was no response and would augment the initial prescription if there was a partial response.

The experts were inclined to use a selective serotonin reuptake inhibitor (SSRI) initially. If there was no response, they would treat with either extended-release venlafaxine (Effexor XR) or sustained-release bupropion (Wellbutrin SR). Second-line treatment for nonresponders included another SSRI or nortriptyline or mirtazapine (Remeron). “Venlafaxine XR rated the highest in usage if the original SSRI didn't work,” said Dr. Apfeldorf.

If a tricyclic is used and there is no response, the next first-line treatment would be venlafaxine XR or an SSRI, according to the experts in the study.

For bipolar disorder, the first choice would be bupropion SR or lithium, then nortriptyline.

“Nothing was considered first line,” said Dr. Apfeldorf, “but we were surprised that lithium still showed up.”

The psychiatrists chose trazodone (Desyrel) as the first-line treatment of insomnia in the geriatric population, with zolpidem (Ambien) and zaleplon (Sonata) use coming later, Dr. Apfeldorf said.

For residual anxiety, the experts chose to increase the dosage of an antidepressant. If an antidepressant and mood stabilizer were required for the acute phase of anxiety, they would continue treatment with the combination. The first choice of mood stabilizer for the geriatric population was divalproex (Depakote), with lithium the second-line choice.

“The experts did not recommend any complementary medicine agents in late-life depression,” he said.

Some experts recommended light therapy as a second treatment to be added to an antidepressant, but most of the experts weren't located in places without a lot of light, Dr. Apfeldorf said.

After the initial episode and treatment, patients should be followed monthly for the first year, then every 1–3 months. Maintenance treatment should continue for 1 year if there was one episode of depression, 2 years if there were two episodes, and more than 3 years if there were three episodes, according to the respondents.

Electroconvulsive therapy is indicated in the geriatric population only if the patient is severely depressed and suicidal or has medical conditions preventing adequate drug treatment, the experts said.

Often, geriatric patients have comorbidities that contribute to depression, such as heart disease. SSRIs were favored for patients with bundle branch block, coronary artery disease, diabetes, and hypotension.

In patients with dementia who also are depressed, the experts chose citalopram (Celexa) and sertraline (Zoloft) as first-line treatments, along with venlafaxine XR.

Other drug combinations with antidepressant drugs also need to be monitored closely, they said.

ALBUQUERQUE, N.M. – A survey of 50 psychiatrists from across the country provides insight into treatment of refractory depression in the elderly, Dr. William Apfeldorf said at a psychiatric symposium sponsored by the University of New Mexico, Albuquerque.

“Treatment guidelines can help but can't fully address the complexity of a complicated case,” said Dr. Apfeldorf of the department of psychiatry at the university.

In the survey, psychiatrists were asked to rate the appropriateness of treatments, with 9 being the treatment of choice, 7–8 being a first-line treatment, 4–6 a second-line treatment, 2–3 being a treatment rarely used, and 1 being a treatment that is never used.

For mild, nonpsychotic major depression in the elderly, the first line of treatment chosen by respondents was pharmacotherapy and psychotherapy. Pharmacotherapy alone was a close second, almost ranking as a first-line treatment.

If the first-line antidepressant failed, the psychiatrists would switch to a different antidepressant if there was no response and would augment the initial prescription if there was a partial response.

The experts were inclined to use a selective serotonin reuptake inhibitor (SSRI) initially. If there was no response, they would treat with either extended-release venlafaxine (Effexor XR) or sustained-release bupropion (Wellbutrin SR). Second-line treatment for nonresponders included another SSRI or nortriptyline or mirtazapine (Remeron). “Venlafaxine XR rated the highest in usage if the original SSRI didn't work,” said Dr. Apfeldorf.

If a tricyclic is used and there is no response, the next first-line treatment would be venlafaxine XR or an SSRI, according to the experts in the study.

For bipolar disorder, the first choice would be bupropion SR or lithium, then nortriptyline.

“Nothing was considered first line,” said Dr. Apfeldorf, “but we were surprised that lithium still showed up.”

The psychiatrists chose trazodone (Desyrel) as the first-line treatment of insomnia in the geriatric population, with zolpidem (Ambien) and zaleplon (Sonata) use coming later, Dr. Apfeldorf said.

For residual anxiety, the experts chose to increase the dosage of an antidepressant. If an antidepressant and mood stabilizer were required for the acute phase of anxiety, they would continue treatment with the combination. The first choice of mood stabilizer for the geriatric population was divalproex (Depakote), with lithium the second-line choice.

“The experts did not recommend any complementary medicine agents in late-life depression,” he said.

Some experts recommended light therapy as a second treatment to be added to an antidepressant, but most of the experts weren't located in places without a lot of light, Dr. Apfeldorf said.

After the initial episode and treatment, patients should be followed monthly for the first year, then every 1–3 months. Maintenance treatment should continue for 1 year if there was one episode of depression, 2 years if there were two episodes, and more than 3 years if there were three episodes, according to the respondents.

Electroconvulsive therapy is indicated in the geriatric population only if the patient is severely depressed and suicidal or has medical conditions preventing adequate drug treatment, the experts said.

Often, geriatric patients have comorbidities that contribute to depression, such as heart disease. SSRIs were favored for patients with bundle branch block, coronary artery disease, diabetes, and hypotension.

In patients with dementia who also are depressed, the experts chose citalopram (Celexa) and sertraline (Zoloft) as first-line treatments, along with venlafaxine XR.

Other drug combinations with antidepressant drugs also need to be monitored closely, they said.

ALBUQUERQUE, N.M. – A survey of 50 psychiatrists from across the country provides insight into treatment of refractory depression in the elderly, Dr. William Apfeldorf said at a psychiatric symposium sponsored by the University of New Mexico, Albuquerque.

“Treatment guidelines can help but can't fully address the complexity of a complicated case,” said Dr. Apfeldorf of the department of psychiatry at the university.

In the survey, psychiatrists were asked to rate the appropriateness of treatments, with 9 being the treatment of choice, 7–8 being a first-line treatment, 4–6 a second-line treatment, 2–3 being a treatment rarely used, and 1 being a treatment that is never used.

For mild, nonpsychotic major depression in the elderly, the first line of treatment chosen by respondents was pharmacotherapy and psychotherapy. Pharmacotherapy alone was a close second, almost ranking as a first-line treatment.

If the first-line antidepressant failed, the psychiatrists would switch to a different antidepressant if there was no response and would augment the initial prescription if there was a partial response.

The experts were inclined to use a selective serotonin reuptake inhibitor (SSRI) initially. If there was no response, they would treat with either extended-release venlafaxine (Effexor XR) or sustained-release bupropion (Wellbutrin SR). Second-line treatment for nonresponders included another SSRI or nortriptyline or mirtazapine (Remeron). “Venlafaxine XR rated the highest in usage if the original SSRI didn't work,” said Dr. Apfeldorf.

If a tricyclic is used and there is no response, the next first-line treatment would be venlafaxine XR or an SSRI, according to the experts in the study.

For bipolar disorder, the first choice would be bupropion SR or lithium, then nortriptyline.

“Nothing was considered first line,” said Dr. Apfeldorf, “but we were surprised that lithium still showed up.”

The psychiatrists chose trazodone (Desyrel) as the first-line treatment of insomnia in the geriatric population, with zolpidem (Ambien) and zaleplon (Sonata) use coming later, Dr. Apfeldorf said.

For residual anxiety, the experts chose to increase the dosage of an antidepressant. If an antidepressant and mood stabilizer were required for the acute phase of anxiety, they would continue treatment with the combination. The first choice of mood stabilizer for the geriatric population was divalproex (Depakote), with lithium the second-line choice.

“The experts did not recommend any complementary medicine agents in late-life depression,” he said.

Some experts recommended light therapy as a second treatment to be added to an antidepressant, but most of the experts weren't located in places without a lot of light, Dr. Apfeldorf said.

After the initial episode and treatment, patients should be followed monthly for the first year, then every 1–3 months. Maintenance treatment should continue for 1 year if there was one episode of depression, 2 years if there were two episodes, and more than 3 years if there were three episodes, according to the respondents.

Electroconvulsive therapy is indicated in the geriatric population only if the patient is severely depressed and suicidal or has medical conditions preventing adequate drug treatment, the experts said.

Often, geriatric patients have comorbidities that contribute to depression, such as heart disease. SSRIs were favored for patients with bundle branch block, coronary artery disease, diabetes, and hypotension.

In patients with dementia who also are depressed, the experts chose citalopram (Celexa) and sertraline (Zoloft) as first-line treatments, along with venlafaxine XR.

Other drug combinations with antidepressant drugs also need to be monitored closely, they said.

ALBUQUERQUE – Conduct disorders represent a complex family of conditions, and effective treatment requires careful assessment of contributing variables and comorbid conditions, Dr. David J. Mullen reported at a psychiatric symposium sponsored by the University of New Mexico.

“Conduct disorders develop over time, as [the] payoff for antisocial behavior … exceeds the payoff for social behavior,” said Dr. Mullen of the department of psychiatry at the university in Albuqerque. “This antisocial behavior may fluctuate, but it is always there.”

The DSM-IV defines conduct disorder as “a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate social norms or rules are violated.”

For a patient to be diagnosed with conduct disorder, at least three characteristic behaviors must have been manifested in the past year, with at least one behavior present in the past 6 months, according to the DSM-IV. The four main groupings of the characteristic behaviors are aggression toward people and animals, destruction of property, deceitfulness or theft, and serious violations of rules.

“These adolescents often bully and intimidate others, get into physical fights, have a weapon that can cause physical harm, can be physically cruel to people and animals, and some have had forced sexual activity,” Dr. Mullen said.

Other behaviors include arson or other serious property destruction, breaking and entering, and lying and conning. “These kids often stay out at night despite parental prohibition,” and they “run away from home and are often truant,” Dr. Mullen said.

Epidemiologic studies have shown that the incidence of conduct disorder ranges from 1.5% to 15% in children and adolescents. It is three to five times more common in boys than in girls, and there is some evidence that the incidence is increasing, especially in urban areas. In adolescents, however, there is a more even distribution among males and females, he noted.

There may be some genetic component to conduct disorder, but the data are stronger for a genetic component to antisocial personality disorder. Other possible biologic risk factors include central nervous system damage from head or face trauma, hormonal imbalances, and difficult temperaments.

Social factors include poverty, abuse or neglect, unsupportive family interactions, and high levels of parental conflict.

Among patients with conduct disorder, those who do better usually have higher intelligence quotients, more positive temperaments, better social skills, areas of competence outside of school, and a supportive adult in their life, he said.

One important comorbidity is attention-deficit hyperactivity disorder, which yields a worse prognosis than does conduct disorder. “These patients tend to be more aggressive and more antisocial than those with conduct disorder alone,” he said. A high percentage of youth with conduct disorder, possibly 60%–80%, also are substance abusers, Dr. Mullen noted.

Youth with conduct disorder also have a higher rate of depression, and there is a high rate of conduct disorder in juvenile bipolar patients, with manic symptoms directly contributing to their antisocial behavior, he said.

Also, some patients subsequently develop schizophrenia after years of exhibiting antisocial and aggressive behaviors.

Psychiatric medication may be effective in treating the symptoms of aggression as well as the exacerbating comorbidities of conduct disorder. “Multimodal interventions such as multisystemic therapy and functional family therapy also are effective,” Dr. Mullen said.

