A macrophage stretching its

pseudopodia to engulf particles

Macrophages can substitute for dendritic cells as primers of T-cell-dependent immune responses, according to research published in Proceedings of the National Academy of Sciences.

The study showed that macrophages that function as a first line of defense in the innate immune system can also present antigens to T cells, a previously unknown role for macrophages in the induction of adaptive immune responses.

“It has been assumed until now that the dendritic cells are considered to be essentially the only cell type responsible for antigen presentation in the immune system,” said Dr Thomas Brocker, of Ludwig-Maximilians-Universität München in Germany.

“We have now discovered that macrophages can also do this job. Not only that, in certain situations, they can be more effective than dendritic cells.”

Dendritic cells present antigens to cytotoxic T lymphocytes (CTLs) if they have been directly infected, but they can also capture and display antigens from other cells. This type of indirect antigen presentation is referred to as cross-presentation.

“So, theoretically, dendritic cells could be responsible for the induction of all CTL-based responses, regardless of whether they are themselves infected or not,” Dr Brocker said. “But the significance of cross-presentation is hotly debated in the literature.”

Dr Brocker and his team used several antigens that were specifically targeted to and processed by macrophages but could not be taken up directly by dendritic cells. They were able to demonstrate that each antigen induced a normal immune response in a mouse model system, and even in a mouse strain that lacked dendritic cells altogether.

Further experiments showed the targeted macrophages were actually able to prime a more comprehensive immune reaction than cross-presenting dendritic cells. They activated T cells specific for all antigen-binding sites (epitopes) presented, whereas cross-presentation by dendritic cells stimulates only those T cells that recognize immunodominant epitopes.

“Macrophages naturally function as filters,” Dr Brocker noted. “They gobble everything up that might be harmful to the organism. And our study shows that, in contrast to cross-priming dendritic cells, they are capable of producing and presenting all T-cell-priming epitopes we tested. Macrophages therefore induce a complete immune response. These observations indicate that the significance of cross-presentation by dendritic cells has been overrated.”

He added that these findings are relevant for the development of immunization strategies.

“Preclinical trials are already underway with vaccines that are designed to activate specific sets of dendritic cells,” Dr Brocker said. “But the weak epitopes are important for a broadly directed immune response, because they can potentially recognize mutant variants of viruses, for instance.”

“Cross-priming dendritic cells fail to induce weakly antigenic epitopes, as our study shows. Our results indicate that it may make more sense to manipulate macrophages directly because they stimulate a wider-ranging immune response.”

A macrophage stretching its

pseudopodia to engulf particles

Macrophages can substitute for dendritic cells as primers of T-cell-dependent immune responses, according to research published in Proceedings of the National Academy of Sciences.

The study showed that macrophages that function as a first line of defense in the innate immune system can also present antigens to T cells, a previously unknown role for macrophages in the induction of adaptive immune responses.

“It has been assumed until now that the dendritic cells are considered to be essentially the only cell type responsible for antigen presentation in the immune system,” said Dr Thomas Brocker, of Ludwig-Maximilians-Universität München in Germany.

“We have now discovered that macrophages can also do this job. Not only that, in certain situations, they can be more effective than dendritic cells.”

Dendritic cells present antigens to cytotoxic T lymphocytes (CTLs) if they have been directly infected, but they can also capture and display antigens from other cells. This type of indirect antigen presentation is referred to as cross-presentation.

“So, theoretically, dendritic cells could be responsible for the induction of all CTL-based responses, regardless of whether they are themselves infected or not,” Dr Brocker said. “But the significance of cross-presentation is hotly debated in the literature.”

Dr Brocker and his team used several antigens that were specifically targeted to and processed by macrophages but could not be taken up directly by dendritic cells. They were able to demonstrate that each antigen induced a normal immune response in a mouse model system, and even in a mouse strain that lacked dendritic cells altogether.

Further experiments showed the targeted macrophages were actually able to prime a more comprehensive immune reaction than cross-presenting dendritic cells. They activated T cells specific for all antigen-binding sites (epitopes) presented, whereas cross-presentation by dendritic cells stimulates only those T cells that recognize immunodominant epitopes.

“Macrophages naturally function as filters,” Dr Brocker noted. “They gobble everything up that might be harmful to the organism. And our study shows that, in contrast to cross-priming dendritic cells, they are capable of producing and presenting all T-cell-priming epitopes we tested. Macrophages therefore induce a complete immune response. These observations indicate that the significance of cross-presentation by dendritic cells has been overrated.”

He added that these findings are relevant for the development of immunization strategies.

“Preclinical trials are already underway with vaccines that are designed to activate specific sets of dendritic cells,” Dr Brocker said. “But the weak epitopes are important for a broadly directed immune response, because they can potentially recognize mutant variants of viruses, for instance.”

“Cross-priming dendritic cells fail to induce weakly antigenic epitopes, as our study shows. Our results indicate that it may make more sense to manipulate macrophages directly because they stimulate a wider-ranging immune response.”

A macrophage stretching its

pseudopodia to engulf particles

Macrophages can substitute for dendritic cells as primers of T-cell-dependent immune responses, according to research published in Proceedings of the National Academy of Sciences.

The study showed that macrophages that function as a first line of defense in the innate immune system can also present antigens to T cells, a previously unknown role for macrophages in the induction of adaptive immune responses.

“It has been assumed until now that the dendritic cells are considered to be essentially the only cell type responsible for antigen presentation in the immune system,” said Dr Thomas Brocker, of Ludwig-Maximilians-Universität München in Germany.

“We have now discovered that macrophages can also do this job. Not only that, in certain situations, they can be more effective than dendritic cells.”

Dendritic cells present antigens to cytotoxic T lymphocytes (CTLs) if they have been directly infected, but they can also capture and display antigens from other cells. This type of indirect antigen presentation is referred to as cross-presentation.

“So, theoretically, dendritic cells could be responsible for the induction of all CTL-based responses, regardless of whether they are themselves infected or not,” Dr Brocker said. “But the significance of cross-presentation is hotly debated in the literature.”

Dr Brocker and his team used several antigens that were specifically targeted to and processed by macrophages but could not be taken up directly by dendritic cells. They were able to demonstrate that each antigen induced a normal immune response in a mouse model system, and even in a mouse strain that lacked dendritic cells altogether.

Further experiments showed the targeted macrophages were actually able to prime a more comprehensive immune reaction than cross-presenting dendritic cells. They activated T cells specific for all antigen-binding sites (epitopes) presented, whereas cross-presentation by dendritic cells stimulates only those T cells that recognize immunodominant epitopes.

“Macrophages naturally function as filters,” Dr Brocker noted. “They gobble everything up that might be harmful to the organism. And our study shows that, in contrast to cross-priming dendritic cells, they are capable of producing and presenting all T-cell-priming epitopes we tested. Macrophages therefore induce a complete immune response. These observations indicate that the significance of cross-presentation by dendritic cells has been overrated.”

He added that these findings are relevant for the development of immunization strategies.

“Preclinical trials are already underway with vaccines that are designed to activate specific sets of dendritic cells,” Dr Brocker said. “But the weak epitopes are important for a broadly directed immune response, because they can potentially recognize mutant variants of viruses, for instance.”

“Cross-priming dendritic cells fail to induce weakly antigenic epitopes, as our study shows. Our results indicate that it may make more sense to manipulate macrophages directly because they stimulate a wider-ranging immune response.”

Pregnant woman

Photo by Nina Matthews

The Royal College of Obstetricians and Gynaecologists (RCOG) has released new guidelines for treating and preventing venous thromboembolism (VTE) during pregnancy, birth, and following delivery.

“These updated guidelines provide new evidence about risk factors for thrombosis in pregnancy and strategies that should be employed to reduce the chances of a thrombosis occurring,” said Andrew Thomson, MD, cochair of the RCOG guidelines committee.

“Furthermore, the guidelines provide updated information on the way women with a suspected thrombosis should be investigated and treated.”

VTE is uncommon in pregnancy or in the first 6 weeks postnatally, and the absolute risk of VTE is around 1 in 1000 pregnancies. It can occur at any stage in pregnancy, but the time of the highest risk is the first 6 weeks following birth, when the risk increases 20-fold.

Risk factors include previous VTE or thrombophilia, obesity, increased maternal age, immobility and long-distance travel, admission to hospital during pregnancy, and other comorbidities such as heart disease, inflammatory bowel disease, and pre-eclampsia.

Additional risk factors occurring during the first trimester of pregnancy include hyperemesis gravidarum, ovarian hyperstimulation, and in vitro fertilization pregnancy. Caesarean section is also a risk factor.

The guidelines emphasize that all women should undergo a thorough assessment for VTE in early pregnancy or prepregnancy and again intrapartum or immediately postpartum.

Any woman with risk factors should be considered for prophylactic low-molecular-weight heparin. The duration of treatment depends on the number of risk factors a woman has. It may be offered both antenatally and after the baby is born.

In addition, women with previous VTE must be offered prepregnancy counseling. A prospective management plan for VTE should also be made, including appropriate treatment to be offered as early as possible and a careful history documented.

The guidance on treating VTE focuses on the acute management of the condition and highlights the signs and symptoms, including leg pain and swelling, lower abdominal pain, shortness of breath, chest pain, coughing blood, and collapse.

Any woman presenting with signs and symptoms suggestive of VTE should be tested for the condition immediately and offered treatment with low-molecular-weight heparin.

All hospitals should have a protocol for the diagnosis of suspected VTE, with the involvement of a multidisciplinary team of obstetricians, radiologists, physicians, and hematologists.

“This guidance provides clinicians with accurate, scientific-based guidelines on the risk factors for VTE, as well as on how to prevent and treat the condition,” said guideline author Catherine Nelson-Piercy, MBBS, of Guy’s and St. Thomas’ NHS Foundation Trust in London, UK.

“It is vital that VTE is discussed with all women who are at risk, and the reasons for individual treatment recommendations must also be explained.”

Pregnant woman

Photo by Nina Matthews

The Royal College of Obstetricians and Gynaecologists (RCOG) has released new guidelines for treating and preventing venous thromboembolism (VTE) during pregnancy, birth, and following delivery.

“These updated guidelines provide new evidence about risk factors for thrombosis in pregnancy and strategies that should be employed to reduce the chances of a thrombosis occurring,” said Andrew Thomson, MD, cochair of the RCOG guidelines committee.

“Furthermore, the guidelines provide updated information on the way women with a suspected thrombosis should be investigated and treated.”

VTE is uncommon in pregnancy or in the first 6 weeks postnatally, and the absolute risk of VTE is around 1 in 1000 pregnancies. It can occur at any stage in pregnancy, but the time of the highest risk is the first 6 weeks following birth, when the risk increases 20-fold.

Risk factors include previous VTE or thrombophilia, obesity, increased maternal age, immobility and long-distance travel, admission to hospital during pregnancy, and other comorbidities such as heart disease, inflammatory bowel disease, and pre-eclampsia.

Additional risk factors occurring during the first trimester of pregnancy include hyperemesis gravidarum, ovarian hyperstimulation, and in vitro fertilization pregnancy. Caesarean section is also a risk factor.

The guidelines emphasize that all women should undergo a thorough assessment for VTE in early pregnancy or prepregnancy and again intrapartum or immediately postpartum.

Any woman with risk factors should be considered for prophylactic low-molecular-weight heparin. The duration of treatment depends on the number of risk factors a woman has. It may be offered both antenatally and after the baby is born.

In addition, women with previous VTE must be offered prepregnancy counseling. A prospective management plan for VTE should also be made, including appropriate treatment to be offered as early as possible and a careful history documented.

The guidance on treating VTE focuses on the acute management of the condition and highlights the signs and symptoms, including leg pain and swelling, lower abdominal pain, shortness of breath, chest pain, coughing blood, and collapse.

Any woman presenting with signs and symptoms suggestive of VTE should be tested for the condition immediately and offered treatment with low-molecular-weight heparin.