Acute care may be helpful as a crisis response to comorbid conditions, but residential care for these youth has little support, he said.

ALBUQUERQUE – Conduct disorders represent a complex family of conditions, and effective treatment requires careful assessment of contributing variables and comorbid conditions, Dr. David J. Mullen reported at a psychiatric symposium sponsored by the University of New Mexico.

“Conduct disorders develop over time, as [the] payoff for antisocial behavior … exceeds the payoff for social behavior,” said Dr. Mullen of the department of psychiatry at the university in Albuqerque. “This antisocial behavior may fluctuate, but it is always there.”

The DSM-IV defines conduct disorder as “a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate social norms or rules are violated.”

For a patient to be diagnosed with conduct disorder, at least three characteristic behaviors must have been manifested in the past year, with at least one behavior present in the past 6 months, according to the DSM-IV. The four main groupings of the characteristic behaviors are aggression toward people and animals, destruction of property, deceitfulness or theft, and serious violations of rules.

“These adolescents often bully and intimidate others, get into physical fights, have a weapon that can cause physical harm, can be physically cruel to people and animals, and some have had forced sexual activity,” Dr. Mullen said.

Other behaviors include arson or other serious property destruction, breaking and entering, and lying and conning. “These kids often stay out at night despite parental prohibition,” and they “run away from home and are often truant,” Dr. Mullen said.

Epidemiologic studies have shown that the incidence of conduct disorder ranges from 1.5% to 15% in children and adolescents. It is three to five times more common in boys than in girls, and there is some evidence that the incidence is increasing, especially in urban areas. In adolescents, however, there is a more even distribution among males and females, he noted.

There may be some genetic component to conduct disorder, but the data are stronger for a genetic component to antisocial personality disorder. Other possible biologic risk factors include central nervous system damage from head or face trauma, hormonal imbalances, and difficult temperaments.

Social factors include poverty, abuse or neglect, unsupportive family interactions, and high levels of parental conflict.

Among patients with conduct disorder, those who do better usually have higher intelligence quotients, more positive temperaments, better social skills, areas of competence outside of school, and a supportive adult in their life, he said.

One important comorbidity is attention-deficit hyperactivity disorder, which yields a worse prognosis than does conduct disorder. “These patients tend to be more aggressive and more antisocial than those with conduct disorder alone,” he said. A high percentage of youth with conduct disorder, possibly 60%–80%, also are substance abusers, Dr. Mullen noted.

Youth with conduct disorder also have a higher rate of depression, and there is a high rate of conduct disorder in juvenile bipolar patients, with manic symptoms directly contributing to their antisocial behavior, he said.

Also, some patients subsequently develop schizophrenia after years of exhibiting antisocial and aggressive behaviors.

Psychiatric medication may be effective in treating the symptoms of aggression as well as the exacerbating comorbidities of conduct disorder. “Multimodal interventions such as multisystemic therapy and functional family therapy also are effective,” Dr. Mullen said.

Acute care may be helpful as a crisis response to comorbid conditions, but residential care for these youth has little support, he said.

ALBUQUERQUE – Conduct disorders represent a complex family of conditions, and effective treatment requires careful assessment of contributing variables and comorbid conditions, Dr. David J. Mullen reported at a psychiatric symposium sponsored by the University of New Mexico.

“Conduct disorders develop over time, as [the] payoff for antisocial behavior … exceeds the payoff for social behavior,” said Dr. Mullen of the department of psychiatry at the university in Albuqerque. “This antisocial behavior may fluctuate, but it is always there.”

The DSM-IV defines conduct disorder as “a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate social norms or rules are violated.”

For a patient to be diagnosed with conduct disorder, at least three characteristic behaviors must have been manifested in the past year, with at least one behavior present in the past 6 months, according to the DSM-IV. The four main groupings of the characteristic behaviors are aggression toward people and animals, destruction of property, deceitfulness or theft, and serious violations of rules.

“These adolescents often bully and intimidate others, get into physical fights, have a weapon that can cause physical harm, can be physically cruel to people and animals, and some have had forced sexual activity,” Dr. Mullen said.

Other behaviors include arson or other serious property destruction, breaking and entering, and lying and conning. “These kids often stay out at night despite parental prohibition,” and they “run away from home and are often truant,” Dr. Mullen said.

Epidemiologic studies have shown that the incidence of conduct disorder ranges from 1.5% to 15% in children and adolescents. It is three to five times more common in boys than in girls, and there is some evidence that the incidence is increasing, especially in urban areas. In adolescents, however, there is a more even distribution among males and females, he noted.

There may be some genetic component to conduct disorder, but the data are stronger for a genetic component to antisocial personality disorder. Other possible biologic risk factors include central nervous system damage from head or face trauma, hormonal imbalances, and difficult temperaments.

Social factors include poverty, abuse or neglect, unsupportive family interactions, and high levels of parental conflict.

Among patients with conduct disorder, those who do better usually have higher intelligence quotients, more positive temperaments, better social skills, areas of competence outside of school, and a supportive adult in their life, he said.

One important comorbidity is attention-deficit hyperactivity disorder, which yields a worse prognosis than does conduct disorder. “These patients tend to be more aggressive and more antisocial than those with conduct disorder alone,” he said. A high percentage of youth with conduct disorder, possibly 60%–80%, also are substance abusers, Dr. Mullen noted.

Youth with conduct disorder also have a higher rate of depression, and there is a high rate of conduct disorder in juvenile bipolar patients, with manic symptoms directly contributing to their antisocial behavior, he said.

Also, some patients subsequently develop schizophrenia after years of exhibiting antisocial and aggressive behaviors.

Psychiatric medication may be effective in treating the symptoms of aggression as well as the exacerbating comorbidities of conduct disorder. “Multimodal interventions such as multisystemic therapy and functional family therapy also are effective,” Dr. Mullen said.

Acute care may be helpful as a crisis response to comorbid conditions, but residential care for these youth has little support, he said.

GRAPEVINE, TEX. — Men who carry the fragile X syndrome gene may be at risk for progressive tremors and weakness as they age, said James Grigsby, Ph.D., at a meeting sponsored by the American College of Medical Genetics.

An estimated 750,000 men carry the gene for fragile X syndrome.“Formerly, these individuals were thought to be unaffected,” said Dr. Grigsby, director of the division of Health Care Policy and Research at the University of Colorado Health Sciences Center. “Men in later life are far more affected than women.”

Epidemiologic studies now show that a high percentage of males develop fragile X-associated tremor-ataxia syndrome (FXTAS). The incidence in men now is thought to be between 1 in 250 to 1 in 813; in women the incidence is 1 in 250–259.

But clinical studies of men and women with the carrier status are revealing more about the neurologic signs and symptoms and are discovering distinct findings on the brains of carriers through MRI.

In one study of 40 men, more than half were affected after age 80; however, 7 (18%) had symptoms occur at age 50–59, Dr. Grigsby said. Syndrome characteristics in a study of 26 affected men included gait ataxia in 25 (96%), intention tremor in 18 (69%), lower extremity weakness in 14 (54%), lower extremity neuropathy in 16 (62%), bradykinesia in 15 (58%), rigidity in 9 (35%), dysarthria in 20 (77%), dysmetria in 24 (92%), bowel incontinence in 8 (31%) and bladder incontinence in 14 (54%), impotence in 21 (81%), cognitive deficit in 19 (73%), and heart failure in more than half.

“The clinical signs are similar to Parkinson's disease,” Dr. Grigsby said. “In studying the cognitive aspect, we don't observe a high level of dementia, and the verbal IQ isn't affected. But there is impairment in working memory, speed and capacity of information processing, and executive cognitive functions.”

Additionally, physicians are finding a high level of heart failure and hypertension in men with FXTAS, he said.

One study of 25 men showed the mean age of onset of FXTAS was 62 years. Many of the men had completed college, with a mean of 16 years of education, and they had a mean IQ of 102.

“Although there was a high number of college graduates in the group, the cognitive levels were less than expected of college graduates,” he said.

Over time the men showed increased apathy, lowered verbal fluency, higher level of disinterest, inappropriate speech, irritability, and an inability to stick to the task at hand, as assessed by a number of tests, including the letter-number sequencing and digit span subtests of the Wechsler Adult Intelligence Scale, Version III.

“There also was a 50% decrease in short-term memory,” according to Dr. Grigsby, reporting on unpublished data

On MRI, there are white-matter lesions and atrophy of the cortex, brainstem, and cerebellum but no evidence of inflammation, Dr. Grigsby said.

GRAPEVINE, TEX. — Men who carry the fragile X syndrome gene may be at risk for progressive tremors and weakness as they age, said James Grigsby, Ph.D., at a meeting sponsored by the American College of Medical Genetics.

An estimated 750,000 men carry the gene for fragile X syndrome.“Formerly, these individuals were thought to be unaffected,” said Dr. Grigsby, director of the division of Health Care Policy and Research at the University of Colorado Health Sciences Center. “Men in later life are far more affected than women.”

Epidemiologic studies now show that a high percentage of males develop fragile X-associated tremor-ataxia syndrome (FXTAS). The incidence in men now is thought to be between 1 in 250 to 1 in 813; in women the incidence is 1 in 250–259.

But clinical studies of men and women with the carrier status are revealing more about the neurologic signs and symptoms and are discovering distinct findings on the brains of carriers through MRI.

In one study of 40 men, more than half were affected after age 80; however, 7 (18%) had symptoms occur at age 50–59, Dr. Grigsby said. Syndrome characteristics in a study of 26 affected men included gait ataxia in 25 (96%), intention tremor in 18 (69%), lower extremity weakness in 14 (54%), lower extremity neuropathy in 16 (62%), bradykinesia in 15 (58%), rigidity in 9 (35%), dysarthria in 20 (77%), dysmetria in 24 (92%), bowel incontinence in 8 (31%) and bladder incontinence in 14 (54%), impotence in 21 (81%), cognitive deficit in 19 (73%), and heart failure in more than half.

“The clinical signs are similar to Parkinson's disease,” Dr. Grigsby said. “In studying the cognitive aspect, we don't observe a high level of dementia, and the verbal IQ isn't affected. But there is impairment in working memory, speed and capacity of information processing, and executive cognitive functions.”

Additionally, physicians are finding a high level of heart failure and hypertension in men with FXTAS, he said.

One study of 25 men showed the mean age of onset of FXTAS was 62 years. Many of the men had completed college, with a mean of 16 years of education, and they had a mean IQ of 102.

“Although there was a high number of college graduates in the group, the cognitive levels were less than expected of college graduates,” he said.

Over time the men showed increased apathy, lowered verbal fluency, higher level of disinterest, inappropriate speech, irritability, and an inability to stick to the task at hand, as assessed by a number of tests, including the letter-number sequencing and digit span subtests of the Wechsler Adult Intelligence Scale, Version III.

“There also was a 50% decrease in short-term memory,” according to Dr. Grigsby, reporting on unpublished data

On MRI, there are white-matter lesions and atrophy of the cortex, brainstem, and cerebellum but no evidence of inflammation, Dr. Grigsby said.

GRAPEVINE, TEX. — Men who carry the fragile X syndrome gene may be at risk for progressive tremors and weakness as they age, said James Grigsby, Ph.D., at a meeting sponsored by the American College of Medical Genetics.