All hospitals should have a protocol for the diagnosis of suspected VTE, with the involvement of a multidisciplinary team of obstetricians, radiologists, physicians, and hematologists.

“This guidance provides clinicians with accurate, scientific-based guidelines on the risk factors for VTE, as well as on how to prevent and treat the condition,” said guideline author Catherine Nelson-Piercy, MBBS, of Guy’s and St. Thomas’ NHS Foundation Trust in London, UK.

“It is vital that VTE is discussed with all women who are at risk, and the reasons for individual treatment recommendations must also be explained.”

Pregnant woman

Photo by Nina Matthews

The Royal College of Obstetricians and Gynaecologists (RCOG) has released new guidelines for treating and preventing venous thromboembolism (VTE) during pregnancy, birth, and following delivery.

“These updated guidelines provide new evidence about risk factors for thrombosis in pregnancy and strategies that should be employed to reduce the chances of a thrombosis occurring,” said Andrew Thomson, MD, cochair of the RCOG guidelines committee.

“Furthermore, the guidelines provide updated information on the way women with a suspected thrombosis should be investigated and treated.”

VTE is uncommon in pregnancy or in the first 6 weeks postnatally, and the absolute risk of VTE is around 1 in 1000 pregnancies. It can occur at any stage in pregnancy, but the time of the highest risk is the first 6 weeks following birth, when the risk increases 20-fold.

Risk factors include previous VTE or thrombophilia, obesity, increased maternal age, immobility and long-distance travel, admission to hospital during pregnancy, and other comorbidities such as heart disease, inflammatory bowel disease, and pre-eclampsia.

Additional risk factors occurring during the first trimester of pregnancy include hyperemesis gravidarum, ovarian hyperstimulation, and in vitro fertilization pregnancy. Caesarean section is also a risk factor.

The guidelines emphasize that all women should undergo a thorough assessment for VTE in early pregnancy or prepregnancy and again intrapartum or immediately postpartum.

Any woman with risk factors should be considered for prophylactic low-molecular-weight heparin. The duration of treatment depends on the number of risk factors a woman has. It may be offered both antenatally and after the baby is born.

In addition, women with previous VTE must be offered prepregnancy counseling. A prospective management plan for VTE should also be made, including appropriate treatment to be offered as early as possible and a careful history documented.

The guidance on treating VTE focuses on the acute management of the condition and highlights the signs and symptoms, including leg pain and swelling, lower abdominal pain, shortness of breath, chest pain, coughing blood, and collapse.

Any woman presenting with signs and symptoms suggestive of VTE should be tested for the condition immediately and offered treatment with low-molecular-weight heparin.

All hospitals should have a protocol for the diagnosis of suspected VTE, with the involvement of a multidisciplinary team of obstetricians, radiologists, physicians, and hematologists.

“This guidance provides clinicians with accurate, scientific-based guidelines on the risk factors for VTE, as well as on how to prevent and treat the condition,” said guideline author Catherine Nelson-Piercy, MBBS, of Guy’s and St. Thomas’ NHS Foundation Trust in London, UK.

“It is vital that VTE is discussed with all women who are at risk, and the reasons for individual treatment recommendations must also be explained.”

Sleep disturbances are common among patients with cancer for many reasons. Sleep problems can be present at any stage during treatment for cancer and in some patients, sleep disturbance may be the presenting symptoms that lead to the diagnosis of some types of cancer. Poor sleep impairs quality of life In people with cancer, but most do not specifically complain of sleep problems unless they are explicitly asked. Insomnia and fatigue are most common sleep disorders in this cohort, although primary sleep disorders, including obstructive sleep apnea and restless legs syndrome, which are common in the general population, have not been carefully studied in the oncology setting despite significant their impairment of quality of life.

Click on the PDF icon at the top of this introduction to read the full article.

Sleep disturbances are common among patients with cancer for many reasons. Sleep problems can be present at any stage during treatment for cancer and in some patients, sleep disturbance may be the presenting symptoms that lead to the diagnosis of some types of cancer. Poor sleep impairs quality of life In people with cancer, but most do not specifically complain of sleep problems unless they are explicitly asked. Insomnia and fatigue are most common sleep disorders in this cohort, although primary sleep disorders, including obstructive sleep apnea and restless legs syndrome, which are common in the general population, have not been carefully studied in the oncology setting despite significant their impairment of quality of life.

Click on the PDF icon at the top of this introduction to read the full article.

Sleep disturbances are common among patients with cancer for many reasons. Sleep problems can be present at any stage during treatment for cancer and in some patients, sleep disturbance may be the presenting symptoms that lead to the diagnosis of some types of cancer. Poor sleep impairs quality of life In people with cancer, but most do not specifically complain of sleep problems unless they are explicitly asked. Insomnia and fatigue are most common sleep disorders in this cohort, although primary sleep disorders, including obstructive sleep apnea and restless legs syndrome, which are common in the general population, have not been carefully studied in the oncology setting despite significant their impairment of quality of life.

Click on the PDF icon at the top of this introduction to read the full article.

School-based educational programs to prevent sexual abuse appear to increase children’s knowledge, disclosure of abuse, and protective behaviors with no measurable harms, based on moderate evidence in an updated Cochrane systematic review.

These programs “seek to prevent child sexual abuse by providing students with knowledge and skills to recognize and avoid potentially sexually abusive situations, and with strategies to physically and verbally repel sexual approaches by offenders,” Kerryann Walsh of Queensland University of Technology in Brisbane, Australia, and her associates reported online. “Interventions aim to transfer the knowledge and skills learned by the child or adolescent in the classroom to real-life situations,” they wrote (Cochrane Database Syst. Rev. 2015 April 16 [doi:10.1001/14651858.CD004380.pub3]).

An estimated 10%-20% of female children and 5%-10% of male children have experienced some form of sexual abuse, ranging from unwanted touching to penetration, but two-thirds of individuals never report their abuse, and most cases are not reported to the authorities. Outcomes linked to sexual abuse include depression, posttraumatic stress disorder, suicidal behaviors, anti-social behaviors, eating disorders, substance abuse, sexual dysfunction, sexual revictimization, and parenting difficulties, as well as various chronic physical health problems.

Walsh’s team searched 14 databases and two trial registers for new randomized controlled trials to update the October 2013 review. This update excluded one previous trial and added 10 new trials through September 2014 to the 14 already included. The 24 total trials analyzed came from the United States, Canada, China, Germany, Spain, Taiwan, and Turkey, and included 5,802 elementary and high school students.

School-based programs increased children’s protective behaviors almost six times over children not receiving the intervention, based on two trials involving 102 children (odds ratio, 5.71).

Questionnaire-based knowledge about sexual abuse increased among children receiving education, based on analysis of 18 trials involving 4,657 children, although the trials differed significantly from one another. Similarly, children’s knowledge increased when assessed using vignettes across 11 trials, also highly heterogeneous, involving 1,688 children. The four trials assessing children’s knowledge over time found they retained their knowledge at least 6 months later.

Children who received the school-based intervention were 3.6 times more likely to disclose previous or current sexual abuse than children who did not receive the intervention (OR, 3.56).

The three trials that assessed harms found no increased or decreased anxiety or fear among the children receiving the intervention, but none of the trials assessed anxiety or fear among the children’s parents. The authors urged caution in interpreting the findings because high or unclear risk of selection bias, detection bias, and attrition bias, and too little information was available for the authors to conduct subgroup analyses. “Study quality was compromised in about half of the included studies due to suboptimal data collection methods for study outcomes and inappropriate data analysis,” the authors wrote.

Further, “studies have not yet adequately measured the long-term benefits of programs in terms of reducing the incidence or prevalence [or both] of child sexual abuse in program participants,” Dr. Walsh and her associates said.

The trials were heterogeneous, and the intervention programs lasted anywhere from a single 45-minute session to 20-minute sessions on each of 8 consecutive days. Common themes among the courses included teaching body ownership, safety rules, private parts of the body, who to tell, and telling apart types of touches and types of secrets. Videos, theatrical plays, and multimedia presentations, sometimes incorporating puppetry, comics, songs and coloring books, were used to deliver the programs. The teaching methods included “rehearsal, practice, role-playing, discussion, and feedback.”

Dr. Walsh received Australian Research Council Discovery Project Scheme funding for research about sexual abuse prevention programs in Australia conducted concurrently with this review. No other authors reported relevant disclosures.

School-based educational programs to prevent sexual abuse appear to increase children’s knowledge, disclosure of abuse, and protective behaviors with no measurable harms, based on moderate evidence in an updated Cochrane systematic review.

These programs “seek to prevent child sexual abuse by providing students with knowledge and skills to recognize and avoid potentially sexually abusive situations, and with strategies to physically and verbally repel sexual approaches by offenders,” Kerryann Walsh of Queensland University of Technology in Brisbane, Australia, and her associates reported online. “Interventions aim to transfer the knowledge and skills learned by the child or adolescent in the classroom to real-life situations,” they wrote (Cochrane Database Syst. Rev. 2015 April 16 [doi:10.1001/14651858.CD004380.pub3]).

An estimated 10%-20% of female children and 5%-10% of male children have experienced some form of sexual abuse, ranging from unwanted touching to penetration, but two-thirds of individuals never report their abuse, and most cases are not reported to the authorities. Outcomes linked to sexual abuse include depression, posttraumatic stress disorder, suicidal behaviors, anti-social behaviors, eating disorders, substance abuse, sexual dysfunction, sexual revictimization, and parenting difficulties, as well as various chronic physical health problems.

Walsh’s team searched 14 databases and two trial registers for new randomized controlled trials to update the October 2013 review. This update excluded one previous trial and added 10 new trials through September 2014 to the 14 already included. The 24 total trials analyzed came from the United States, Canada, China, Germany, Spain, Taiwan, and Turkey, and included 5,802 elementary and high school students.

School-based programs increased children’s protective behaviors almost six times over children not receiving the intervention, based on two trials involving 102 children (odds ratio, 5.71).

Questionnaire-based knowledge about sexual abuse increased among children receiving education, based on analysis of 18 trials involving 4,657 children, although the trials differed significantly from one another. Similarly, children’s knowledge increased when assessed using vignettes across 11 trials, also highly heterogeneous, involving 1,688 children. The four trials assessing children’s knowledge over time found they retained their knowledge at least 6 months later.

Children who received the school-based intervention were 3.6 times more likely to disclose previous or current sexual abuse than children who did not receive the intervention (OR, 3.56).

The three trials that assessed harms found no increased or decreased anxiety or fear among the children receiving the intervention, but none of the trials assessed anxiety or fear among the children’s parents. The authors urged caution in interpreting the findings because high or unclear risk of selection bias, detection bias, and attrition bias, and too little information was available for the authors to conduct subgroup analyses. “Study quality was compromised in about half of the included studies due to suboptimal data collection methods for study outcomes and inappropriate data analysis,” the authors wrote.

Further, “studies have not yet adequately measured the long-term benefits of programs in terms of reducing the incidence or prevalence [or both] of child sexual abuse in program participants,” Dr. Walsh and her associates said.

The trials were heterogeneous, and the intervention programs lasted anywhere from a single 45-minute session to 20-minute sessions on each of 8 consecutive days. Common themes among the courses included teaching body ownership, safety rules, private parts of the body, who to tell, and telling apart types of touches and types of secrets. Videos, theatrical plays, and multimedia presentations, sometimes incorporating puppetry, comics, songs and coloring books, were used to deliver the programs. The teaching methods included “rehearsal, practice, role-playing, discussion, and feedback.”

Dr. Walsh received Australian Research Council Discovery Project Scheme funding for research about sexual abuse prevention programs in Australia conducted concurrently with this review. No other authors reported relevant disclosures.

School-based educational programs to prevent sexual abuse appear to increase children’s knowledge, disclosure of abuse, and protective behaviors with no measurable harms, based on moderate evidence in an updated Cochrane systematic review.

These programs “seek to prevent child sexual abuse by providing students with knowledge and skills to recognize and avoid potentially sexually abusive situations, and with strategies to physically and verbally repel sexual approaches by offenders,” Kerryann Walsh of Queensland University of Technology in Brisbane, Australia, and her associates reported online. “Interventions aim to transfer the knowledge and skills learned by the child or adolescent in the classroom to real-life situations,” they wrote (Cochrane Database Syst. Rev. 2015 April 16 [doi:10.1001/14651858.CD004380.pub3]).

An estimated 10%-20% of female children and 5%-10% of male children have experienced some form of sexual abuse, ranging from unwanted touching to penetration, but two-thirds of individuals never report their abuse, and most cases are not reported to the authorities. Outcomes linked to sexual abuse include depression, posttraumatic stress disorder, suicidal behaviors, anti-social behaviors, eating disorders, substance abuse, sexual dysfunction, sexual revictimization, and parenting difficulties, as well as various chronic physical health problems.

Walsh’s team searched 14 databases and two trial registers for new randomized controlled trials to update the October 2013 review. This update excluded one previous trial and added 10 new trials through September 2014 to the 14 already included. The 24 total trials analyzed came from the United States, Canada, China, Germany, Spain, Taiwan, and Turkey, and included 5,802 elementary and high school students.

School-based programs increased children’s protective behaviors almost six times over children not receiving the intervention, based on two trials involving 102 children (odds ratio, 5.71).

Questionnaire-based knowledge about sexual abuse increased among children receiving education, based on analysis of 18 trials involving 4,657 children, although the trials differed significantly from one another. Similarly, children’s knowledge increased when assessed using vignettes across 11 trials, also highly heterogeneous, involving 1,688 children. The four trials assessing children’s knowledge over time found they retained their knowledge at least 6 months later.

Children who received the school-based intervention were 3.6 times more likely to disclose previous or current sexual abuse than children who did not receive the intervention (OR, 3.56).

The three trials that assessed harms found no increased or decreased anxiety or fear among the children receiving the intervention, but none of the trials assessed anxiety or fear among the children’s parents. The authors urged caution in interpreting the findings because high or unclear risk of selection bias, detection bias, and attrition bias, and too little information was available for the authors to conduct subgroup analyses. “Study quality was compromised in about half of the included studies due to suboptimal data collection methods for study outcomes and inappropriate data analysis,” the authors wrote.

Further, “studies have not yet adequately measured the long-term benefits of programs in terms of reducing the incidence or prevalence [or both] of child sexual abuse in program participants,” Dr. Walsh and her associates said.

The trials were heterogeneous, and the intervention programs lasted anywhere from a single 45-minute session to 20-minute sessions on each of 8 consecutive days. Common themes among the courses included teaching body ownership, safety rules, private parts of the body, who to tell, and telling apart types of touches and types of secrets. Videos, theatrical plays, and multimedia presentations, sometimes incorporating puppetry, comics, songs and coloring books, were used to deliver the programs. The teaching methods included “rehearsal, practice, role-playing, discussion, and feedback.”

Dr. Walsh received Australian Research Council Discovery Project Scheme funding for research about sexual abuse prevention programs in Australia conducted concurrently with this review. No other authors reported relevant disclosures.

Emergency medical workers who worked on-site immediately after the 9/11 attacks in New York are at significantly higher risk of chronic illness than employees who did not work there, according to Jennifer Yip and her associates.

Incidence of both gastroesophageal reflux disease and obstructive airways disease was 12%, with rhinosinusitis incidence at 11%. On-site EMS workers had depression rates of 17% and posttraumatic stress disorder rates of 7%. On-site EMS workers were four times more likely to have GERD or rhinosinusitis, seven times more likely to have PTSD, and twice as likely to have depression as a similar group of workers who were not at the World Trade Center.

The study findings demonstrate “that the burden of disease over the 12-year study period was substantial, highlighting the need for continued monitoring and treatment of EMS workers,” the investigators concluded.Find the full study in Occupational and Environmental Medicine (doi:10.1136/oemed-2014-102601).

Emergency medical workers who worked on-site immediately after the 9/11 attacks in New York are at significantly higher risk of chronic illness than employees who did not work there, according to Jennifer Yip and her associates.

Incidence of both gastroesophageal reflux disease and obstructive airways disease was 12%, with rhinosinusitis incidence at 11%. On-site EMS workers had depression rates of 17% and posttraumatic stress disorder rates of 7%. On-site EMS workers were four times more likely to have GERD or rhinosinusitis, seven times more likely to have PTSD, and twice as likely to have depression as a similar group of workers who were not at the World Trade Center.

The study findings demonstrate “that the burden of disease over the 12-year study period was substantial, highlighting the need for continued monitoring and treatment of EMS workers,” the investigators concluded.Find the full study in Occupational and Environmental Medicine (doi:10.1136/oemed-2014-102601).

Emergency medical workers who worked on-site immediately after the 9/11 attacks in New York are at significantly higher risk of chronic illness than employees who did not work there, according to Jennifer Yip and her associates.

Incidence of both gastroesophageal reflux disease and obstructive airways disease was 12%, with rhinosinusitis incidence at 11%. On-site EMS workers had depression rates of 17% and posttraumatic stress disorder rates of 7%. On-site EMS workers were four times more likely to have GERD or rhinosinusitis, seven times more likely to have PTSD, and twice as likely to have depression as a similar group of workers who were not at the World Trade Center.

The study findings demonstrate “that the burden of disease over the 12-year study period was substantial, highlighting the need for continued monitoring and treatment of EMS workers,” the investigators concluded.Find the full study in Occupational and Environmental Medicine (doi:10.1136/oemed-2014-102601).

Obstetric providers are being called upon to care for an increasing number of cancer survivors. Whether it was a childhood cancer or one faced in early adulthood, pregnant cancer survivors raise a unique set of questions and concerns. A general knowledge about management is essential in counseling these women prior to and early in pregnancy.

For the woman who presents preconception, one of the most common questions is when is the best time for pregnancy. Importantly, there are no absolute guidelines on how long a woman should be “disease free.” Many providers suggest waiting 2 years from the time of diagnosis. This “conventional wisdom” is not based on evidence (Oncology 2005;19:693-7). Instead, the type of cancer and the length of treatment can help determine the answer.

Many oncologists prefer a specific time for monitoring after treatment to ensure that initial treatment has been successful. For example, in the case of melanoma, after 2 years, the estimate of recurrence risk may be more accurate (Cancer Causes Control 2008;19:437-42). After breast cancer, women are often followed with MRI with contrast and mammogram. Since both are problematic in pregnancy, 3-5 years may be more appropriate.

Many patients are concerned about the risk of recurrence during pregnancy. Though data are limited, pregnancy does not appear to increase the risk of disease recurrence or decrease disease-free survival, even in the case of more aggressive cancers such as melanoma. This remains true in the setting of hormone receptor–positive cancers, specifically breast cancer (Lancet 1997;350:319-22).

Preconception counseling

The risks for a cancer survivor during pregnancy will vary depending on the treatments she has received. Preconception evaluation should be modified for the specific oncologic therapies. For example, women who received chest radiation, or anthracycline-based chemotherapies (or any cardiotoxic medications) should have a cardiac evaluation as they are at risk of cardiac dysfunction prior to and during pregnancy (Matern. Child. Health J. 2006;10[suppl. 1]:165-8).

Additionally, because chemotherapy may be hepatotoxic or nephrotoxic, baseline liver and renal function tests should almost always be performed. It is not unreasonable to follow these during pregnancy given the physiologic changes.

Many women also are concerned about the risks that prior cancer therapies may have for their baby. Prior chemotherapy and radiation therapy do not appear to confer any increased risk for genetic conditions, anomalies, or childhood cancer (Am. J. Obstet. Gynecol. 2002;187:1070-80). Additionally, previous chemotherapy alone does not increase the risk of adverse pregnancy outcomes.

In contrast, prior radiation to the abdomen and pelvis has been associated with an increased risk of miscarriage, growth restriction, preterm delivery, and stillbirth (J. Natl. Cancer Instit. Monogr. 2005;34:64-8; Lancet 2010;376:624-30). There is an increased risk of cancer in the offspring of women whose cancer is the result of hereditary cancer syndromes, such as BRCA or hereditary nonpolyposis colorectal cancer. Discussions with a genetics counselor may be helpful if there are any questions related to these syndromes.

Pregnancy management

Once pregnant, management requires a multidisciplinary approach. Surveillance options are limited during pregnancy. CT should be avoided, and radiographs limited. Ultrasound of the abdomen is safe, but optimal images are often obscured in later trimesters. Ultimately, indicated imaging should not be forsaken if there are any signs or symptoms that raise concerns for recurrence. Additionally, many tumor markers may be unreliable during pregnancy, such as CA-125 in the first trimester, or alpha-FP and CEA anytime.

Specific recommendations for antenatal testing do not exist and should be assessed on a case-by-case basis; especially in the case of women who have had prior radiation therapy. Our recommendation is to perform growth surveillance, which may include sonography at varying intervals. Also consider weekly fetal testing from 32 weeks in normally growing fetuses.

Solely being a cancer survivor is not an indication for early delivery or induction of labor. In the majority of cases, mode of delivery should be guided by obstetric indications, though previous pelvic surgery and reconstruction may be indications for cesarean delivery. Despite being in remission, some cancers metastasize to the placenta, most commonly melanoma and hematologic cancers. Very rarely, these cancers can also metastasize to the fetus. Thus, the placenta should be sent for histologic evaluation, with a notation to the pathologist about the patient’s prior cancer (Obstet. Gynecol. Surv. 1989;44:535-40; Ultrasound. Obstet. Gynecol. 2009;33:235-44).

In most cases, pregnancy after cancer is uncomplicated with good outcomes for both mother and baby. However, there are potential medical and obstetric complications that cannot be overlooked. Interdisciplinary management is crucial to ensure a safe transition from cancer survivor to mother.

What to consider when counseling cancer survivors about pregnancy

• The recommended disease-free interval prior to pregnancy may vary by cancer type, and is largely driven by disease surveillance needs and recurrence intervals.

• Prior cancer, associated operations, and chemotherapies do not typically confer additional risks in pregnancy. Exceptions include melanoma and blood cell cancers, which may metastasize to the placenta and fetus, even following periods of remission.

• Radiation therapy to the abdomen and pelvis may induce changes that predispose to growth restriction, preterm birth, and stillbirth. Enhanced surveillance may be reasonable in these cases.

• Preconception or early pregnancy assessment for end organ dysfunction is recommended for women who have received certain therapies: cardiac evaluation following chest radiation or anthracycline-based therapy; liver and kidney function for most chemotherapies.

Dr. Ivester is an associate professor of maternal-fetal medicine and an associate professor of maternal and child health at the University of North Carolina at Chapel Hill. Dr. Dotters-Katz is a maternal-fetal medicine fellow at University of North Carolina at Chapel Hill, who completed her ob.gyn. residency at Duke University. Her academic interests include oncology and infectious diseases as they relate to pregnancy. The authors reported having no financial disclosures. Email them at [email protected].

Obstetric providers are being called upon to care for an increasing number of cancer survivors. Whether it was a childhood cancer or one faced in early adulthood, pregnant cancer survivors raise a unique set of questions and concerns. A general knowledge about management is essential in counseling these women prior to and early in pregnancy.

For the woman who presents preconception, one of the most common questions is when is the best time for pregnancy. Importantly, there are no absolute guidelines on how long a woman should be “disease free.” Many providers suggest waiting 2 years from the time of diagnosis. This “conventional wisdom” is not based on evidence (Oncology 2005;19:693-7). Instead, the type of cancer and the length of treatment can help determine the answer.

Many oncologists prefer a specific time for monitoring after treatment to ensure that initial treatment has been successful. For example, in the case of melanoma, after 2 years, the estimate of recurrence risk may be more accurate (Cancer Causes Control 2008;19:437-42). After breast cancer, women are often followed with MRI with contrast and mammogram. Since both are problematic in pregnancy, 3-5 years may be more appropriate.