An estimated 750,000 men carry the gene for fragile X syndrome.“Formerly, these individuals were thought to be unaffected,” said Dr. Grigsby, director of the division of Health Care Policy and Research at the University of Colorado Health Sciences Center. “Men in later life are far more affected than women.”

Epidemiologic studies now show that a high percentage of males develop fragile X-associated tremor-ataxia syndrome (FXTAS). The incidence in men now is thought to be between 1 in 250 to 1 in 813; in women the incidence is 1 in 250–259.

But clinical studies of men and women with the carrier status are revealing more about the neurologic signs and symptoms and are discovering distinct findings on the brains of carriers through MRI.

In one study of 40 men, more than half were affected after age 80; however, 7 (18%) had symptoms occur at age 50–59, Dr. Grigsby said. Syndrome characteristics in a study of 26 affected men included gait ataxia in 25 (96%), intention tremor in 18 (69%), lower extremity weakness in 14 (54%), lower extremity neuropathy in 16 (62%), bradykinesia in 15 (58%), rigidity in 9 (35%), dysarthria in 20 (77%), dysmetria in 24 (92%), bowel incontinence in 8 (31%) and bladder incontinence in 14 (54%), impotence in 21 (81%), cognitive deficit in 19 (73%), and heart failure in more than half.

“The clinical signs are similar to Parkinson's disease,” Dr. Grigsby said. “In studying the cognitive aspect, we don't observe a high level of dementia, and the verbal IQ isn't affected. But there is impairment in working memory, speed and capacity of information processing, and executive cognitive functions.”

Additionally, physicians are finding a high level of heart failure and hypertension in men with FXTAS, he said.

One study of 25 men showed the mean age of onset of FXTAS was 62 years. Many of the men had completed college, with a mean of 16 years of education, and they had a mean IQ of 102.

“Although there was a high number of college graduates in the group, the cognitive levels were less than expected of college graduates,” he said.

Over time the men showed increased apathy, lowered verbal fluency, higher level of disinterest, inappropriate speech, irritability, and an inability to stick to the task at hand, as assessed by a number of tests, including the letter-number sequencing and digit span subtests of the Wechsler Adult Intelligence Scale, Version III.

“There also was a 50% decrease in short-term memory,” according to Dr. Grigsby, reporting on unpublished data

On MRI, there are white-matter lesions and atrophy of the cortex, brainstem, and cerebellum but no evidence of inflammation, Dr. Grigsby said.

ALBUQUERQUE — Training family members can successfully get alcoholic patients and other substance abusers into treatment, a New Mexico psychologist said.

A new program that trains a spouse or other family member how best to deal with the addicted patient has shown a 64% success rate in getting loved ones into treatment. And this success rate far exceeds those of interventional programs and Al-Anon.

“The key is family members,” Robert J. Meyers, Ph.D., said at a psychiatric symposium sponsored by the University of New Mexico. “They have an enormous amount of information on the user that is very important. They help us get the individual to accept treatment.”

The Community Reinforcement and Family Training (CRAFT) approach, a 12-session program created by Dr. Meyers, seeks to empower spouses and other family members. The goals in part are to get families to take care of themselves and to lead fuller lives.

“We try to teach family members how to disassociate themselves from the user when they are drunk or stoned, and we show them how to give praise when the user is sober,” said Dr. Meyers, of the Center on Alcoholism, Substance Abuse, and Other Addictions at the University of New Mexico.

Many alcohol and drug abusers do not wish to enter treatment. “This program helps get them in the system before they totally unravel with driving under the influence records, prison, or hurting someone,” he said.

More traditional approaches, such as 12-step programs, advise waiting until the abuser wants help. For example, participants in the Johnson Institute Intervention program invite friends to a “surprise party” and as part of that exercise, a list is drawn up of all “the horrible things” the person has done. Al-Anon programs, which help partners and children of alcoholics, often do not get the alcoholic patient into treatment, he said.

The three major goals of the CRAFT program are to reduce the loved one's drinking, engage the person into treatment, and improve the functioning of the concerned significant other.

The CRAFT program, in 1-hour sessions, gives family members skills aimed at promoting sobriety in the loved ones by teaching them how to change their own behavior to have a positive impact. “They are taught how to change their interaction style, a new way of dealing with the drinker or drug abuser,” said Dr. Meyers, coauthor of “Get Your Loved One Sober: Alternatives to Nagging, Pleading, and Threatening” (Center City, Minn.: Hazelden Publishing and Educational Services, 2004).

The therapist helps the user find prosocial rewards in an effort to get the person to stop. “It's not meant to be a rigid treatment method,” Dr. Meyers said. “The key is to define what is rewarding to the individual user. Each culture has different rewards, and that's the challenge. People have to quit for a reason.”

To study the effectiveness of the program, researchers studied 130 men and women who answered an advertisement for the program. The significant others randomly were assigned to one of three interventions: CRAFT, the Johnson Institute Intervention, and Al-Anon Facilitation Therapy.

The significant other had to be a first-degree relative and had to be in contact with the substance abuser at least 40% of the time. The substance abuser had to be resistant to treatment, and there could be no planned separation or plans to change living arrangements.

The resulting treatment engagement rates after the sessions were 64% for the CRAFT program, 23% for the Johnson program, and 13% for Al-Anon.

But the program not only had a higher success rate for the substance abuser entering treatment; the emotional health of the spouses and other loved ones dramatically improved. The significant others' Beck Depression Inventory scores dropped from 10 to 6; there were significant changes in their levels of anger, and a significant lessening of anxiety.

“Problems with family relationships were reduced, family cohesion went up, and family conflict was reduced,” Dr. Meyers said.

The program teaches spouses, parents, and other relatives how to avoid arguments and deal with the potential of domestic violence, he said. “It teaches them how to get the loved one to stop drinking without nagging, pleading, or threatening.”

The CRAFT program also received funding from the National Institute on Drug Abuse for a demonstration project targeting treatment-resistant drug abusers. The drugs of choice included cocaine (used by 37%), marijuana (35%), stimulants (16%), opiates (8%), and sedatives or tranquilizers (3%). All but 3% of the significant others were women; about half were white and the other half Hispanic.

After the spouses and relatives underwent the CRAFT program, 74% of the drug abusers entered treatment, Dr. Meyer said. “The data really surprised us.”

ALBUQUERQUE — Training family members can successfully get alcoholic patients and other substance abusers into treatment, a New Mexico psychologist said.

A new program that trains a spouse or other family member how best to deal with the addicted patient has shown a 64% success rate in getting loved ones into treatment. And this success rate far exceeds those of interventional programs and Al-Anon.

“The key is family members,” Robert J. Meyers, Ph.D., said at a psychiatric symposium sponsored by the University of New Mexico. “They have an enormous amount of information on the user that is very important. They help us get the individual to accept treatment.”

The Community Reinforcement and Family Training (CRAFT) approach, a 12-session program created by Dr. Meyers, seeks to empower spouses and other family members. The goals in part are to get families to take care of themselves and to lead fuller lives.

“We try to teach family members how to disassociate themselves from the user when they are drunk or stoned, and we show them how to give praise when the user is sober,” said Dr. Meyers, of the Center on Alcoholism, Substance Abuse, and Other Addictions at the University of New Mexico.

Many alcohol and drug abusers do not wish to enter treatment. “This program helps get them in the system before they totally unravel with driving under the influence records, prison, or hurting someone,” he said.

More traditional approaches, such as 12-step programs, advise waiting until the abuser wants help. For example, participants in the Johnson Institute Intervention program invite friends to a “surprise party” and as part of that exercise, a list is drawn up of all “the horrible things” the person has done. Al-Anon programs, which help partners and children of alcoholics, often do not get the alcoholic patient into treatment, he said.

The three major goals of the CRAFT program are to reduce the loved one's drinking, engage the person into treatment, and improve the functioning of the concerned significant other.

The CRAFT program, in 1-hour sessions, gives family members skills aimed at promoting sobriety in the loved ones by teaching them how to change their own behavior to have a positive impact. “They are taught how to change their interaction style, a new way of dealing with the drinker or drug abuser,” said Dr. Meyers, coauthor of “Get Your Loved One Sober: Alternatives to Nagging, Pleading, and Threatening” (Center City, Minn.: Hazelden Publishing and Educational Services, 2004).

The therapist helps the user find prosocial rewards in an effort to get the person to stop. “It's not meant to be a rigid treatment method,” Dr. Meyers said. “The key is to define what is rewarding to the individual user. Each culture has different rewards, and that's the challenge. People have to quit for a reason.”

To study the effectiveness of the program, researchers studied 130 men and women who answered an advertisement for the program. The significant others randomly were assigned to one of three interventions: CRAFT, the Johnson Institute Intervention, and Al-Anon Facilitation Therapy.

The significant other had to be a first-degree relative and had to be in contact with the substance abuser at least 40% of the time. The substance abuser had to be resistant to treatment, and there could be no planned separation or plans to change living arrangements.

The resulting treatment engagement rates after the sessions were 64% for the CRAFT program, 23% for the Johnson program, and 13% for Al-Anon.

But the program not only had a higher success rate for the substance abuser entering treatment; the emotional health of the spouses and other loved ones dramatically improved. The significant others' Beck Depression Inventory scores dropped from 10 to 6; there were significant changes in their levels of anger, and a significant lessening of anxiety.

“Problems with family relationships were reduced, family cohesion went up, and family conflict was reduced,” Dr. Meyers said.

The program teaches spouses, parents, and other relatives how to avoid arguments and deal with the potential of domestic violence, he said. “It teaches them how to get the loved one to stop drinking without nagging, pleading, or threatening.”

The CRAFT program also received funding from the National Institute on Drug Abuse for a demonstration project targeting treatment-resistant drug abusers. The drugs of choice included cocaine (used by 37%), marijuana (35%), stimulants (16%), opiates (8%), and sedatives or tranquilizers (3%). All but 3% of the significant others were women; about half were white and the other half Hispanic.

After the spouses and relatives underwent the CRAFT program, 74% of the drug abusers entered treatment, Dr. Meyer said. “The data really surprised us.”

ALBUQUERQUE — Training family members can successfully get alcoholic patients and other substance abusers into treatment, a New Mexico psychologist said.

A new program that trains a spouse or other family member how best to deal with the addicted patient has shown a 64% success rate in getting loved ones into treatment. And this success rate far exceeds those of interventional programs and Al-Anon.

“The key is family members,” Robert J. Meyers, Ph.D., said at a psychiatric symposium sponsored by the University of New Mexico. “They have an enormous amount of information on the user that is very important. They help us get the individual to accept treatment.”

The Community Reinforcement and Family Training (CRAFT) approach, a 12-session program created by Dr. Meyers, seeks to empower spouses and other family members. The goals in part are to get families to take care of themselves and to lead fuller lives.

“We try to teach family members how to disassociate themselves from the user when they are drunk or stoned, and we show them how to give praise when the user is sober,” said Dr. Meyers, of the Center on Alcoholism, Substance Abuse, and Other Addictions at the University of New Mexico.

Many alcohol and drug abusers do not wish to enter treatment. “This program helps get them in the system before they totally unravel with driving under the influence records, prison, or hurting someone,” he said.

More traditional approaches, such as 12-step programs, advise waiting until the abuser wants help. For example, participants in the Johnson Institute Intervention program invite friends to a “surprise party” and as part of that exercise, a list is drawn up of all “the horrible things” the person has done. Al-Anon programs, which help partners and children of alcoholics, often do not get the alcoholic patient into treatment, he said.