Many patients are concerned about the risk of recurrence during pregnancy. Though data are limited, pregnancy does not appear to increase the risk of disease recurrence or decrease disease-free survival, even in the case of more aggressive cancers such as melanoma. This remains true in the setting of hormone receptor–positive cancers, specifically breast cancer (Lancet 1997;350:319-22).

Preconception counseling

The risks for a cancer survivor during pregnancy will vary depending on the treatments she has received. Preconception evaluation should be modified for the specific oncologic therapies. For example, women who received chest radiation, or anthracycline-based chemotherapies (or any cardiotoxic medications) should have a cardiac evaluation as they are at risk of cardiac dysfunction prior to and during pregnancy (Matern. Child. Health J. 2006;10[suppl. 1]:165-8).

Additionally, because chemotherapy may be hepatotoxic or nephrotoxic, baseline liver and renal function tests should almost always be performed. It is not unreasonable to follow these during pregnancy given the physiologic changes.

Many women also are concerned about the risks that prior cancer therapies may have for their baby. Prior chemotherapy and radiation therapy do not appear to confer any increased risk for genetic conditions, anomalies, or childhood cancer (Am. J. Obstet. Gynecol. 2002;187:1070-80). Additionally, previous chemotherapy alone does not increase the risk of adverse pregnancy outcomes.

In contrast, prior radiation to the abdomen and pelvis has been associated with an increased risk of miscarriage, growth restriction, preterm delivery, and stillbirth (J. Natl. Cancer Instit. Monogr. 2005;34:64-8; Lancet 2010;376:624-30). There is an increased risk of cancer in the offspring of women whose cancer is the result of hereditary cancer syndromes, such as BRCA or hereditary nonpolyposis colorectal cancer. Discussions with a genetics counselor may be helpful if there are any questions related to these syndromes.

Pregnancy management

Once pregnant, management requires a multidisciplinary approach. Surveillance options are limited during pregnancy. CT should be avoided, and radiographs limited. Ultrasound of the abdomen is safe, but optimal images are often obscured in later trimesters. Ultimately, indicated imaging should not be forsaken if there are any signs or symptoms that raise concerns for recurrence. Additionally, many tumor markers may be unreliable during pregnancy, such as CA-125 in the first trimester, or alpha-FP and CEA anytime.

Specific recommendations for antenatal testing do not exist and should be assessed on a case-by-case basis; especially in the case of women who have had prior radiation therapy. Our recommendation is to perform growth surveillance, which may include sonography at varying intervals. Also consider weekly fetal testing from 32 weeks in normally growing fetuses.

Solely being a cancer survivor is not an indication for early delivery or induction of labor. In the majority of cases, mode of delivery should be guided by obstetric indications, though previous pelvic surgery and reconstruction may be indications for cesarean delivery. Despite being in remission, some cancers metastasize to the placenta, most commonly melanoma and hematologic cancers. Very rarely, these cancers can also metastasize to the fetus. Thus, the placenta should be sent for histologic evaluation, with a notation to the pathologist about the patient’s prior cancer (Obstet. Gynecol. Surv. 1989;44:535-40; Ultrasound. Obstet. Gynecol. 2009;33:235-44).

In most cases, pregnancy after cancer is uncomplicated with good outcomes for both mother and baby. However, there are potential medical and obstetric complications that cannot be overlooked. Interdisciplinary management is crucial to ensure a safe transition from cancer survivor to mother.

What to consider when counseling cancer survivors about pregnancy

• The recommended disease-free interval prior to pregnancy may vary by cancer type, and is largely driven by disease surveillance needs and recurrence intervals.

• Prior cancer, associated operations, and chemotherapies do not typically confer additional risks in pregnancy. Exceptions include melanoma and blood cell cancers, which may metastasize to the placenta and fetus, even following periods of remission.

• Radiation therapy to the abdomen and pelvis may induce changes that predispose to growth restriction, preterm birth, and stillbirth. Enhanced surveillance may be reasonable in these cases.

• Preconception or early pregnancy assessment for end organ dysfunction is recommended for women who have received certain therapies: cardiac evaluation following chest radiation or anthracycline-based therapy; liver and kidney function for most chemotherapies.

Dr. Ivester is an associate professor of maternal-fetal medicine and an associate professor of maternal and child health at the University of North Carolina at Chapel Hill. Dr. Dotters-Katz is a maternal-fetal medicine fellow at University of North Carolina at Chapel Hill, who completed her ob.gyn. residency at Duke University. Her academic interests include oncology and infectious diseases as they relate to pregnancy. The authors reported having no financial disclosures. Email them at [email protected].

Obstetric providers are being called upon to care for an increasing number of cancer survivors. Whether it was a childhood cancer or one faced in early adulthood, pregnant cancer survivors raise a unique set of questions and concerns. A general knowledge about management is essential in counseling these women prior to and early in pregnancy.

For the woman who presents preconception, one of the most common questions is when is the best time for pregnancy. Importantly, there are no absolute guidelines on how long a woman should be “disease free.” Many providers suggest waiting 2 years from the time of diagnosis. This “conventional wisdom” is not based on evidence (Oncology 2005;19:693-7). Instead, the type of cancer and the length of treatment can help determine the answer.

Many oncologists prefer a specific time for monitoring after treatment to ensure that initial treatment has been successful. For example, in the case of melanoma, after 2 years, the estimate of recurrence risk may be more accurate (Cancer Causes Control 2008;19:437-42). After breast cancer, women are often followed with MRI with contrast and mammogram. Since both are problematic in pregnancy, 3-5 years may be more appropriate.

Many patients are concerned about the risk of recurrence during pregnancy. Though data are limited, pregnancy does not appear to increase the risk of disease recurrence or decrease disease-free survival, even in the case of more aggressive cancers such as melanoma. This remains true in the setting of hormone receptor–positive cancers, specifically breast cancer (Lancet 1997;350:319-22).

Preconception counseling

The risks for a cancer survivor during pregnancy will vary depending on the treatments she has received. Preconception evaluation should be modified for the specific oncologic therapies. For example, women who received chest radiation, or anthracycline-based chemotherapies (or any cardiotoxic medications) should have a cardiac evaluation as they are at risk of cardiac dysfunction prior to and during pregnancy (Matern. Child. Health J. 2006;10[suppl. 1]:165-8).

Additionally, because chemotherapy may be hepatotoxic or nephrotoxic, baseline liver and renal function tests should almost always be performed. It is not unreasonable to follow these during pregnancy given the physiologic changes.

Many women also are concerned about the risks that prior cancer therapies may have for their baby. Prior chemotherapy and radiation therapy do not appear to confer any increased risk for genetic conditions, anomalies, or childhood cancer (Am. J. Obstet. Gynecol. 2002;187:1070-80). Additionally, previous chemotherapy alone does not increase the risk of adverse pregnancy outcomes.

In contrast, prior radiation to the abdomen and pelvis has been associated with an increased risk of miscarriage, growth restriction, preterm delivery, and stillbirth (J. Natl. Cancer Instit. Monogr. 2005;34:64-8; Lancet 2010;376:624-30). There is an increased risk of cancer in the offspring of women whose cancer is the result of hereditary cancer syndromes, such as BRCA or hereditary nonpolyposis colorectal cancer. Discussions with a genetics counselor may be helpful if there are any questions related to these syndromes.

Pregnancy management

Once pregnant, management requires a multidisciplinary approach. Surveillance options are limited during pregnancy. CT should be avoided, and radiographs limited. Ultrasound of the abdomen is safe, but optimal images are often obscured in later trimesters. Ultimately, indicated imaging should not be forsaken if there are any signs or symptoms that raise concerns for recurrence. Additionally, many tumor markers may be unreliable during pregnancy, such as CA-125 in the first trimester, or alpha-FP and CEA anytime.

Specific recommendations for antenatal testing do not exist and should be assessed on a case-by-case basis; especially in the case of women who have had prior radiation therapy. Our recommendation is to perform growth surveillance, which may include sonography at varying intervals. Also consider weekly fetal testing from 32 weeks in normally growing fetuses.

Solely being a cancer survivor is not an indication for early delivery or induction of labor. In the majority of cases, mode of delivery should be guided by obstetric indications, though previous pelvic surgery and reconstruction may be indications for cesarean delivery. Despite being in remission, some cancers metastasize to the placenta, most commonly melanoma and hematologic cancers. Very rarely, these cancers can also metastasize to the fetus. Thus, the placenta should be sent for histologic evaluation, with a notation to the pathologist about the patient’s prior cancer (Obstet. Gynecol. Surv. 1989;44:535-40; Ultrasound. Obstet. Gynecol. 2009;33:235-44).

In most cases, pregnancy after cancer is uncomplicated with good outcomes for both mother and baby. However, there are potential medical and obstetric complications that cannot be overlooked. Interdisciplinary management is crucial to ensure a safe transition from cancer survivor to mother.

What to consider when counseling cancer survivors about pregnancy

• The recommended disease-free interval prior to pregnancy may vary by cancer type, and is largely driven by disease surveillance needs and recurrence intervals.

• Prior cancer, associated operations, and chemotherapies do not typically confer additional risks in pregnancy. Exceptions include melanoma and blood cell cancers, which may metastasize to the placenta and fetus, even following periods of remission.

• Radiation therapy to the abdomen and pelvis may induce changes that predispose to growth restriction, preterm birth, and stillbirth. Enhanced surveillance may be reasonable in these cases.

• Preconception or early pregnancy assessment for end organ dysfunction is recommended for women who have received certain therapies: cardiac evaluation following chest radiation or anthracycline-based therapy; liver and kidney function for most chemotherapies.

Dr. Ivester is an associate professor of maternal-fetal medicine and an associate professor of maternal and child health at the University of North Carolina at Chapel Hill. Dr. Dotters-Katz is a maternal-fetal medicine fellow at University of North Carolina at Chapel Hill, who completed her ob.gyn. residency at Duke University. Her academic interests include oncology and infectious diseases as they relate to pregnancy. The authors reported having no financial disclosures. Email them at [email protected].

Introduction

Stimulant medications are an important part of attention-deficit/hyperactivity disorder (ADHD) treatment for most affected children and teens. But studies suggest that children and teens may not take their prescribed medication anywhere from 13% to as much as 64% of the time. As teenagers develop an appropriate increased desire for autonomy, they wish to have greater participation in their medication decisions, sometimes to the dismay of their parents.

Case

Will is an engaging young man who has been on stimulants for many years. However, he is frequently in conflict with his parents over an array of issues, including being annoyed at being reminded to take his medications. Although he is willing to take medication some of the time, he often forgets. He commonly fails to complete his homework, a further source of conflict.

Discussion

Parents can get frustrated with their teens and drawn into a control struggle over medication and other issues. Teenagers want to have more control of their lives, and sometimes this takes the form of not wanting to take medication. The No. 1 goal is to help the family move away from digging themselves further into conflict, and instead to have a genuine discussion about the pros and cons of medication.

This starts with listening seriously to the teenager. It helps to reassure teens that you are not going to get mad at them for not taking medication, but that instead you really value the information about how often they are taking it and, if they are skipping some doses or not taking it at all, the reason for that.

It is crucial to find out the real reason why someone is not taking his medication. Sometimes teens are genuinely forgetting. Here it can be helpful to be sure that the medication has to be taken as few times a day as possible, and then to set some kind of alarm reminder. This is one area where the omnipresence of cell phones is very useful. Help parents and teens negotiate about whether the parent will remind the teen, as repeated reminders can be irritating. Divided pill containers help both the parent and teen know whether the medication has been taken or not. If you formulate a plan with the family, write it down so that you can ask next time how it worked out, because if you are asking someone to make a behavior change, it is important to pay attention to whether they did it or not.

Other times it is clear that the teen doesn’t want to take the medication. In this situation, it is important to get the specifics. It is key to convey that the teen’s point of view is very important.

Reasons for not wanting to take a medication include some type of side effect, embarrassment about having to take the medication in school, inconvenience, or a general feeling that the teen doesn’t want to be on medication.

A genuinely collaborative attitude is the best approach. Restate what you have heard from the teen about his or her viewpoint. Help the parents state their concerns (for instance, about school success, driving safety, or the potential for impulsive behavior) in a noncritical manner. Then outline options and discuss the possible pros and cons of the different choices, including going off the medication as one option. By considering this as an option, you will have an opportunity to discuss what the drawbacks, as well as the advantages, might be.

When it comes to ADHD, there are many choices. These can include trying a different stimulant or using a nonstimulant such as atomoxetine or an alpha-adrenergic agonist. Because these medications have very different side effect profiles, they may be more acceptable to the teenager, although they also may have different efficacy. There are also psychotherapeutic options such as organizational skills training. By discussing a variety of choices and listening to the teen’s concerns and hopes, the teenager is engaged in taking responsibility for his own choices.

Once a choice is decided upon, it is important to follow up and review how well the plan is working and revise if necessary.

When to consult

If parents and teens are unable to participate in discussion and come up with a plan, family therapy to improve communication and address parenting issues can be recommended.

Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Hall said that she had no relevant financial disclosures. To comment, e-mail her at [email protected].

Introduction

Stimulant medications are an important part of attention-deficit/hyperactivity disorder (ADHD) treatment for most affected children and teens. But studies suggest that children and teens may not take their prescribed medication anywhere from 13% to as much as 64% of the time. As teenagers develop an appropriate increased desire for autonomy, they wish to have greater participation in their medication decisions, sometimes to the dismay of their parents.

Case

Will is an engaging young man who has been on stimulants for many years. However, he is frequently in conflict with his parents over an array of issues, including being annoyed at being reminded to take his medications. Although he is willing to take medication some of the time, he often forgets. He commonly fails to complete his homework, a further source of conflict.

Discussion

Parents can get frustrated with their teens and drawn into a control struggle over medication and other issues. Teenagers want to have more control of their lives, and sometimes this takes the form of not wanting to take medication. The No. 1 goal is to help the family move away from digging themselves further into conflict, and instead to have a genuine discussion about the pros and cons of medication.

This starts with listening seriously to the teenager. It helps to reassure teens that you are not going to get mad at them for not taking medication, but that instead you really value the information about how often they are taking it and, if they are skipping some doses or not taking it at all, the reason for that.

It is crucial to find out the real reason why someone is not taking his medication. Sometimes teens are genuinely forgetting. Here it can be helpful to be sure that the medication has to be taken as few times a day as possible, and then to set some kind of alarm reminder. This is one area where the omnipresence of cell phones is very useful. Help parents and teens negotiate about whether the parent will remind the teen, as repeated reminders can be irritating. Divided pill containers help both the parent and teen know whether the medication has been taken or not. If you formulate a plan with the family, write it down so that you can ask next time how it worked out, because if you are asking someone to make a behavior change, it is important to pay attention to whether they did it or not.

Other times it is clear that the teen doesn’t want to take the medication. In this situation, it is important to get the specifics. It is key to convey that the teen’s point of view is very important.

Reasons for not wanting to take a medication include some type of side effect, embarrassment about having to take the medication in school, inconvenience, or a general feeling that the teen doesn’t want to be on medication.

A genuinely collaborative attitude is the best approach. Restate what you have heard from the teen about his or her viewpoint. Help the parents state their concerns (for instance, about school success, driving safety, or the potential for impulsive behavior) in a noncritical manner. Then outline options and discuss the possible pros and cons of the different choices, including going off the medication as one option. By considering this as an option, you will have an opportunity to discuss what the drawbacks, as well as the advantages, might be.

When it comes to ADHD, there are many choices. These can include trying a different stimulant or using a nonstimulant such as atomoxetine or an alpha-adrenergic agonist. Because these medications have very different side effect profiles, they may be more acceptable to the teenager, although they also may have different efficacy. There are also psychotherapeutic options such as organizational skills training. By discussing a variety of choices and listening to the teen’s concerns and hopes, the teenager is engaged in taking responsibility for his own choices.

Once a choice is decided upon, it is important to follow up and review how well the plan is working and revise if necessary.

When to consult

If parents and teens are unable to participate in discussion and come up with a plan, family therapy to improve communication and address parenting issues can be recommended.

Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Hall said that she had no relevant financial disclosures. To comment, e-mail her at [email protected].

Introduction

Stimulant medications are an important part of attention-deficit/hyperactivity disorder (ADHD) treatment for most affected children and teens. But studies suggest that children and teens may not take their prescribed medication anywhere from 13% to as much as 64% of the time. As teenagers develop an appropriate increased desire for autonomy, they wish to have greater participation in their medication decisions, sometimes to the dismay of their parents.

Case

Will is an engaging young man who has been on stimulants for many years. However, he is frequently in conflict with his parents over an array of issues, including being annoyed at being reminded to take his medications. Although he is willing to take medication some of the time, he often forgets. He commonly fails to complete his homework, a further source of conflict.

Discussion

Parents can get frustrated with their teens and drawn into a control struggle over medication and other issues. Teenagers want to have more control of their lives, and sometimes this takes the form of not wanting to take medication. The No. 1 goal is to help the family move away from digging themselves further into conflict, and instead to have a genuine discussion about the pros and cons of medication.

This starts with listening seriously to the teenager. It helps to reassure teens that you are not going to get mad at them for not taking medication, but that instead you really value the information about how often they are taking it and, if they are skipping some doses or not taking it at all, the reason for that.

It is crucial to find out the real reason why someone is not taking his medication. Sometimes teens are genuinely forgetting. Here it can be helpful to be sure that the medication has to be taken as few times a day as possible, and then to set some kind of alarm reminder. This is one area where the omnipresence of cell phones is very useful. Help parents and teens negotiate about whether the parent will remind the teen, as repeated reminders can be irritating. Divided pill containers help both the parent and teen know whether the medication has been taken or not. If you formulate a plan with the family, write it down so that you can ask next time how it worked out, because if you are asking someone to make a behavior change, it is important to pay attention to whether they did it or not.

Other times it is clear that the teen doesn’t want to take the medication. In this situation, it is important to get the specifics. It is key to convey that the teen’s point of view is very important.

Reasons for not wanting to take a medication include some type of side effect, embarrassment about having to take the medication in school, inconvenience, or a general feeling that the teen doesn’t want to be on medication.

A genuinely collaborative attitude is the best approach. Restate what you have heard from the teen about his or her viewpoint. Help the parents state their concerns (for instance, about school success, driving safety, or the potential for impulsive behavior) in a noncritical manner. Then outline options and discuss the possible pros and cons of the different choices, including going off the medication as one option. By considering this as an option, you will have an opportunity to discuss what the drawbacks, as well as the advantages, might be.

When it comes to ADHD, there are many choices. These can include trying a different stimulant or using a nonstimulant such as atomoxetine or an alpha-adrenergic agonist. Because these medications have very different side effect profiles, they may be more acceptable to the teenager, although they also may have different efficacy. There are also psychotherapeutic options such as organizational skills training. By discussing a variety of choices and listening to the teen’s concerns and hopes, the teenager is engaged in taking responsibility for his own choices.

Once a choice is decided upon, it is important to follow up and review how well the plan is working and revise if necessary.

When to consult

If parents and teens are unable to participate in discussion and come up with a plan, family therapy to improve communication and address parenting issues can be recommended.

Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Hall said that she had no relevant financial disclosures. To comment, e-mail her at [email protected].

SCOTTSDALE, ARIZ.– Abdominal aortic aneurysm repair in patients 80 years and older can be performed safely and with good medium-term survival rates, a prospective single-site study has shown.

Perioperative mortality in elective and emergent AAA repair for octogenarians was 2% and 35%, respectively, with a median survival rate of 19 months in both groups.

Courtesy Wikimedia Commons/Milorad Dimic, MD/Creative Commons License

According to these data, “Patients shouldn’t be turned down for aneurysm repair on the basis of their age alone,” Dr. Christopher M. Lamb, a vascular surgery fellow at the University of California Davis Medical Center in Sacramento, said during a presentation at this year’s Southern Association for Vascular Surgery annual meeting.

“However, whether we should be doing these procedures is a different question, and I don’t think these data allow us to answer that question properly.”Dr. Lamb and his colleagues reviewed the records of 847 consecutive patients aged 80 years or older, seen between April 2005 and February 2014 for any type of AAA repair. Cases were sorted according to whether they were elective, ruptured, or urgent but unruptured. A total of 226 patients met the study’s age criteria; there were nearly seven men for every woman, all with a median age of 83 years. Of the elective AAA repair arm of the study, 131 patients (116 men) with a median age of 82 years had an endovascular repair, while the rest underwent open surgical repair. The combined 30-day mortality rate for these patients was 2.3%, with no significant difference between either the endovascular aneurysm repair (EVAR) or the open surgical repair (OSR) patients (1.9% vs. 4.2%; P = .458). The median survival of all elective repair patients was 19 months (interquartile range, 10-35), with no difference seen between the two groups (P = .113)Of the 65 patients (53 men) with ruptured AAA, the median age was 83 years. A third had open repair (32.3%), while the rest had EVAR. The combined 30-day mortality rate was 35.4% but was significantly higher after OSR (52.4% vs. 27.3%; P = .048). The median survival rate was 6 months (IQR, 6-42) when 30-day mortality rates were excluded. The median survival rates in patients who lived longer than 30 days was significantly higher in OSR patients (42.5 months vs. 11 months; P = .019).

Of the 23 men and 7 women with symptomatic but unruptured AAA, all but 1 had EVAR. At 30 days, there was one diverticular perforation–related postoperative death in the EVAR group, which had a median survival rate of 29 months. There being only a single patient in the OSR group obviated a comparative median survival rate analysis.

A subanalysis of the final 20 months of the study showed that 41% of octogenarians seeking any type of AAA repair at the site were rejected (48 rejections vs. 69 repairs). Those who were rejected for repair tended to be older, with a median age of 86 years vs. 83 years for patients who underwent repair (P = .0004).

Dr. Lamb noted that although the findings demonstrate acceptable overall safety rates for the entire cohort, without a control group of patients that did not have AAA repair, it would be hard to draw a definite conclusion about the utility of the findings, and that more data were warranted; however, the potential for limited long-term survival with what previous reports have suggested may include “a reduced quality of life for a good part of it, possibly raises the question that these patients should be treated conservatively, more often.”

The rejection rate data prompted the presentation’s discussant, Dr. William D. Jordan Jr., section chief of vascular surgery at the University of Alabama at Birmingham and the presentation’s discussant, to challenge the findings and asked whether a single surgeon selected the patients.

“You said there is not a selection bias in your study, but I beg to differ. Perhaps all these kinds of studies have a selection bias, and I believe they should. We should select the appropriate patients for the appropriate procedure at the appropriate time, with the appropriate expectation of outcome. Bias in this setting may be seen as good,” Dr. Jordan said.Dr. Lamb responded that the treatment algorithm at the site for all patients with a confirmed AAA of 5.5 cm or greater included CT imaging that is reviewed by a multidisciplinary team comprising vascular surgeons and interventional radiologists, who then evaluated the patients according to their physiology and anatomy, as well as their comorbidities, with the intention that whenever possible, EVAR rather than open repair would be performed.

As to whether there was a bias toward not repairing AAA in older patients, Dr. Lamb said it was incumbent on any health system to evaluate a procedure’s cost-effectiveness, but that, “the life expectancy of a vascular patient is often more limited than I think we’d like to believe ... we don’t know what the natural history of these patients’ life expectancy is. We don’t know from these data what the cause of death was, but anecdotally, we didn’t see hundreds of patients return with ruptured aneurysms after an EVAR.”

“I would truly like to see how many [of these patients] who make it out of the hospital return to normal living within 6 months,” Dr. Samuel R. Money, chair of surgery at the Mayo Clinic in Scottsdale, Ariz., said in an interview following the presentation. “At some point, the question becomes ‘Can we afford to spend $100,000 dollars to keep a 90-year-old patient alive for 6 more months?’ Can this society sustain the cost of that?”