The three major goals of the CRAFT program are to reduce the loved one's drinking, engage the person into treatment, and improve the functioning of the concerned significant other.

The CRAFT program, in 1-hour sessions, gives family members skills aimed at promoting sobriety in the loved ones by teaching them how to change their own behavior to have a positive impact. “They are taught how to change their interaction style, a new way of dealing with the drinker or drug abuser,” said Dr. Meyers, coauthor of “Get Your Loved One Sober: Alternatives to Nagging, Pleading, and Threatening” (Center City, Minn.: Hazelden Publishing and Educational Services, 2004).

The therapist helps the user find prosocial rewards in an effort to get the person to stop. “It's not meant to be a rigid treatment method,” Dr. Meyers said. “The key is to define what is rewarding to the individual user. Each culture has different rewards, and that's the challenge. People have to quit for a reason.”

To study the effectiveness of the program, researchers studied 130 men and women who answered an advertisement for the program. The significant others randomly were assigned to one of three interventions: CRAFT, the Johnson Institute Intervention, and Al-Anon Facilitation Therapy.

The significant other had to be a first-degree relative and had to be in contact with the substance abuser at least 40% of the time. The substance abuser had to be resistant to treatment, and there could be no planned separation or plans to change living arrangements.

The resulting treatment engagement rates after the sessions were 64% for the CRAFT program, 23% for the Johnson program, and 13% for Al-Anon.

But the program not only had a higher success rate for the substance abuser entering treatment; the emotional health of the spouses and other loved ones dramatically improved. The significant others' Beck Depression Inventory scores dropped from 10 to 6; there were significant changes in their levels of anger, and a significant lessening of anxiety.

“Problems with family relationships were reduced, family cohesion went up, and family conflict was reduced,” Dr. Meyers said.

The program teaches spouses, parents, and other relatives how to avoid arguments and deal with the potential of domestic violence, he said. “It teaches them how to get the loved one to stop drinking without nagging, pleading, or threatening.”

The CRAFT program also received funding from the National Institute on Drug Abuse for a demonstration project targeting treatment-resistant drug abusers. The drugs of choice included cocaine (used by 37%), marijuana (35%), stimulants (16%), opiates (8%), and sedatives or tranquilizers (3%). All but 3% of the significant others were women; about half were white and the other half Hispanic.

After the spouses and relatives underwent the CRAFT program, 74% of the drug abusers entered treatment, Dr. Meyer said. “The data really surprised us.”

ALBUQUERQUE, N.M. – Training family members can successfully get alcoholic patients and other substance abusers into treatment, a New Mexico psychologist said.

A new program that trains a spouse or other family member how best to deal with the addicted patient has shown a 64% success rate in getting loved ones into treatment. And this success rate far exceeds those of interventional programs and Al-Anon.

“The key is family members,” Robert J. Meyers, Ph.D., said at a psychiatric symposium sponsored by the University of New Mexico. “They have an enormous amount of information on the user that is very important. They help us get the individual to accept treatment.”

The Community Reinforcement and Family Training (CRAFT) approach, a 12-session program created by Dr. Meyers, seeks to empower spouses and other family members. The goals in part are to get families to take care of themselves and to lead fuller lives.

“We try to teach family members how to disassociate themselves from the user when they are drunk or stoned, and we show them how to give praise when the user is sober,” said Dr. Meyers, of the Center on Alcoholism, Substance Abuse, and Other Addictions at the University of New Mexico.

Many alcohol and drug abusers do not wish to enter treatment. “This program helps get them in the system before they totally unravel with driving under the influence records, prison, or hurting someone,” he said.

More traditional approaches, such as 12-step programs, advise waiting until the abuser wants help. For example, participants in the Johnson Institute Intervention program invite friends to a “surprise party” and as part of that exercise, a list is drawn up of all “the horrible things” the person has done. Al-Anon programs, which help partners and children of alcoholics, often do not get the alcoholic patient into treatment, he said.

The three major goals of the CRAFT program are to reduce the loved one's drinking, engage the person into treatment, and improve the functioning of the concerned significant other.

The CRAFT program, in 1-hour sessions, gives family members skills aimed at promoting sobriety in the loved ones by teaching them how to change their own behavior to have a positive impact. “They are taught how to change their interaction style, a new way of dealing with the drinker or drug abuser,” said Dr. Meyers, coauthor of “Get Your Loved One Sober: Alternatives to Nagging, Pleading, and Threatening” (Center City, Minn.: Hazelden Publishing and Educational Services, 2004).

The therapist helps the user find prosocial rewards in an effort to get the person to stop. “It's not meant to be a rigid treatment method,” Dr. Meyers said. “The key is to define what is rewarding to the individual user. Each culture has different rewards, and that's the challenge. People have to quit for a reason.”

To study the effectiveness of the program, researchers studied 130 men and women who answered an advertisement for the program. The significant others were randomly assigned to one of three interventions: CRAFT, the Johnson Institute Intervention, and Al-Anon Facilitation Therapy.

The significant other had to be a first-degree relative and had to be in contact with the substance abuser at least 40% of the time. The substance abuser had to be resistant to treatment, and there could be no planned separation or plans to change living arrangements.

The resulting treatment engagement rates after the sessions were 64% for the CRAFT program, 23% for the Johnson program, and 13% for Al-Anon.

But the program not only had a higher success rate for the substance abuser entering treatment; the emotional health of the spouses and other loved ones dramatically improved. The significant others' Beck Depression Inventory scores dropped from 10 to 6; there were significant changes in their levels of anger, and a significant lessening of anxiety.

“Problems with family relationships were reduced, family cohesion went up, and family conflict was reduced,” Dr. Meyers said.

The program teaches spouses, parents, and other relatives how to avoid arguments and deal with the potential of domestic violence, he explained. “It teaches them how to get the loved one to stop drinking without nagging, pleading, or threatening.”

The CRAFT program also received funding from the National Institute on Drug Abuse for a demonstration project targeting treatment-resistant drug abusers. The drugs of choice included cocaine (used by 37%), marijuana (35%), stimulants (16%), opiates (8%), and sedatives or tranquilizers (3%). All but 3% of the significant others were women; about half were white and the other half Hispanic.

After the spouses and relatives underwent the CRAFT program, 74% of the drug abusers entered treatment, Dr. Meyer said. “The data really surprised us.”

Other studies of the CRAFT program have shown similar results, Dr. Meyers said.

“There is a gigantic difference in the programs,” Dr. Meyers added. “The CRAFT program helps the family member navigate the world of the substance abuser. Most have said they never would go to treatment, but they went–and stayed.”

ALBUQUERQUE, N.M. – Training family members can successfully get alcoholic patients and other substance abusers into treatment, a New Mexico psychologist said.

A new program that trains a spouse or other family member how best to deal with the addicted patient has shown a 64% success rate in getting loved ones into treatment. And this success rate far exceeds those of interventional programs and Al-Anon.

“The key is family members,” Robert J. Meyers, Ph.D., said at a psychiatric symposium sponsored by the University of New Mexico. “They have an enormous amount of information on the user that is very important. They help us get the individual to accept treatment.”

The Community Reinforcement and Family Training (CRAFT) approach, a 12-session program created by Dr. Meyers, seeks to empower spouses and other family members. The goals in part are to get families to take care of themselves and to lead fuller lives.

“We try to teach family members how to disassociate themselves from the user when they are drunk or stoned, and we show them how to give praise when the user is sober,” said Dr. Meyers, of the Center on Alcoholism, Substance Abuse, and Other Addictions at the University of New Mexico.

Many alcohol and drug abusers do not wish to enter treatment. “This program helps get them in the system before they totally unravel with driving under the influence records, prison, or hurting someone,” he said.

More traditional approaches, such as 12-step programs, advise waiting until the abuser wants help. For example, participants in the Johnson Institute Intervention program invite friends to a “surprise party” and as part of that exercise, a list is drawn up of all “the horrible things” the person has done. Al-Anon programs, which help partners and children of alcoholics, often do not get the alcoholic patient into treatment, he said.

The three major goals of the CRAFT program are to reduce the loved one's drinking, engage the person into treatment, and improve the functioning of the concerned significant other.

The CRAFT program, in 1-hour sessions, gives family members skills aimed at promoting sobriety in the loved ones by teaching them how to change their own behavior to have a positive impact. “They are taught how to change their interaction style, a new way of dealing with the drinker or drug abuser,” said Dr. Meyers, coauthor of “Get Your Loved One Sober: Alternatives to Nagging, Pleading, and Threatening” (Center City, Minn.: Hazelden Publishing and Educational Services, 2004).

The therapist helps the user find prosocial rewards in an effort to get the person to stop. “It's not meant to be a rigid treatment method,” Dr. Meyers said. “The key is to define what is rewarding to the individual user. Each culture has different rewards, and that's the challenge. People have to quit for a reason.”

To study the effectiveness of the program, researchers studied 130 men and women who answered an advertisement for the program. The significant others were randomly assigned to one of three interventions: CRAFT, the Johnson Institute Intervention, and Al-Anon Facilitation Therapy.

The significant other had to be a first-degree relative and had to be in contact with the substance abuser at least 40% of the time. The substance abuser had to be resistant to treatment, and there could be no planned separation or plans to change living arrangements.

The resulting treatment engagement rates after the sessions were 64% for the CRAFT program, 23% for the Johnson program, and 13% for Al-Anon.

But the program not only had a higher success rate for the substance abuser entering treatment; the emotional health of the spouses and other loved ones dramatically improved. The significant others' Beck Depression Inventory scores dropped from 10 to 6; there were significant changes in their levels of anger, and a significant lessening of anxiety.

“Problems with family relationships were reduced, family cohesion went up, and family conflict was reduced,” Dr. Meyers said.

The program teaches spouses, parents, and other relatives how to avoid arguments and deal with the potential of domestic violence, he explained. “It teaches them how to get the loved one to stop drinking without nagging, pleading, or threatening.”

The CRAFT program also received funding from the National Institute on Drug Abuse for a demonstration project targeting treatment-resistant drug abusers. The drugs of choice included cocaine (used by 37%), marijuana (35%), stimulants (16%), opiates (8%), and sedatives or tranquilizers (3%). All but 3% of the significant others were women; about half were white and the other half Hispanic.

After the spouses and relatives underwent the CRAFT program, 74% of the drug abusers entered treatment, Dr. Meyer said. “The data really surprised us.”

Other studies of the CRAFT program have shown similar results, Dr. Meyers said.

“There is a gigantic difference in the programs,” Dr. Meyers added. “The CRAFT program helps the family member navigate the world of the substance abuser. Most have said they never would go to treatment, but they went–and stayed.”

ALBUQUERQUE, N.M. – Training family members can successfully get alcoholic patients and other substance abusers into treatment, a New Mexico psychologist said.

A new program that trains a spouse or other family member how best to deal with the addicted patient has shown a 64% success rate in getting loved ones into treatment. And this success rate far exceeds those of interventional programs and Al-Anon.

“The key is family members,” Robert J. Meyers, Ph.D., said at a psychiatric symposium sponsored by the University of New Mexico. “They have an enormous amount of information on the user that is very important. They help us get the individual to accept treatment.”

The Community Reinforcement and Family Training (CRAFT) approach, a 12-session program created by Dr. Meyers, seeks to empower spouses and other family members. The goals in part are to get families to take care of themselves and to lead fuller lives.

“We try to teach family members how to disassociate themselves from the user when they are drunk or stoned, and we show them how to give praise when the user is sober,” said Dr. Meyers, of the Center on Alcoholism, Substance Abuse, and Other Addictions at the University of New Mexico.

Many alcohol and drug abusers do not wish to enter treatment. “This program helps get them in the system before they totally unravel with driving under the influence records, prison, or hurting someone,” he said.

More traditional approaches, such as 12-step programs, advise waiting until the abuser wants help. For example, participants in the Johnson Institute Intervention program invite friends to a “surprise party” and as part of that exercise, a list is drawn up of all “the horrible things” the person has done. Al-Anon programs, which help partners and children of alcoholics, often do not get the alcoholic patient into treatment, he said.

The three major goals of the CRAFT program are to reduce the loved one's drinking, engage the person into treatment, and improve the functioning of the concerned significant other.

The CRAFT program, in 1-hour sessions, gives family members skills aimed at promoting sobriety in the loved ones by teaching them how to change their own behavior to have a positive impact. “They are taught how to change their interaction style, a new way of dealing with the drinker or drug abuser,” said Dr. Meyers, coauthor of “Get Your Loved One Sober: Alternatives to Nagging, Pleading, and Threatening” (Center City, Minn.: Hazelden Publishing and Educational Services, 2004).

The therapist helps the user find prosocial rewards in an effort to get the person to stop. “It's not meant to be a rigid treatment method,” Dr. Meyers said. “The key is to define what is rewarding to the individual user. Each culture has different rewards, and that's the challenge. People have to quit for a reason.”

To study the effectiveness of the program, researchers studied 130 men and women who answered an advertisement for the program. The significant others were randomly assigned to one of three interventions: CRAFT, the Johnson Institute Intervention, and Al-Anon Facilitation Therapy.

The significant other had to be a first-degree relative and had to be in contact with the substance abuser at least 40% of the time. The substance abuser had to be resistant to treatment, and there could be no planned separation or plans to change living arrangements.

The resulting treatment engagement rates after the sessions were 64% for the CRAFT program, 23% for the Johnson program, and 13% for Al-Anon.

But the program not only had a higher success rate for the substance abuser entering treatment; the emotional health of the spouses and other loved ones dramatically improved. The significant others' Beck Depression Inventory scores dropped from 10 to 6; there were significant changes in their levels of anger, and a significant lessening of anxiety.

“Problems with family relationships were reduced, family cohesion went up, and family conflict was reduced,” Dr. Meyers said.

The program teaches spouses, parents, and other relatives how to avoid arguments and deal with the potential of domestic violence, he explained. “It teaches them how to get the loved one to stop drinking without nagging, pleading, or threatening.”

The CRAFT program also received funding from the National Institute on Drug Abuse for a demonstration project targeting treatment-resistant drug abusers. The drugs of choice included cocaine (used by 37%), marijuana (35%), stimulants (16%), opiates (8%), and sedatives or tranquilizers (3%). All but 3% of the significant others were women; about half were white and the other half Hispanic.

After the spouses and relatives underwent the CRAFT program, 74% of the drug abusers entered treatment, Dr. Meyer said. “The data really surprised us.”

Other studies of the CRAFT program have shown similar results, Dr. Meyers said.

“There is a gigantic difference in the programs,” Dr. Meyers added. “The CRAFT program helps the family member navigate the world of the substance abuser. Most have said they never would go to treatment, but they went–and stayed.”

GRAPEVINE, TEX. – A tiered diagnostic work-up can double the rate of diagnosis of the syndromes and conditions associated with early-childhood autism, G. Bradley Schaefer, M.D., reported at a meeting sponsored by the American College of Medical Genetics.

The reported incidence of autism has increased fourfold, to 4–5 per 1,000, said Dr. Schaefer, professor of pediatrics at the University of Nebraska, Omaha.

Despite this dramatic increase, only about 20% of patients are now identified with a known syndrome or condition as the underlying cause of the autism, he said.

But that can be increased to 40% of patients if a tiered system of diagnosis is used, he said. His group applied the diagnostic system to all children with autism in University of Nebraska clinics over a 3-year period.

“All patients with autism should see a geneticist,” Dr. Schaefer said. “Families need and want to know why the autism occurred and the risk of recurrence. Diagnosing the condition also has implications for outcome and long-term treatment.”

What is known is that autism is four times more common in males than females, and the likelihood of recurrence within a family depends on the sex of the autistic child. In a family with an autistic girl, there is a 4% chance of autism in a second child. If the affected child is a boy, there is a 7% chance of recurrence. If two children are affected, the recurrence rate is 25%. “There are different genes associated with autism,” he said. “But with some of the newer genetic tests developed in the past 5 years, the diagnosis of the causative syndromes and conditions is increasing.”

The initial evaluation to identify autism should include a dysmorphologic examination, including a Wood's-lamp evaluation and, if autism is suspected, targeted testing. There should be a standard metabolic screening, sensory screening, EEG, and, if clinical indicators are present, a screening for toxoplasmosis, rubella, Cytomegalovirus, and herpes (TORCH) titers, which detects congenital infections–particularly fetal rubella.

If the underlying condition or syndrome is not detected, then testing for prometaphase chromosomes and fragile X syndrome, as well as a brain MRI, should be done.

The third tier comprises MECP2 gene testing; 15-interphase fluorescence in situ hybridization (FISH); 15-methylation/FISH for Prader-Willi, Angelman's, and other syndromes; 17q FISH for Smith-Magenis syndrome; serum and urine uric-acid tests; and a subtelomeric FISH panel if the IQ is below 50.

The fourth tier is less clear and includes metabolic tests that are sometimes unavailable, he said, adding that the tests are of unclear utility but can increase the diagnosis rate.

The final tier includes subtelomeric FISH; comparative genomic hybridization; screening for folate-sensitive fragile sites, 7-dehydrocholesterol, and the UBE3A gene; and an extended metabolic work-up. If testing is done beyond the initial examination, the rate of identification doubles, he said.

“It's exciting to know that we are better at figuring out the causes of autism,” Dr. Schaefer said. “This can have an effect on the long-term outcome of the patient and set the stage for future treatments.”

GRAPEVINE, TEX. – A tiered diagnostic work-up can double the rate of diagnosis of the syndromes and conditions associated with early-childhood autism, G. Bradley Schaefer, M.D., reported at a meeting sponsored by the American College of Medical Genetics.

The reported incidence of autism has increased fourfold, to 4–5 per 1,000, said Dr. Schaefer, professor of pediatrics at the University of Nebraska, Omaha.

Despite this dramatic increase, only about 20% of patients are now identified with a known syndrome or condition as the underlying cause of the autism, he said.

But that can be increased to 40% of patients if a tiered system of diagnosis is used, he said. His group applied the diagnostic system to all children with autism in University of Nebraska clinics over a 3-year period.

“All patients with autism should see a geneticist,” Dr. Schaefer said. “Families need and want to know why the autism occurred and the risk of recurrence. Diagnosing the condition also has implications for outcome and long-term treatment.”

What is known is that autism is four times more common in males than females, and the likelihood of recurrence within a family depends on the sex of the autistic child. In a family with an autistic girl, there is a 4% chance of autism in a second child. If the affected child is a boy, there is a 7% chance of recurrence. If two children are affected, the recurrence rate is 25%. “There are different genes associated with autism,” he said. “But with some of the newer genetic tests developed in the past 5 years, the diagnosis of the causative syndromes and conditions is increasing.”

The initial evaluation to identify autism should include a dysmorphologic examination, including a Wood's-lamp evaluation and, if autism is suspected, targeted testing. There should be a standard metabolic screening, sensory screening, EEG, and, if clinical indicators are present, a screening for toxoplasmosis, rubella, Cytomegalovirus, and herpes (TORCH) titers, which detects congenital infections–particularly fetal rubella.

If the underlying condition or syndrome is not detected, then testing for prometaphase chromosomes and fragile X syndrome, as well as a brain MRI, should be done.

The third tier comprises MECP2 gene testing; 15-interphase fluorescence in situ hybridization (FISH); 15-methylation/FISH for Prader-Willi, Angelman's, and other syndromes; 17q FISH for Smith-Magenis syndrome; serum and urine uric-acid tests; and a subtelomeric FISH panel if the IQ is below 50.

The fourth tier is less clear and includes metabolic tests that are sometimes unavailable, he said, adding that the tests are of unclear utility but can increase the diagnosis rate.

The final tier includes subtelomeric FISH; comparative genomic hybridization; screening for folate-sensitive fragile sites, 7-dehydrocholesterol, and the UBE3A gene; and an extended metabolic work-up. If testing is done beyond the initial examination, the rate of identification doubles, he said.

“It's exciting to know that we are better at figuring out the causes of autism,” Dr. Schaefer said. “This can have an effect on the long-term outcome of the patient and set the stage for future treatments.”

GRAPEVINE, TEX. – A tiered diagnostic work-up can double the rate of diagnosis of the syndromes and conditions associated with early-childhood autism, G. Bradley Schaefer, M.D., reported at a meeting sponsored by the American College of Medical Genetics.

The reported incidence of autism has increased fourfold, to 4–5 per 1,000, said Dr. Schaefer, professor of pediatrics at the University of Nebraska, Omaha.

Despite this dramatic increase, only about 20% of patients are now identified with a known syndrome or condition as the underlying cause of the autism, he said.

But that can be increased to 40% of patients if a tiered system of diagnosis is used, he said. His group applied the diagnostic system to all children with autism in University of Nebraska clinics over a 3-year period.

“All patients with autism should see a geneticist,” Dr. Schaefer said. “Families need and want to know why the autism occurred and the risk of recurrence. Diagnosing the condition also has implications for outcome and long-term treatment.”

What is known is that autism is four times more common in males than females, and the likelihood of recurrence within a family depends on the sex of the autistic child. In a family with an autistic girl, there is a 4% chance of autism in a second child. If the affected child is a boy, there is a 7% chance of recurrence. If two children are affected, the recurrence rate is 25%. “There are different genes associated with autism,” he said. “But with some of the newer genetic tests developed in the past 5 years, the diagnosis of the causative syndromes and conditions is increasing.”

The initial evaluation to identify autism should include a dysmorphologic examination, including a Wood's-lamp evaluation and, if autism is suspected, targeted testing. There should be a standard metabolic screening, sensory screening, EEG, and, if clinical indicators are present, a screening for toxoplasmosis, rubella, Cytomegalovirus, and herpes (TORCH) titers, which detects congenital infections–particularly fetal rubella.

If the underlying condition or syndrome is not detected, then testing for prometaphase chromosomes and fragile X syndrome, as well as a brain MRI, should be done.

The third tier comprises MECP2 gene testing; 15-interphase fluorescence in situ hybridization (FISH); 15-methylation/FISH for Prader-Willi, Angelman's, and other syndromes; 17q FISH for Smith-Magenis syndrome; serum and urine uric-acid tests; and a subtelomeric FISH panel if the IQ is below 50.

The fourth tier is less clear and includes metabolic tests that are sometimes unavailable, he said, adding that the tests are of unclear utility but can increase the diagnosis rate.

The final tier includes subtelomeric FISH; comparative genomic hybridization; screening for folate-sensitive fragile sites, 7-dehydrocholesterol, and the UBE3A gene; and an extended metabolic work-up. If testing is done beyond the initial examination, the rate of identification doubles, he said.