[email protected]


On Twitter @whitneymcknight

SCOTTSDALE, ARIZ.– Abdominal aortic aneurysm repair in patients 80 years and older can be performed safely and with good medium-term survival rates, a prospective single-site study has shown.

Perioperative mortality in elective and emergent AAA repair for octogenarians was 2% and 35%, respectively, with a median survival rate of 19 months in both groups.

Courtesy Wikimedia Commons/Milorad Dimic, MD/Creative Commons License

According to these data, “Patients shouldn’t be turned down for aneurysm repair on the basis of their age alone,” Dr. Christopher M. Lamb, a vascular surgery fellow at the University of California Davis Medical Center in Sacramento, said during a presentation at this year’s Southern Association for Vascular Surgery annual meeting.

“However, whether we should be doing these procedures is a different question, and I don’t think these data allow us to answer that question properly.”Dr. Lamb and his colleagues reviewed the records of 847 consecutive patients aged 80 years or older, seen between April 2005 and February 2014 for any type of AAA repair. Cases were sorted according to whether they were elective, ruptured, or urgent but unruptured. A total of 226 patients met the study’s age criteria; there were nearly seven men for every woman, all with a median age of 83 years. Of the elective AAA repair arm of the study, 131 patients (116 men) with a median age of 82 years had an endovascular repair, while the rest underwent open surgical repair. The combined 30-day mortality rate for these patients was 2.3%, with no significant difference between either the endovascular aneurysm repair (EVAR) or the open surgical repair (OSR) patients (1.9% vs. 4.2%; P = .458). The median survival of all elective repair patients was 19 months (interquartile range, 10-35), with no difference seen between the two groups (P = .113)Of the 65 patients (53 men) with ruptured AAA, the median age was 83 years. A third had open repair (32.3%), while the rest had EVAR. The combined 30-day mortality rate was 35.4% but was significantly higher after OSR (52.4% vs. 27.3%; P = .048). The median survival rate was 6 months (IQR, 6-42) when 30-day mortality rates were excluded. The median survival rates in patients who lived longer than 30 days was significantly higher in OSR patients (42.5 months vs. 11 months; P = .019).

Of the 23 men and 7 women with symptomatic but unruptured AAA, all but 1 had EVAR. At 30 days, there was one diverticular perforation–related postoperative death in the EVAR group, which had a median survival rate of 29 months. There being only a single patient in the OSR group obviated a comparative median survival rate analysis.

A subanalysis of the final 20 months of the study showed that 41% of octogenarians seeking any type of AAA repair at the site were rejected (48 rejections vs. 69 repairs). Those who were rejected for repair tended to be older, with a median age of 86 years vs. 83 years for patients who underwent repair (P = .0004).

Dr. Lamb noted that although the findings demonstrate acceptable overall safety rates for the entire cohort, without a control group of patients that did not have AAA repair, it would be hard to draw a definite conclusion about the utility of the findings, and that more data were warranted; however, the potential for limited long-term survival with what previous reports have suggested may include “a reduced quality of life for a good part of it, possibly raises the question that these patients should be treated conservatively, more often.”

The rejection rate data prompted the presentation’s discussant, Dr. William D. Jordan Jr., section chief of vascular surgery at the University of Alabama at Birmingham and the presentation’s discussant, to challenge the findings and asked whether a single surgeon selected the patients.

“You said there is not a selection bias in your study, but I beg to differ. Perhaps all these kinds of studies have a selection bias, and I believe they should. We should select the appropriate patients for the appropriate procedure at the appropriate time, with the appropriate expectation of outcome. Bias in this setting may be seen as good,” Dr. Jordan said.Dr. Lamb responded that the treatment algorithm at the site for all patients with a confirmed AAA of 5.5 cm or greater included CT imaging that is reviewed by a multidisciplinary team comprising vascular surgeons and interventional radiologists, who then evaluated the patients according to their physiology and anatomy, as well as their comorbidities, with the intention that whenever possible, EVAR rather than open repair would be performed.

As to whether there was a bias toward not repairing AAA in older patients, Dr. Lamb said it was incumbent on any health system to evaluate a procedure’s cost-effectiveness, but that, “the life expectancy of a vascular patient is often more limited than I think we’d like to believe ... we don’t know what the natural history of these patients’ life expectancy is. We don’t know from these data what the cause of death was, but anecdotally, we didn’t see hundreds of patients return with ruptured aneurysms after an EVAR.”

“I would truly like to see how many [of these patients] who make it out of the hospital return to normal living within 6 months,” Dr. Samuel R. Money, chair of surgery at the Mayo Clinic in Scottsdale, Ariz., said in an interview following the presentation. “At some point, the question becomes ‘Can we afford to spend $100,000 dollars to keep a 90-year-old patient alive for 6 more months?’ Can this society sustain the cost of that?”

[email protected]


On Twitter @whitneymcknight

SCOTTSDALE, ARIZ.– Abdominal aortic aneurysm repair in patients 80 years and older can be performed safely and with good medium-term survival rates, a prospective single-site study has shown.

Perioperative mortality in elective and emergent AAA repair for octogenarians was 2% and 35%, respectively, with a median survival rate of 19 months in both groups.

Courtesy Wikimedia Commons/Milorad Dimic, MD/Creative Commons License

According to these data, “Patients shouldn’t be turned down for aneurysm repair on the basis of their age alone,” Dr. Christopher M. Lamb, a vascular surgery fellow at the University of California Davis Medical Center in Sacramento, said during a presentation at this year’s Southern Association for Vascular Surgery annual meeting.

“However, whether we should be doing these procedures is a different question, and I don’t think these data allow us to answer that question properly.”Dr. Lamb and his colleagues reviewed the records of 847 consecutive patients aged 80 years or older, seen between April 2005 and February 2014 for any type of AAA repair. Cases were sorted according to whether they were elective, ruptured, or urgent but unruptured. A total of 226 patients met the study’s age criteria; there were nearly seven men for every woman, all with a median age of 83 years. Of the elective AAA repair arm of the study, 131 patients (116 men) with a median age of 82 years had an endovascular repair, while the rest underwent open surgical repair. The combined 30-day mortality rate for these patients was 2.3%, with no significant difference between either the endovascular aneurysm repair (EVAR) or the open surgical repair (OSR) patients (1.9% vs. 4.2%; P = .458). The median survival of all elective repair patients was 19 months (interquartile range, 10-35), with no difference seen between the two groups (P = .113)Of the 65 patients (53 men) with ruptured AAA, the median age was 83 years. A third had open repair (32.3%), while the rest had EVAR. The combined 30-day mortality rate was 35.4% but was significantly higher after OSR (52.4% vs. 27.3%; P = .048). The median survival rate was 6 months (IQR, 6-42) when 30-day mortality rates were excluded. The median survival rates in patients who lived longer than 30 days was significantly higher in OSR patients (42.5 months vs. 11 months; P = .019).

Of the 23 men and 7 women with symptomatic but unruptured AAA, all but 1 had EVAR. At 30 days, there was one diverticular perforation–related postoperative death in the EVAR group, which had a median survival rate of 29 months. There being only a single patient in the OSR group obviated a comparative median survival rate analysis.

A subanalysis of the final 20 months of the study showed that 41% of octogenarians seeking any type of AAA repair at the site were rejected (48 rejections vs. 69 repairs). Those who were rejected for repair tended to be older, with a median age of 86 years vs. 83 years for patients who underwent repair (P = .0004).

Dr. Lamb noted that although the findings demonstrate acceptable overall safety rates for the entire cohort, without a control group of patients that did not have AAA repair, it would be hard to draw a definite conclusion about the utility of the findings, and that more data were warranted; however, the potential for limited long-term survival with what previous reports have suggested may include “a reduced quality of life for a good part of it, possibly raises the question that these patients should be treated conservatively, more often.”

The rejection rate data prompted the presentation’s discussant, Dr. William D. Jordan Jr., section chief of vascular surgery at the University of Alabama at Birmingham and the presentation’s discussant, to challenge the findings and asked whether a single surgeon selected the patients.

“You said there is not a selection bias in your study, but I beg to differ. Perhaps all these kinds of studies have a selection bias, and I believe they should. We should select the appropriate patients for the appropriate procedure at the appropriate time, with the appropriate expectation of outcome. Bias in this setting may be seen as good,” Dr. Jordan said.Dr. Lamb responded that the treatment algorithm at the site for all patients with a confirmed AAA of 5.5 cm or greater included CT imaging that is reviewed by a multidisciplinary team comprising vascular surgeons and interventional radiologists, who then evaluated the patients according to their physiology and anatomy, as well as their comorbidities, with the intention that whenever possible, EVAR rather than open repair would be performed.

As to whether there was a bias toward not repairing AAA in older patients, Dr. Lamb said it was incumbent on any health system to evaluate a procedure’s cost-effectiveness, but that, “the life expectancy of a vascular patient is often more limited than I think we’d like to believe ... we don’t know what the natural history of these patients’ life expectancy is. We don’t know from these data what the cause of death was, but anecdotally, we didn’t see hundreds of patients return with ruptured aneurysms after an EVAR.”

“I would truly like to see how many [of these patients] who make it out of the hospital return to normal living within 6 months,” Dr. Samuel R. Money, chair of surgery at the Mayo Clinic in Scottsdale, Ariz., said in an interview following the presentation. “At some point, the question becomes ‘Can we afford to spend $100,000 dollars to keep a 90-year-old patient alive for 6 more months?’ Can this society sustain the cost of that?”

[email protected]


On Twitter @whitneymcknight

A major challenge faced by parents is the task of setting basic ground rules and expectations for their children, and then enforcing these with limits, rewards, and consequences. This task is made far more difficult when parents are separated or divorced. Agreeing upon and enforcing rules in separate homes often becomes burdened by the angry baggage that led to the divorce. When a family in your practice is going through a divorce, you have an opportunity to provide the parents with valuable strategies to manage rules effectively so that conflict is minimized.

Many happily married parents who communicate very well on most matters struggle to get on the same page when negotiating rules and limits. One parent’s sense of what is an appropriate bedtime, how children should help with chores, or even how often they can have sweets can become a deeply held belief and might be very different than their spouse’s opinions. Sometimes, a parent has old anger about how they were raised and finds it hard to distinguish what might have been better for them, compared with what is best for their own child. Cultural and family differences on how much choice children should have at different ages, criteria and severity of any consequences for misbehavior, and opportunities for redemption or amnesty all add complexity to the discussion. Once they have found common ground on what makes sense for their joint rules, values, and needs of their child, they have to manage enforcing rules and limits, agreeing upon appropriate rewards and punishments, and bearing the inevitable distress of their children when facing a limit or consequence. And, of course, once parents think they have it all figured out, their children react and grow, and they must reset the rules, expectations, and consequences.

When parents get separated or divorced, this process becomes considerably more difficult. Negotiating new rules or limits is very difficult when communication is hampered by conflict. Parental guilt about the divorce itself, anger at old hurts or disputes about money and custody, missing the child between visits, and remarriages all add baggage to the discussion of a reasonable bedtime or consequences for a poor grade at school. If the divorce required aggressive negotiation between lawyers, appointment of a guardian ad Litem to manage ongoing disputes involving the children, or a court case to reach resolution, the tensions between parents can be intense, enduring, and with no issue too small to add fuel to the arguments. Enforcing limits is much harder for a single parent than when there are two parents doing the enforcement. And divorced parents, already feeling guilty and insecure, are more likely to suspend rules or limits so that they don’t have to be the “bad parent.” For the child or children, the stress and disruptions that come with divorce can cause an increase in regressed or disrespectful behavior. While it can be a time when limits are increasingly tested, being reasonable and consistent in enforcing limits becomes more important, as it provides reassuring steadiness in the midst of turbulent change.