“It's exciting to know that we are better at figuring out the causes of autism,” Dr. Schaefer said. “This can have an effect on the long-term outcome of the patient and set the stage for future treatments.”

GRAPEVINE, TEX. — African American women are almost as likely to pursue genetic testing for breast cancer as are white women, North Carolina researchers report.

“There is a perception in the genetic counseling field that African Americans are less likely to pursue genetic testing when it's offered,” said Lisa Susswein, genetic counselor, University of North Carolina at Chapel Hill. “It has been thought that there were cultural barriers and, possibly, the inability to pay that kept African Americans from genetic testing.”

But when women diagnosed with or at high risk for breast cancer were offered a test to detect BRCA1 or BRCA2 gene mutations, both African Americans and whites accepted. The results were presented at a meeting sponsored by the American College of Medical Genetics.

The test was offered to women who exceeded a 5%–10% risk of harboring a BRCA mutation as well as to women recently diagnosed with breast cancer. The test was offered to more than 800 women referred to the center.

Of those in the overall high-risk population who were offered the test, 58% of white women and 43% of African American women pursued the test. Among those women recently diagnosed with breast cancer, acceptance was 61% among whites and 50% among African American women, which was not a statistically significant difference.

Many studies have shown black women are less likely to pursue genetics testing, she said. “This may have been perpetuated by physicians not offering genetics testing, and it's a circle that continues.”

Regardless of race, it is important to do testing in breast cancer patients before the primary surgery so they can be given the opportunity to have one surgery with prophylactic double mastectomies, she said.

“This shows that African American women are interested in BRCA testing,” Ms. Susswein said. “We … shouldn't shy away from offering them the test.”

GRAPEVINE, TEX. — African American women are almost as likely to pursue genetic testing for breast cancer as are white women, North Carolina researchers report.

“There is a perception in the genetic counseling field that African Americans are less likely to pursue genetic testing when it's offered,” said Lisa Susswein, genetic counselor, University of North Carolina at Chapel Hill. “It has been thought that there were cultural barriers and, possibly, the inability to pay that kept African Americans from genetic testing.”

But when women diagnosed with or at high risk for breast cancer were offered a test to detect BRCA1 or BRCA2 gene mutations, both African Americans and whites accepted. The results were presented at a meeting sponsored by the American College of Medical Genetics.

The test was offered to women who exceeded a 5%–10% risk of harboring a BRCA mutation as well as to women recently diagnosed with breast cancer. The test was offered to more than 800 women referred to the center.

Of those in the overall high-risk population who were offered the test, 58% of white women and 43% of African American women pursued the test. Among those women recently diagnosed with breast cancer, acceptance was 61% among whites and 50% among African American women, which was not a statistically significant difference.

Many studies have shown black women are less likely to pursue genetics testing, she said. “This may have been perpetuated by physicians not offering genetics testing, and it's a circle that continues.”

Regardless of race, it is important to do testing in breast cancer patients before the primary surgery so they can be given the opportunity to have one surgery with prophylactic double mastectomies, she said.

“This shows that African American women are interested in BRCA testing,” Ms. Susswein said. “We … shouldn't shy away from offering them the test.”

GRAPEVINE, TEX. — African American women are almost as likely to pursue genetic testing for breast cancer as are white women, North Carolina researchers report.

“There is a perception in the genetic counseling field that African Americans are less likely to pursue genetic testing when it's offered,” said Lisa Susswein, genetic counselor, University of North Carolina at Chapel Hill. “It has been thought that there were cultural barriers and, possibly, the inability to pay that kept African Americans from genetic testing.”

But when women diagnosed with or at high risk for breast cancer were offered a test to detect BRCA1 or BRCA2 gene mutations, both African Americans and whites accepted. The results were presented at a meeting sponsored by the American College of Medical Genetics.

The test was offered to women who exceeded a 5%–10% risk of harboring a BRCA mutation as well as to women recently diagnosed with breast cancer. The test was offered to more than 800 women referred to the center.

Of those in the overall high-risk population who were offered the test, 58% of white women and 43% of African American women pursued the test. Among those women recently diagnosed with breast cancer, acceptance was 61% among whites and 50% among African American women, which was not a statistically significant difference.

Many studies have shown black women are less likely to pursue genetics testing, she said. “This may have been perpetuated by physicians not offering genetics testing, and it's a circle that continues.”

Regardless of race, it is important to do testing in breast cancer patients before the primary surgery so they can be given the opportunity to have one surgery with prophylactic double mastectomies, she said.

“This shows that African American women are interested in BRCA testing,” Ms. Susswein said. “We … shouldn't shy away from offering them the test.”

GRAPEVINE, TEX. – Physicians need to be alert to a cause of autism that might not be immediately apparent in milder cases, a Colorado pediatrician warned.

Smith-Lemli-Opitz syndrome (SLOS), a disorder caused by a defect in the cholesterol metabolic pathway, should be in the differential diagnosis for children presenting with autism, said Ellen Elias, M.D., director of the special care clinic of the Children's Hospital, Denver.

Some SLOS children with autism never see a geneticist and may be followed by a developmental pediatrician or neurologist, she said. “Often, they are not diagnosed if they are a milder case without the usual facial features.”

Yet a simple blood test can alert parents to the 25% recurrence rate as well as treatment that can alleviate some behavioral problems in this syndrome, she said.

SLOS is an autosomal recessive disorder caused by a metabolic error in the cholesterol pathway. Children with SLOS have distinct facial features: smaller heads, upturned noses, and small chins; growth retardation; mental retardation; and multiple birth defects. In milder forms of the syndrome, children might not have the distinctive facial features and may present with autism, Dr. Elias and her associates wrote in a poster presentation at the American College of Medical Genetics.

In a study of 15 patients with confirmed SLOS followed in the clinic, the researchers found that three males had the classic autism phenotype but didn't have the classic physical features of SLOS. Two of the boys had sisters with SLOS but without autism. Dr. Elias predicts that the syndrome is far more common than the estimated 20,000 children with the classic form. “People at the mild end of the syndrome don't get tested or identified,” she said.

“The incidence of autism has increased dramatically over the past 10 years,” she said. Although genetic etiologies are suspected, only 10% of autism patients are identified as having a genetic diagnosis.

The simple blood test for SLOS testing for elevated serum 7-dehydrocholesterol was developed in 1994 and can be used prenatally and in children suspected of having the syndrome. It also allows diagnosis of the children who fall into the milder end of the spectrum, particularly those who lack the typical facial features or birth defects associated with the classic SLOS.

In children presenting with autism without the typical features with SLOS, she advised physicians to test for SLOS in children with milder features. Physicians should look for growth retardation, a head that is on the small side, and webbing between the second and third toe.

If children aren't diagnosed correctly, they won't receive adequate treatment, and there is a chance of siblings being born with the syndrome, Dr. Elias said.

Children with SLOS can benefit from cholesterol treatment, which lessens some behavioral side effects of the syndrome, such as irritability and attention deficit, she said. In addition, children with SLOS should not be treated with Haldol (haloperidol) or BuSpar (buspirone), which can exacerbate the biochemical parameters of the syndrome.

If SLOS is suspected, it is important that the blood sample be sent to a special laboratory, because many hospital-based laboratories cannot distinguish between cholesterol and its precursor, 7-dehydrocholesterol, she said.

“There is a tendency to look at these children and think they are normal in appearance and simply have autism,” Dr. Elias said. “It is important not to miss a diagnosis of a child with SLOS in a child presenting with autism, so that appropriate genetic counseling can be provided to the family and [cholesterol treatment] may ameliorate problematic behavior in the child.”

GRAPEVINE, TEX. – Physicians need to be alert to a cause of autism that might not be immediately apparent in milder cases, a Colorado pediatrician warned.

Smith-Lemli-Opitz syndrome (SLOS), a disorder caused by a defect in the cholesterol metabolic pathway, should be in the differential diagnosis for children presenting with autism, said Ellen Elias, M.D., director of the special care clinic of the Children's Hospital, Denver.

Some SLOS children with autism never see a geneticist and may be followed by a developmental pediatrician or neurologist, she said. “Often, they are not diagnosed if they are a milder case without the usual facial features.”

Yet a simple blood test can alert parents to the 25% recurrence rate as well as treatment that can alleviate some behavioral problems in this syndrome, she said.

SLOS is an autosomal recessive disorder caused by a metabolic error in the cholesterol pathway. Children with SLOS have distinct facial features: smaller heads, upturned noses, and small chins; growth retardation; mental retardation; and multiple birth defects. In milder forms of the syndrome, children might not have the distinctive facial features and may present with autism, Dr. Elias and her associates wrote in a poster presentation at the American College of Medical Genetics.

In a study of 15 patients with confirmed SLOS followed in the clinic, the researchers found that three males had the classic autism phenotype but didn't have the classic physical features of SLOS. Two of the boys had sisters with SLOS but without autism. Dr. Elias predicts that the syndrome is far more common than the estimated 20,000 children with the classic form. “People at the mild end of the syndrome don't get tested or identified,” she said.

“The incidence of autism has increased dramatically over the past 10 years,” she said. Although genetic etiologies are suspected, only 10% of autism patients are identified as having a genetic diagnosis.

The simple blood test for SLOS testing for elevated serum 7-dehydrocholesterol was developed in 1994 and can be used prenatally and in children suspected of having the syndrome. It also allows diagnosis of the children who fall into the milder end of the spectrum, particularly those who lack the typical facial features or birth defects associated with the classic SLOS.

In children presenting with autism without the typical features with SLOS, she advised physicians to test for SLOS in children with milder features. Physicians should look for growth retardation, a head that is on the small side, and webbing between the second and third toe.

If children aren't diagnosed correctly, they won't receive adequate treatment, and there is a chance of siblings being born with the syndrome, Dr. Elias said.

Children with SLOS can benefit from cholesterol treatment, which lessens some behavioral side effects of the syndrome, such as irritability and attention deficit, she said. In addition, children with SLOS should not be treated with Haldol (haloperidol) or BuSpar (buspirone), which can exacerbate the biochemical parameters of the syndrome.

If SLOS is suspected, it is important that the blood sample be sent to a special laboratory, because many hospital-based laboratories cannot distinguish between cholesterol and its precursor, 7-dehydrocholesterol, she said.

“There is a tendency to look at these children and think they are normal in appearance and simply have autism,” Dr. Elias said. “It is important not to miss a diagnosis of a child with SLOS in a child presenting with autism, so that appropriate genetic counseling can be provided to the family and [cholesterol treatment] may ameliorate problematic behavior in the child.”

GRAPEVINE, TEX. – Physicians need to be alert to a cause of autism that might not be immediately apparent in milder cases, a Colorado pediatrician warned.

Smith-Lemli-Opitz syndrome (SLOS), a disorder caused by a defect in the cholesterol metabolic pathway, should be in the differential diagnosis for children presenting with autism, said Ellen Elias, M.D., director of the special care clinic of the Children's Hospital, Denver.

Some SLOS children with autism never see a geneticist and may be followed by a developmental pediatrician or neurologist, she said. “Often, they are not diagnosed if they are a milder case without the usual facial features.”

Yet a simple blood test can alert parents to the 25% recurrence rate as well as treatment that can alleviate some behavioral problems in this syndrome, she said.

SLOS is an autosomal recessive disorder caused by a metabolic error in the cholesterol pathway. Children with SLOS have distinct facial features: smaller heads, upturned noses, and small chins; growth retardation; mental retardation; and multiple birth defects. In milder forms of the syndrome, children might not have the distinctive facial features and may present with autism, Dr. Elias and her associates wrote in a poster presentation at the American College of Medical Genetics.

In a study of 15 patients with confirmed SLOS followed in the clinic, the researchers found that three males had the classic autism phenotype but didn't have the classic physical features of SLOS. Two of the boys had sisters with SLOS but without autism. Dr. Elias predicts that the syndrome is far more common than the estimated 20,000 children with the classic form. “People at the mild end of the syndrome don't get tested or identified,” she said.

“The incidence of autism has increased dramatically over the past 10 years,” she said. Although genetic etiologies are suspected, only 10% of autism patients are identified as having a genetic diagnosis.

The simple blood test for SLOS testing for elevated serum 7-dehydrocholesterol was developed in 1994 and can be used prenatally and in children suspected of having the syndrome. It also allows diagnosis of the children who fall into the milder end of the spectrum, particularly those who lack the typical facial features or birth defects associated with the classic SLOS.

In children presenting with autism without the typical features with SLOS, she advised physicians to test for SLOS in children with milder features. Physicians should look for growth retardation, a head that is on the small side, and webbing between the second and third toe.

If children aren't diagnosed correctly, they won't receive adequate treatment, and there is a chance of siblings being born with the syndrome, Dr. Elias said.

Children with SLOS can benefit from cholesterol treatment, which lessens some behavioral side effects of the syndrome, such as irritability and attention deficit, she said. In addition, children with SLOS should not be treated with Haldol (haloperidol) or BuSpar (buspirone), which can exacerbate the biochemical parameters of the syndrome.

If SLOS is suspected, it is important that the blood sample be sent to a special laboratory, because many hospital-based laboratories cannot distinguish between cholesterol and its precursor, 7-dehydrocholesterol, she said.

“There is a tendency to look at these children and think they are normal in appearance and simply have autism,” Dr. Elias said. “It is important not to miss a diagnosis of a child with SLOS in a child presenting with autism, so that appropriate genetic counseling can be provided to the family and [cholesterol treatment] may ameliorate problematic behavior in the child.”

LAS VEGAS — The worst advice a physician can give to an injured young ballet dancer is to “quit dancing,” a San Francisco sports medicine physician said at a meeting sponsored by the American Academy of Pediatrics and California Chapter 2 of the AAP.

“This is the last time you will see this girl. This will drive [her] into the arms of irregular practitioners,” said James G. Garrick, M.D., director of the Center for Sports Medicine, Saint Francis Memorial Hospital, San Francisco.

Physicians must realize that these are committed young people who follow instructions. “There are more little girls taking ballet than little boys playing football, soccer, or baseball,” Dr. Garrick commented. Limiting ballet while doing other exercises works when ballet dancers are injured.

Seventy-seven percent of ballet injuries occur in females, with 32% occurring between the ages of 12 and 17 years. Injuries usually are in the lower body—26% occurring in the foot, 21% in the knee, and 17% in the ankle. But in student dancers, one-third of injuries occur in the foot and toes.

Younger dancers have more foot injuries, said Dr. Garrick, whose clinic has treated more than 5,000 ballet dancers. “They have more foot injuries because they are too young to take care of their feet. In time, they learn.”

But fortunately, the injury rate is quite low in the younger ages and only starts to rise in the teenage years when “girls get pretty serious about dancing,” he said. These girls are taking two or three dance classes a day, three or four times a week.

Most of the injuries—42%—are attributed to overuse, Dr. Garrick said. Overuse injuries are highest among younger dancers.

Ballet also requires abnormal body motion with femoral retroversion, hyperextended knees, excessive ankle dorsiflexion, and excessive ankle plantar flexion.

When an injury does occur, physicians should request that the dancer limit her ballet until the injury heals instead of requesting she stop dancing. Dr. Garrick said a dancer can be asked to not jump and make quick turns, and to do more barre work where there is support and they are working on extending range of motion in a way that doesn't require strength.

He recommended Pilates and an exercise bicycle for dancers to stay in shape once an injury occurs; running should be avoided.

“Always provide an alternative for time missed from dancing,” he said. “Recommend exercise that doesn't require painful motion of anything that will worsen the injury.”

Begin isometrics on the day of injury. Use electrical muscle stimulation, if possible, and resistance bands to strengthen muscles with limited range of motion exercises, he said.

Ankle sprains are the most common acute injury and usually are lateral. Dr. Garrick recommended horseshoe compression in the area to prevent swelling. “It's important to get some compression in this area.” If the ankle swells, then there is a loss of motion and then a loss of muscle strength, which makes patients more apt to have future sprained ankles.

Another common injury is posterior ankle impingement in the back of the ankle. “This usually occurs in a dancer's career when they are starting to get very serious, commonly in ages 15–19 years,” he said. “Often it occurs with intense rehearsals or preparing for auditions.”

Physicians need to reproduce the pain actively or passively to diagnose. If taking x-rays, then the ankle should be flexed and bearing weight if possible. At times, MRI is necessary and can reveal cysts or ganglia, compromised articular cartilage, or posterior talus.

Other injuries that can occur are stress fractures, knee injuries, hip pain, and spondylolysis.

Dr. Garrick said surgery isn't commonly used in ballet dancers, adding that few procedures are effective for these injuries. “There are minor complications in many operations that are disasters for ballet dancers,” he said.

LAS VEGAS — The worst advice a physician can give to an injured young ballet dancer is to “quit dancing,” a San Francisco sports medicine physician said at a meeting sponsored by the American Academy of Pediatrics and California Chapter 2 of the AAP.

“This is the last time you will see this girl. This will drive [her] into the arms of irregular practitioners,” said James G. Garrick, M.D., director of the Center for Sports Medicine, Saint Francis Memorial Hospital, San Francisco.

Physicians must realize that these are committed young people who follow instructions. “There are more little girls taking ballet than little boys playing football, soccer, or baseball,” Dr. Garrick commented. Limiting ballet while doing other exercises works when ballet dancers are injured.

Seventy-seven percent of ballet injuries occur in females, with 32% occurring between the ages of 12 and 17 years. Injuries usually are in the lower body—26% occurring in the foot, 21% in the knee, and 17% in the ankle. But in student dancers, one-third of injuries occur in the foot and toes.

Younger dancers have more foot injuries, said Dr. Garrick, whose clinic has treated more than 5,000 ballet dancers. “They have more foot injuries because they are too young to take care of their feet. In time, they learn.”

But fortunately, the injury rate is quite low in the younger ages and only starts to rise in the teenage years when “girls get pretty serious about dancing,” he said. These girls are taking two or three dance classes a day, three or four times a week.

Most of the injuries—42%—are attributed to overuse, Dr. Garrick said. Overuse injuries are highest among younger dancers.

Ballet also requires abnormal body motion with femoral retroversion, hyperextended knees, excessive ankle dorsiflexion, and excessive ankle plantar flexion.

When an injury does occur, physicians should request that the dancer limit her ballet until the injury heals instead of requesting she stop dancing. Dr. Garrick said a dancer can be asked to not jump and make quick turns, and to do more barre work where there is support and they are working on extending range of motion in a way that doesn't require strength.

He recommended Pilates and an exercise bicycle for dancers to stay in shape once an injury occurs; running should be avoided.

“Always provide an alternative for time missed from dancing,” he said. “Recommend exercise that doesn't require painful motion of anything that will worsen the injury.”

Begin isometrics on the day of injury. Use electrical muscle stimulation, if possible, and resistance bands to strengthen muscles with limited range of motion exercises, he said.

Ankle sprains are the most common acute injury and usually are lateral. Dr. Garrick recommended horseshoe compression in the area to prevent swelling. “It's important to get some compression in this area.” If the ankle swells, then there is a loss of motion and then a loss of muscle strength, which makes patients more apt to have future sprained ankles.

Another common injury is posterior ankle impingement in the back of the ankle. “This usually occurs in a dancer's career when they are starting to get very serious, commonly in ages 15–19 years,” he said. “Often it occurs with intense rehearsals or preparing for auditions.”

Physicians need to reproduce the pain actively or passively to diagnose. If taking x-rays, then the ankle should be flexed and bearing weight if possible. At times, MRI is necessary and can reveal cysts or ganglia, compromised articular cartilage, or posterior talus.

Other injuries that can occur are stress fractures, knee injuries, hip pain, and spondylolysis.

Dr. Garrick said surgery isn't commonly used in ballet dancers, adding that few procedures are effective for these injuries. “There are minor complications in many operations that are disasters for ballet dancers,” he said.

LAS VEGAS — The worst advice a physician can give to an injured young ballet dancer is to “quit dancing,” a San Francisco sports medicine physician said at a meeting sponsored by the American Academy of Pediatrics and California Chapter 2 of the AAP.

“This is the last time you will see this girl. This will drive [her] into the arms of irregular practitioners,” said James G. Garrick, M.D., director of the Center for Sports Medicine, Saint Francis Memorial Hospital, San Francisco.

Physicians must realize that these are committed young people who follow instructions. “There are more little girls taking ballet than little boys playing football, soccer, or baseball,” Dr. Garrick commented. Limiting ballet while doing other exercises works when ballet dancers are injured.

Seventy-seven percent of ballet injuries occur in females, with 32% occurring between the ages of 12 and 17 years. Injuries usually are in the lower body—26% occurring in the foot, 21% in the knee, and 17% in the ankle. But in student dancers, one-third of injuries occur in the foot and toes.

Younger dancers have more foot injuries, said Dr. Garrick, whose clinic has treated more than 5,000 ballet dancers. “They have more foot injuries because they are too young to take care of their feet. In time, they learn.”

But fortunately, the injury rate is quite low in the younger ages and only starts to rise in the teenage years when “girls get pretty serious about dancing,” he said. These girls are taking two or three dance classes a day, three or four times a week.

Most of the injuries—42%—are attributed to overuse, Dr. Garrick said. Overuse injuries are highest among younger dancers.

Ballet also requires abnormal body motion with femoral retroversion, hyperextended knees, excessive ankle dorsiflexion, and excessive ankle plantar flexion.

When an injury does occur, physicians should request that the dancer limit her ballet until the injury heals instead of requesting she stop dancing. Dr. Garrick said a dancer can be asked to not jump and make quick turns, and to do more barre work where there is support and they are working on extending range of motion in a way that doesn't require strength.

He recommended Pilates and an exercise bicycle for dancers to stay in shape once an injury occurs; running should be avoided.

“Always provide an alternative for time missed from dancing,” he said. “Recommend exercise that doesn't require painful motion of anything that will worsen the injury.”

Begin isometrics on the day of injury. Use electrical muscle stimulation, if possible, and resistance bands to strengthen muscles with limited range of motion exercises, he said.

Ankle sprains are the most common acute injury and usually are lateral. Dr. Garrick recommended horseshoe compression in the area to prevent swelling. “It's important to get some compression in this area.” If the ankle swells, then there is a loss of motion and then a loss of muscle strength, which makes patients more apt to have future sprained ankles.

Another common injury is posterior ankle impingement in the back of the ankle. “This usually occurs in a dancer's career when they are starting to get very serious, commonly in ages 15–19 years,” he said. “Often it occurs with intense rehearsals or preparing for auditions.”