Let’s take the example of a 12-year-old coming home from school with poor grades. One parent may see the need for a tutor, but might be using that approach as part of a financial attack if the other parent has to pay for it. The other parent may want to limit the use of computer games or access to television until the grades go up. And one may expect movement from a D to a C average while the other may expect A’s, period. Is the poor grade based on lack of ability, effort, an attempt to get attention, a reaction to the divorce, or preoccupation with ongoing parental discord? What is the impact on the child if in one home there is a tutor and a C expectation, and in the other there is no tutor, no computer use, no TV... and these change every time the child moves from one home to the other? A child striving to overcome a poor grade needs calm, consistent, patient, and optimistic support, rather than managing the increased tension across two homes or feeling like the cause of increased conflict. Virtually any reasonable approach is better for the child than each parent doing something different as a reflection of ongoing tension. Pediatricians can be extraordinarily helpful to their patient if they can get divorced parents to agree on a single approach that is based on their child’s needs rather than past and ongoing angers. The emotional damage of ongoing discord is far worse than any C average.

As the pediatrician to a family managing divorce, you may be one of the few authority figures whom both parents and the children all still respect and trust. You are in a strong position to ask a parent during an appointment how rules and limits are being managed across two homes. Find out if they have a clear plan for handling routine communication about the children, whether about summer camps or a new curfew, so that they don’t default to communicating only once there is a crisis. See if rules are a vehicle for ongoing parental fighting so that a minor difference (an 8 o’clock bedtime in one house versus 9 o’clock in the other) carries a high emotional charge. Find out if there are certain rules that have become very hard to enforce, or if their child has been testing limits more. Ask if there has been a consequence enforced in one home, but not in another. Often simply providing a calm affirmation that increased limit testing is normal in children after a divorce is very reassuring for parents. Remind them that providing reasonably consistent rules and limits will be very helpful to their children during this period, the opposite of making them a “bad parent.”

Some divorced parents will become more rigid about rules, managing any infraction or extenuating circumstance more like a contract negotiation. These parents might benefit from a suggestion that consistency and simplicity are the keys to effective rules across two households. Rules also provide an opportunity to listen to their children’s thoughts and feelings and share the family’s values that are the basis for the rules. Parents should be curious about their children’s opinions and be ready to show thoughtful flexibility when rules become outdated or special circumstances exist.

You can suggest a rule the parents should follow. While they can talk honestly about what each parent may struggle with or acknowledge clear differences in style or personality, they should strive to never vilify the other parent. Even in circumstances in which it is very difficult for two parents to collaborate, sharing grievances with the children will only be painful and confusing for them.

Lastly, pediatricians can discuss the long-term goals that all parents, even those alienated from each other, share. Children will do best when they have a positive, honest, warm relationship with each parent, and do not carry responsibility for negotiating conflict between their parents. Ultimately, more autonomy and fewer rules will be an important part of the child’s adolescence. Discord between parents, sabotaging of rules and consequences, and explicit contempt for their children’s other parent all will lead to children feeling burdened, having lower self-esteem, and being at greater risk for serious problems in school, emotionally or with substances as they grow into adolescents and young adults. If you are frustrated in your effort to protect children from ongoing discord, suggest a referral to a mental health clinician with expertise helping parents after a divorce.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at [email protected].

A major challenge faced by parents is the task of setting basic ground rules and expectations for their children, and then enforcing these with limits, rewards, and consequences. This task is made far more difficult when parents are separated or divorced. Agreeing upon and enforcing rules in separate homes often becomes burdened by the angry baggage that led to the divorce. When a family in your practice is going through a divorce, you have an opportunity to provide the parents with valuable strategies to manage rules effectively so that conflict is minimized.

Many happily married parents who communicate very well on most matters struggle to get on the same page when negotiating rules and limits. One parent’s sense of what is an appropriate bedtime, how children should help with chores, or even how often they can have sweets can become a deeply held belief and might be very different than their spouse’s opinions. Sometimes, a parent has old anger about how they were raised and finds it hard to distinguish what might have been better for them, compared with what is best for their own child. Cultural and family differences on how much choice children should have at different ages, criteria and severity of any consequences for misbehavior, and opportunities for redemption or amnesty all add complexity to the discussion. Once they have found common ground on what makes sense for their joint rules, values, and needs of their child, they have to manage enforcing rules and limits, agreeing upon appropriate rewards and punishments, and bearing the inevitable distress of their children when facing a limit or consequence. And, of course, once parents think they have it all figured out, their children react and grow, and they must reset the rules, expectations, and consequences.

When parents get separated or divorced, this process becomes considerably more difficult. Negotiating new rules or limits is very difficult when communication is hampered by conflict. Parental guilt about the divorce itself, anger at old hurts or disputes about money and custody, missing the child between visits, and remarriages all add baggage to the discussion of a reasonable bedtime or consequences for a poor grade at school. If the divorce required aggressive negotiation between lawyers, appointment of a guardian ad Litem to manage ongoing disputes involving the children, or a court case to reach resolution, the tensions between parents can be intense, enduring, and with no issue too small to add fuel to the arguments. Enforcing limits is much harder for a single parent than when there are two parents doing the enforcement. And divorced parents, already feeling guilty and insecure, are more likely to suspend rules or limits so that they don’t have to be the “bad parent.” For the child or children, the stress and disruptions that come with divorce can cause an increase in regressed or disrespectful behavior. While it can be a time when limits are increasingly tested, being reasonable and consistent in enforcing limits becomes more important, as it provides reassuring steadiness in the midst of turbulent change.

Let’s take the example of a 12-year-old coming home from school with poor grades. One parent may see the need for a tutor, but might be using that approach as part of a financial attack if the other parent has to pay for it. The other parent may want to limit the use of computer games or access to television until the grades go up. And one may expect movement from a D to a C average while the other may expect A’s, period. Is the poor grade based on lack of ability, effort, an attempt to get attention, a reaction to the divorce, or preoccupation with ongoing parental discord? What is the impact on the child if in one home there is a tutor and a C expectation, and in the other there is no tutor, no computer use, no TV... and these change every time the child moves from one home to the other? A child striving to overcome a poor grade needs calm, consistent, patient, and optimistic support, rather than managing the increased tension across two homes or feeling like the cause of increased conflict. Virtually any reasonable approach is better for the child than each parent doing something different as a reflection of ongoing tension. Pediatricians can be extraordinarily helpful to their patient if they can get divorced parents to agree on a single approach that is based on their child’s needs rather than past and ongoing angers. The emotional damage of ongoing discord is far worse than any C average.

As the pediatrician to a family managing divorce, you may be one of the few authority figures whom both parents and the children all still respect and trust. You are in a strong position to ask a parent during an appointment how rules and limits are being managed across two homes. Find out if they have a clear plan for handling routine communication about the children, whether about summer camps or a new curfew, so that they don’t default to communicating only once there is a crisis. See if rules are a vehicle for ongoing parental fighting so that a minor difference (an 8 o’clock bedtime in one house versus 9 o’clock in the other) carries a high emotional charge. Find out if there are certain rules that have become very hard to enforce, or if their child has been testing limits more. Ask if there has been a consequence enforced in one home, but not in another. Often simply providing a calm affirmation that increased limit testing is normal in children after a divorce is very reassuring for parents. Remind them that providing reasonably consistent rules and limits will be very helpful to their children during this period, the opposite of making them a “bad parent.”

Some divorced parents will become more rigid about rules, managing any infraction or extenuating circumstance more like a contract negotiation. These parents might benefit from a suggestion that consistency and simplicity are the keys to effective rules across two households. Rules also provide an opportunity to listen to their children’s thoughts and feelings and share the family’s values that are the basis for the rules. Parents should be curious about their children’s opinions and be ready to show thoughtful flexibility when rules become outdated or special circumstances exist.

You can suggest a rule the parents should follow. While they can talk honestly about what each parent may struggle with or acknowledge clear differences in style or personality, they should strive to never vilify the other parent. Even in circumstances in which it is very difficult for two parents to collaborate, sharing grievances with the children will only be painful and confusing for them.

Lastly, pediatricians can discuss the long-term goals that all parents, even those alienated from each other, share. Children will do best when they have a positive, honest, warm relationship with each parent, and do not carry responsibility for negotiating conflict between their parents. Ultimately, more autonomy and fewer rules will be an important part of the child’s adolescence. Discord between parents, sabotaging of rules and consequences, and explicit contempt for their children’s other parent all will lead to children feeling burdened, having lower self-esteem, and being at greater risk for serious problems in school, emotionally or with substances as they grow into adolescents and young adults. If you are frustrated in your effort to protect children from ongoing discord, suggest a referral to a mental health clinician with expertise helping parents after a divorce.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at [email protected].

A major challenge faced by parents is the task of setting basic ground rules and expectations for their children, and then enforcing these with limits, rewards, and consequences. This task is made far more difficult when parents are separated or divorced. Agreeing upon and enforcing rules in separate homes often becomes burdened by the angry baggage that led to the divorce. When a family in your practice is going through a divorce, you have an opportunity to provide the parents with valuable strategies to manage rules effectively so that conflict is minimized.

Many happily married parents who communicate very well on most matters struggle to get on the same page when negotiating rules and limits. One parent’s sense of what is an appropriate bedtime, how children should help with chores, or even how often they can have sweets can become a deeply held belief and might be very different than their spouse’s opinions. Sometimes, a parent has old anger about how they were raised and finds it hard to distinguish what might have been better for them, compared with what is best for their own child. Cultural and family differences on how much choice children should have at different ages, criteria and severity of any consequences for misbehavior, and opportunities for redemption or amnesty all add complexity to the discussion. Once they have found common ground on what makes sense for their joint rules, values, and needs of their child, they have to manage enforcing rules and limits, agreeing upon appropriate rewards and punishments, and bearing the inevitable distress of their children when facing a limit or consequence. And, of course, once parents think they have it all figured out, their children react and grow, and they must reset the rules, expectations, and consequences.

When parents get separated or divorced, this process becomes considerably more difficult. Negotiating new rules or limits is very difficult when communication is hampered by conflict. Parental guilt about the divorce itself, anger at old hurts or disputes about money and custody, missing the child between visits, and remarriages all add baggage to the discussion of a reasonable bedtime or consequences for a poor grade at school. If the divorce required aggressive negotiation between lawyers, appointment of a guardian ad Litem to manage ongoing disputes involving the children, or a court case to reach resolution, the tensions between parents can be intense, enduring, and with no issue too small to add fuel to the arguments. Enforcing limits is much harder for a single parent than when there are two parents doing the enforcement. And divorced parents, already feeling guilty and insecure, are more likely to suspend rules or limits so that they don’t have to be the “bad parent.” For the child or children, the stress and disruptions that come with divorce can cause an increase in regressed or disrespectful behavior. While it can be a time when limits are increasingly tested, being reasonable and consistent in enforcing limits becomes more important, as it provides reassuring steadiness in the midst of turbulent change.

Let’s take the example of a 12-year-old coming home from school with poor grades. One parent may see the need for a tutor, but might be using that approach as part of a financial attack if the other parent has to pay for it. The other parent may want to limit the use of computer games or access to television until the grades go up. And one may expect movement from a D to a C average while the other may expect A’s, period. Is the poor grade based on lack of ability, effort, an attempt to get attention, a reaction to the divorce, or preoccupation with ongoing parental discord? What is the impact on the child if in one home there is a tutor and a C expectation, and in the other there is no tutor, no computer use, no TV... and these change every time the child moves from one home to the other? A child striving to overcome a poor grade needs calm, consistent, patient, and optimistic support, rather than managing the increased tension across two homes or feeling like the cause of increased conflict. Virtually any reasonable approach is better for the child than each parent doing something different as a reflection of ongoing tension. Pediatricians can be extraordinarily helpful to their patient if they can get divorced parents to agree on a single approach that is based on their child’s needs rather than past and ongoing angers. The emotional damage of ongoing discord is far worse than any C average.