Physicians need to reproduce the pain actively or passively to diagnose. If taking x-rays, then the ankle should be flexed and bearing weight if possible. At times, MRI is necessary and can reveal cysts or ganglia, compromised articular cartilage, or posterior talus.

Other injuries that can occur are stress fractures, knee injuries, hip pain, and spondylolysis.

Dr. Garrick said surgery isn't commonly used in ballet dancers, adding that few procedures are effective for these injuries. “There are minor complications in many operations that are disasters for ballet dancers,” he said.

SCOTTSDALE, ARIZ. — Although childhood malignant melanomas are rare, physicians must keep an eye out for them, Ronald C. Hansen, M.D., said at a pediatric update sponsored by Phoenix Children's Hospital.

About 2% of all melanomas appear in children, but the types that commonly occur in children are different from those found in adults. Melanomas in children arise from congenital nevi, de novo nodular nevi, and superficial spreading melanomas that are sun induced, said Dr. Hansen, a dermatologist at the hospital.

Although 70% of melanomas in adults are sun induced, superficial spreading melanomas, about 80% in children arise from congenital nevi or de novo nodular lesions, he said. “There are very, very different concepts of melanoma in childhood.” Congenital nevi that occur in 2% of children arise during the first 4 months of life. Most are small, less than 1.5 cm.

Excision of congenital nevi is not necessary in infancy, but Dr. Hansen suggests that children with nevi be followed closely. “In children, these are more important than the other moles.”

Melanomas in small congenital nevi usually occur at or after puberty, he said. “I recommend prophylactic excision at age 10 in girls and at age 13 in boys, especially if the nevi are on the scalp, face, or trunk. This is a treatment strategy. It's not necessarily what everyone else advocates.”

Giant nevi in children and those over 6 cm in a newborn, have a 5%–8% melanoma risk. Many of these nevi are too large to totally excise. However, Dr. Hansen recommends prophylactic excision in the areas of highest risk, such as the head, spine, and midline of the back.

The second most common type in children is nodular melanoma, constituting 40% of the melanomas in childhood. The nodules are rapidly growing and a red, bluish purple in color. They often ulcerate and, at times, bleed.

This is a highly fatal type, he said. The nodules are thick at the time of diagnosis.

And, in third place are the superficial spreading malignant melanomas. Here the ABCD rule applies: asymmetry, border irregularity, color variation, and diameter over 6 mm. However, the idea that the lesion in a child has to be more than 6 mm is not reality, Dr. Hansen said.

“This is increasing because of the sun exposure of kids,” he said.

Melanomas start out as a speck, and only 20%–40% start in preexisting moles, he said. About 60%–80% start in de novo moles. “It's the new kid on the block, the new mole that can get you into trouble,” he said.

All nevi have some potential to develop melanoma, but it is very low, Dr. Hansen said. “Congenital and dysplastic nevi have the most potential.”

Dysplastic or atypical nevi, once considered precursors of melanoma, are so common that the predictive value is less than once thought, Dr. Hansen said.

These nevi look very similar to melanoma. Usually, they are over 5 mm in diameter, have color variegation, and have fried-egg morphology with a central papule and red/tan halo. The borders are not clearly defined. These occur in 50% of affected whites; one or two of these probably means very little, Dr. Hansen said.

However, if a person has more than 100 moles, a family history of melanoma, and several large atypical nevi, there is a 50% chance of melanoma.

“These individuals have to be followed carefully,” he said. “We have seen teenagers that fit this category, and we follow them like a hawk.”

Early recognition and referral is essential, followed by biopsy and surgical excision, he said. Adjunctive therapies have marginal additional value. The depth of the lesion is extremely important, with a depth of less than 1 mm being 95% curable and up to 3 mm being 40% curable.

Dermoscopy has evolved as an essential tool to follow pigmented lesions, he said, adding that high-risk families may need 3-month evaluations and frequent biopsies.

There has been a 20-fold increase in the incidence of melanoma since 1930. “This is about the time that people decided to get stupid and take off their clothes for recreational sun,” he said.

The best prevention is staying out of the sun at its highest intensity, wearing protective clothing, and applying sunscreens, he said. “We need an outbreak of common sense.”

SCOTTSDALE, ARIZ. — Although childhood malignant melanomas are rare, physicians must keep an eye out for them, Ronald C. Hansen, M.D., said at a pediatric update sponsored by Phoenix Children's Hospital.

About 2% of all melanomas appear in children, but the types that commonly occur in children are different from those found in adults. Melanomas in children arise from congenital nevi, de novo nodular nevi, and superficial spreading melanomas that are sun induced, said Dr. Hansen, a dermatologist at the hospital.

Although 70% of melanomas in adults are sun induced, superficial spreading melanomas, about 80% in children arise from congenital nevi or de novo nodular lesions, he said. “There are very, very different concepts of melanoma in childhood.” Congenital nevi that occur in 2% of children arise during the first 4 months of life. Most are small, less than 1.5 cm.

Excision of congenital nevi is not necessary in infancy, but Dr. Hansen suggests that children with nevi be followed closely. “In children, these are more important than the other moles.”

Melanomas in small congenital nevi usually occur at or after puberty, he said. “I recommend prophylactic excision at age 10 in girls and at age 13 in boys, especially if the nevi are on the scalp, face, or trunk. This is a treatment strategy. It's not necessarily what everyone else advocates.”

Giant nevi in children and those over 6 cm in a newborn, have a 5%–8% melanoma risk. Many of these nevi are too large to totally excise. However, Dr. Hansen recommends prophylactic excision in the areas of highest risk, such as the head, spine, and midline of the back.

The second most common type in children is nodular melanoma, constituting 40% of the melanomas in childhood. The nodules are rapidly growing and a red, bluish purple in color. They often ulcerate and, at times, bleed.

This is a highly fatal type, he said. The nodules are thick at the time of diagnosis.

And, in third place are the superficial spreading malignant melanomas. Here the ABCD rule applies: asymmetry, border irregularity, color variation, and diameter over 6 mm. However, the idea that the lesion in a child has to be more than 6 mm is not reality, Dr. Hansen said.

“This is increasing because of the sun exposure of kids,” he said.

Melanomas start out as a speck, and only 20%–40% start in preexisting moles, he said. About 60%–80% start in de novo moles. “It's the new kid on the block, the new mole that can get you into trouble,” he said.

All nevi have some potential to develop melanoma, but it is very low, Dr. Hansen said. “Congenital and dysplastic nevi have the most potential.”

Dysplastic or atypical nevi, once considered precursors of melanoma, are so common that the predictive value is less than once thought, Dr. Hansen said.

These nevi look very similar to melanoma. Usually, they are over 5 mm in diameter, have color variegation, and have fried-egg morphology with a central papule and red/tan halo. The borders are not clearly defined. These occur in 50% of affected whites; one or two of these probably means very little, Dr. Hansen said.

However, if a person has more than 100 moles, a family history of melanoma, and several large atypical nevi, there is a 50% chance of melanoma.

“These individuals have to be followed carefully,” he said. “We have seen teenagers that fit this category, and we follow them like a hawk.”

Early recognition and referral is essential, followed by biopsy and surgical excision, he said. Adjunctive therapies have marginal additional value. The depth of the lesion is extremely important, with a depth of less than 1 mm being 95% curable and up to 3 mm being 40% curable.

Dermoscopy has evolved as an essential tool to follow pigmented lesions, he said, adding that high-risk families may need 3-month evaluations and frequent biopsies.

There has been a 20-fold increase in the incidence of melanoma since 1930. “This is about the time that people decided to get stupid and take off their clothes for recreational sun,” he said.

The best prevention is staying out of the sun at its highest intensity, wearing protective clothing, and applying sunscreens, he said. “We need an outbreak of common sense.”

SCOTTSDALE, ARIZ. — Although childhood malignant melanomas are rare, physicians must keep an eye out for them, Ronald C. Hansen, M.D., said at a pediatric update sponsored by Phoenix Children's Hospital.

About 2% of all melanomas appear in children, but the types that commonly occur in children are different from those found in adults. Melanomas in children arise from congenital nevi, de novo nodular nevi, and superficial spreading melanomas that are sun induced, said Dr. Hansen, a dermatologist at the hospital.

Although 70% of melanomas in adults are sun induced, superficial spreading melanomas, about 80% in children arise from congenital nevi or de novo nodular lesions, he said. “There are very, very different concepts of melanoma in childhood.” Congenital nevi that occur in 2% of children arise during the first 4 months of life. Most are small, less than 1.5 cm.

Excision of congenital nevi is not necessary in infancy, but Dr. Hansen suggests that children with nevi be followed closely. “In children, these are more important than the other moles.”

Melanomas in small congenital nevi usually occur at or after puberty, he said. “I recommend prophylactic excision at age 10 in girls and at age 13 in boys, especially if the nevi are on the scalp, face, or trunk. This is a treatment strategy. It's not necessarily what everyone else advocates.”

Giant nevi in children and those over 6 cm in a newborn, have a 5%–8% melanoma risk. Many of these nevi are too large to totally excise. However, Dr. Hansen recommends prophylactic excision in the areas of highest risk, such as the head, spine, and midline of the back.

The second most common type in children is nodular melanoma, constituting 40% of the melanomas in childhood. The nodules are rapidly growing and a red, bluish purple in color. They often ulcerate and, at times, bleed.

This is a highly fatal type, he said. The nodules are thick at the time of diagnosis.

And, in third place are the superficial spreading malignant melanomas. Here the ABCD rule applies: asymmetry, border irregularity, color variation, and diameter over 6 mm. However, the idea that the lesion in a child has to be more than 6 mm is not reality, Dr. Hansen said.

“This is increasing because of the sun exposure of kids,” he said.

Melanomas start out as a speck, and only 20%–40% start in preexisting moles, he said. About 60%–80% start in de novo moles. “It's the new kid on the block, the new mole that can get you into trouble,” he said.

All nevi have some potential to develop melanoma, but it is very low, Dr. Hansen said. “Congenital and dysplastic nevi have the most potential.”

Dysplastic or atypical nevi, once considered precursors of melanoma, are so common that the predictive value is less than once thought, Dr. Hansen said.

These nevi look very similar to melanoma. Usually, they are over 5 mm in diameter, have color variegation, and have fried-egg morphology with a central papule and red/tan halo. The borders are not clearly defined. These occur in 50% of affected whites; one or two of these probably means very little, Dr. Hansen said.

However, if a person has more than 100 moles, a family history of melanoma, and several large atypical nevi, there is a 50% chance of melanoma.

“These individuals have to be followed carefully,” he said. “We have seen teenagers that fit this category, and we follow them like a hawk.”

Early recognition and referral is essential, followed by biopsy and surgical excision, he said. Adjunctive therapies have marginal additional value. The depth of the lesion is extremely important, with a depth of less than 1 mm being 95% curable and up to 3 mm being 40% curable.

Dermoscopy has evolved as an essential tool to follow pigmented lesions, he said, adding that high-risk families may need 3-month evaluations and frequent biopsies.

There has been a 20-fold increase in the incidence of melanoma since 1930. “This is about the time that people decided to get stupid and take off their clothes for recreational sun,” he said.

The best prevention is staying out of the sun at its highest intensity, wearing protective clothing, and applying sunscreens, he said. “We need an outbreak of common sense.”