As the pediatrician to a family managing divorce, you may be one of the few authority figures whom both parents and the children all still respect and trust. You are in a strong position to ask a parent during an appointment how rules and limits are being managed across two homes. Find out if they have a clear plan for handling routine communication about the children, whether about summer camps or a new curfew, so that they don’t default to communicating only once there is a crisis. See if rules are a vehicle for ongoing parental fighting so that a minor difference (an 8 o’clock bedtime in one house versus 9 o’clock in the other) carries a high emotional charge. Find out if there are certain rules that have become very hard to enforce, or if their child has been testing limits more. Ask if there has been a consequence enforced in one home, but not in another. Often simply providing a calm affirmation that increased limit testing is normal in children after a divorce is very reassuring for parents. Remind them that providing reasonably consistent rules and limits will be very helpful to their children during this period, the opposite of making them a “bad parent.”

Some divorced parents will become more rigid about rules, managing any infraction or extenuating circumstance more like a contract negotiation. These parents might benefit from a suggestion that consistency and simplicity are the keys to effective rules across two households. Rules also provide an opportunity to listen to their children’s thoughts and feelings and share the family’s values that are the basis for the rules. Parents should be curious about their children’s opinions and be ready to show thoughtful flexibility when rules become outdated or special circumstances exist.

You can suggest a rule the parents should follow. While they can talk honestly about what each parent may struggle with or acknowledge clear differences in style or personality, they should strive to never vilify the other parent. Even in circumstances in which it is very difficult for two parents to collaborate, sharing grievances with the children will only be painful and confusing for them.

Lastly, pediatricians can discuss the long-term goals that all parents, even those alienated from each other, share. Children will do best when they have a positive, honest, warm relationship with each parent, and do not carry responsibility for negotiating conflict between their parents. Ultimately, more autonomy and fewer rules will be an important part of the child’s adolescence. Discord between parents, sabotaging of rules and consequences, and explicit contempt for their children’s other parent all will lead to children feeling burdened, having lower self-esteem, and being at greater risk for serious problems in school, emotionally or with substances as they grow into adolescents and young adults. If you are frustrated in your effort to protect children from ongoing discord, suggest a referral to a mental health clinician with expertise helping parents after a divorce.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at [email protected].

“So tell me, Kathy,” I asked as I walked in. “Is the wedding still on?”

“Yes!” she said.

I was kidding, of course. I wanted to defuse the tension every bride feels as her big day approaches. With her nuptials 2 months off, Kathy was here for an acne tune-up.

Good news: no new pimples. Though Kathy had stopped squeezing her old ones, their marks were fading slowly. Brides don’t want to depend on makeup or Photoshop.

Her current regimen was a topical antibiotic in the morning and a retinoid at night. The question was whether to add or change anything.

“Maybe we should consider adding an oral medicine to help speed healing?” I asked. Then I watched her eyes. Her frown gave me my answer.

“I’d prefer to avoid oral medications unless I absolutely need them,” Kathy said.

“No problem,” I said. “You’re doing well, and we still have 2 months for the marks you have to fade.” I arranged to see her again shortly before the wedding, for any last-minute adjustments.

Outside the exam room, I took my student aside. “That’s how you negotiate,” I told her.

“Some young women approach their weddings in a kind of panic. They want to do whatever it takes to speed healing. If Kathy had felt that way, and I told her things were fine as they were, she would have been upset. ‘Isn’t there something else we can do, maybe something to take by mouth?’ she’d have asked.

“Instead, Kathy felt the opposite,” I told my student. “When patients have a specific problem, you can make a shrewd guess about how aggressive they want to be in addressing it. But you can’t be sure. That means watching their eyes and body language when making suggestions.

“Of course, not every medical condition is negotiable. Sometimes, the matter is so urgent or dire that there really is only one thing to do. Then you have to be more direct. But many situations are not so clear cut. You and the patient will have choices. Which is best may depend less on the medical condition than on the patient’s mindset and circumstances.

“Your job is to know the options, watch their eyes, and negotiate,” I said.

My student nodded, probably noticing that this is not standard clinical advice. In school, they teach you to make the right diagnosis and prescribe the treatment of choice. Anything else would be substandard care, a dereliction of professional duty.

Nowadays, teachers – and insurers – go in for algorithms, cookbook medicine. If the patient has this, do this. If that, do that. “How do you treat acne?” students often ask at the start of their rotation. “Can you give me a decision tree?”

These days more and more doctors spend their visit time clicking tablets or laptops. If the patient has acne, they are checking off vital data points like:

• Are there pimples, pustules, whiteheads, blackheads, cysts?

• How many of each?

• Where they are – face, chest, back?

This information is supposed to objectively describe and grade the patient’s acne. You click what is important: what you can count and measure.

Here is what electronic medical records do not have you click off:

• Is the patient getting married soon?

• Is she afraid of oral antibiotics because she’s heard they wreck your immune system and make you sick?

• Have her friends recommended an acne cream they are sure is the best thing since sliced tretinoin?

They don’t make boxes for what goes on inside people’s brains. You can’t count or measure that, and if you can’t count it, it doesn’t count.

So doctors click what they tell us to. As we click the keyboard, we are not looking at the patient’s face. So we don’t know whether the patient is buying what we have to offer.

More medical treatment than we care to admit is – or should be – a process of negotiation. Negotiating means looking people in the eye and hearing what they say and the way they say it. That way you know not only what they have, but what they want. In Kathy’s case, that would be a wedding to remember.

As she proceeds in her career, my student may do more than counting pimples and grading acne. At any rate, I hope so.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

“So tell me, Kathy,” I asked as I walked in. “Is the wedding still on?”

“Yes!” she said.

I was kidding, of course. I wanted to defuse the tension every bride feels as her big day approaches. With her nuptials 2 months off, Kathy was here for an acne tune-up.

Good news: no new pimples. Though Kathy had stopped squeezing her old ones, their marks were fading slowly. Brides don’t want to depend on makeup or Photoshop.

Her current regimen was a topical antibiotic in the morning and a retinoid at night. The question was whether to add or change anything.

“Maybe we should consider adding an oral medicine to help speed healing?” I asked. Then I watched her eyes. Her frown gave me my answer.

“I’d prefer to avoid oral medications unless I absolutely need them,” Kathy said.

“No problem,” I said. “You’re doing well, and we still have 2 months for the marks you have to fade.” I arranged to see her again shortly before the wedding, for any last-minute adjustments.

Outside the exam room, I took my student aside. “That’s how you negotiate,” I told her.

“Some young women approach their weddings in a kind of panic. They want to do whatever it takes to speed healing. If Kathy had felt that way, and I told her things were fine as they were, she would have been upset. ‘Isn’t there something else we can do, maybe something to take by mouth?’ she’d have asked.

“Instead, Kathy felt the opposite,” I told my student. “When patients have a specific problem, you can make a shrewd guess about how aggressive they want to be in addressing it. But you can’t be sure. That means watching their eyes and body language when making suggestions.

“Of course, not every medical condition is negotiable. Sometimes, the matter is so urgent or dire that there really is only one thing to do. Then you have to be more direct. But many situations are not so clear cut. You and the patient will have choices. Which is best may depend less on the medical condition than on the patient’s mindset and circumstances.

“Your job is to know the options, watch their eyes, and negotiate,” I said.

My student nodded, probably noticing that this is not standard clinical advice. In school, they teach you to make the right diagnosis and prescribe the treatment of choice. Anything else would be substandard care, a dereliction of professional duty.

Nowadays, teachers – and insurers – go in for algorithms, cookbook medicine. If the patient has this, do this. If that, do that. “How do you treat acne?” students often ask at the start of their rotation. “Can you give me a decision tree?”

These days more and more doctors spend their visit time clicking tablets or laptops. If the patient has acne, they are checking off vital data points like:

• Are there pimples, pustules, whiteheads, blackheads, cysts?

• How many of each?

• Where they are – face, chest, back?

This information is supposed to objectively describe and grade the patient’s acne. You click what is important: what you can count and measure.

Here is what electronic medical records do not have you click off:

• Is the patient getting married soon?

• Is she afraid of oral antibiotics because she’s heard they wreck your immune system and make you sick?

• Have her friends recommended an acne cream they are sure is the best thing since sliced tretinoin?

They don’t make boxes for what goes on inside people’s brains. You can’t count or measure that, and if you can’t count it, it doesn’t count.

So doctors click what they tell us to. As we click the keyboard, we are not looking at the patient’s face. So we don’t know whether the patient is buying what we have to offer.

More medical treatment than we care to admit is – or should be – a process of negotiation. Negotiating means looking people in the eye and hearing what they say and the way they say it. That way you know not only what they have, but what they want. In Kathy’s case, that would be a wedding to remember.

As she proceeds in her career, my student may do more than counting pimples and grading acne. At any rate, I hope so.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

“So tell me, Kathy,” I asked as I walked in. “Is the wedding still on?”

“Yes!” she said.

I was kidding, of course. I wanted to defuse the tension every bride feels as her big day approaches. With her nuptials 2 months off, Kathy was here for an acne tune-up.

Good news: no new pimples. Though Kathy had stopped squeezing her old ones, their marks were fading slowly. Brides don’t want to depend on makeup or Photoshop.

Her current regimen was a topical antibiotic in the morning and a retinoid at night. The question was whether to add or change anything.

“Maybe we should consider adding an oral medicine to help speed healing?” I asked. Then I watched her eyes. Her frown gave me my answer.

“I’d prefer to avoid oral medications unless I absolutely need them,” Kathy said.

“No problem,” I said. “You’re doing well, and we still have 2 months for the marks you have to fade.” I arranged to see her again shortly before the wedding, for any last-minute adjustments.

Outside the exam room, I took my student aside. “That’s how you negotiate,” I told her.

“Some young women approach their weddings in a kind of panic. They want to do whatever it takes to speed healing. If Kathy had felt that way, and I told her things were fine as they were, she would have been upset. ‘Isn’t there something else we can do, maybe something to take by mouth?’ she’d have asked.

“Instead, Kathy felt the opposite,” I told my student. “When patients have a specific problem, you can make a shrewd guess about how aggressive they want to be in addressing it. But you can’t be sure. That means watching their eyes and body language when making suggestions.

“Of course, not every medical condition is negotiable. Sometimes, the matter is so urgent or dire that there really is only one thing to do. Then you have to be more direct. But many situations are not so clear cut. You and the patient will have choices. Which is best may depend less on the medical condition than on the patient’s mindset and circumstances.

“Your job is to know the options, watch their eyes, and negotiate,” I said.

My student nodded, probably noticing that this is not standard clinical advice. In school, they teach you to make the right diagnosis and prescribe the treatment of choice. Anything else would be substandard care, a dereliction of professional duty.

Nowadays, teachers – and insurers – go in for algorithms, cookbook medicine. If the patient has this, do this. If that, do that. “How do you treat acne?” students often ask at the start of their rotation. “Can you give me a decision tree?”

These days more and more doctors spend their visit time clicking tablets or laptops. If the patient has acne, they are checking off vital data points like:

• Are there pimples, pustules, whiteheads, blackheads, cysts?

• How many of each?

• Where they are – face, chest, back?

This information is supposed to objectively describe and grade the patient’s acne. You click what is important: what you can count and measure.

Here is what electronic medical records do not have you click off:

• Is the patient getting married soon?

• Is she afraid of oral antibiotics because she’s heard they wreck your immune system and make you sick?

• Have her friends recommended an acne cream they are sure is the best thing since sliced tretinoin?

They don’t make boxes for what goes on inside people’s brains. You can’t count or measure that, and if you can’t count it, it doesn’t count.

So doctors click what they tell us to. As we click the keyboard, we are not looking at the patient’s face. So we don’t know whether the patient is buying what we have to offer.

More medical treatment than we care to admit is – or should be – a process of negotiation. Negotiating means looking people in the eye and hearing what they say and the way they say it. That way you know not only what they have, but what they want. In Kathy’s case, that would be a wedding to remember.

As she proceeds in her career, my student may do more than counting pimples and grading acne. At any rate, I hope so.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.