Child Psychiatry Consult

I have learned a few things in my almost half-century of hurtling through space with all of you on this fragile blue-green rock. My most recent enlightenment is that the universe has a way of flipping our certitude on its head. Mental acrobatics requires flexibility, requiring us to bend so we don’t break.

On July 1, Minnesota began allowing clinicians to certify patients for “intractable pain” as a qualifying condition for the Minnesota Medical Cannabis Program. Recall that medical marijuana is a Schedule I drug, and we cannot prescribe it. These programs are set up in such a way that the only role a clinician plays is to certify patients with qualifying conditions. This allows a patient to pay a registration fee and visit a cannabis patient center, where a pharmacist will recommend cannabis dose and type.

Months before this, I was waxing professorial about our lack of certainty about dosing and efficacy of medical marijuana. Then I met a 30-year-old with chronic back pain.

She had been evaluated by every subspecialist. This patient was taking and failing supertherapeutic doses of NSAIDs, acetaminophen, and gabapentin. No more surgical options existed. She had been removed from opioid contracts for aberrant behavior. She had had a hysterectomy for severe bleeding. She was in pain and asking for help.

She relates to you that street marijuana has helped with the pain, but she is worried about being arrested and losing her job. Do we put her on another opioid contract? Do we throw up our hands in defeat, apologize, and show her the door?

Serendipitously, I ran across a study evaluating the relationship between cannabis use over a 20-year period and health conditions. The study by Madeline Meier, Ph.D., and her colleagues evaluated 1,037 New Zealanders followed into their late 30s. Laboratory measures were available, and tobacco use was determined (JAMA Psychiatry. 2016 Jul 1;73[7]:731-40).

Cannabis was associated with poorer periodontal health, but with no other health conditions in early midlife. In contrast, tobacco use was associated with significant adverse health consequences in multiple domains.

This study looked at smoked cannabis. In contrast, the cannabis that my patient would take is an oil, negating any potential respiratory health issues from by-products of burning. Furthermore, products with higher concentrations of or consisting exclusively of cannabidiol can be selected. Cannabidiol is proposed to possess health benefits and is not psychoactive.

As the opioid crisis rages, solutions are not readily presenting themselves. Will we be on the wrong side of medical history by providing patients with chronic pain access to medical marijuana? Perhaps we can avoid, at least for a short time, the all-too inevitable outcome of chronic pain patients in their 30s: ever-increasing opioid doses with the same amount of pain, frequent emergency department visits, a fractured patient-physician relationship, and drug overdose.

For our patients’ sake, I hope we can bend before we break.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

I have learned a few things in my almost half-century of hurtling through space with all of you on this fragile blue-green rock. My most recent enlightenment is that the universe has a way of flipping our certitude on its head. Mental acrobatics requires flexibility, requiring us to bend so we don’t break.

On July 1, Minnesota began allowing clinicians to certify patients for “intractable pain” as a qualifying condition for the Minnesota Medical Cannabis Program. Recall that medical marijuana is a Schedule I drug, and we cannot prescribe it. These programs are set up in such a way that the only role a clinician plays is to certify patients with qualifying conditions. This allows a patient to pay a registration fee and visit a cannabis patient center, where a pharmacist will recommend cannabis dose and type.

Months before this, I was waxing professorial about our lack of certainty about dosing and efficacy of medical marijuana. Then I met a 30-year-old with chronic back pain.

She had been evaluated by every subspecialist. This patient was taking and failing supertherapeutic doses of NSAIDs, acetaminophen, and gabapentin. No more surgical options existed. She had been removed from opioid contracts for aberrant behavior. She had had a hysterectomy for severe bleeding. She was in pain and asking for help.

She relates to you that street marijuana has helped with the pain, but she is worried about being arrested and losing her job. Do we put her on another opioid contract? Do we throw up our hands in defeat, apologize, and show her the door?

Serendipitously, I ran across a study evaluating the relationship between cannabis use over a 20-year period and health conditions. The study by Madeline Meier, Ph.D., and her colleagues evaluated 1,037 New Zealanders followed into their late 30s. Laboratory measures were available, and tobacco use was determined (JAMA Psychiatry. 2016 Jul 1;73[7]:731-40).

Cannabis was associated with poorer periodontal health, but with no other health conditions in early midlife. In contrast, tobacco use was associated with significant adverse health consequences in multiple domains.

This study looked at smoked cannabis. In contrast, the cannabis that my patient would take is an oil, negating any potential respiratory health issues from by-products of burning. Furthermore, products with higher concentrations of or consisting exclusively of cannabidiol can be selected. Cannabidiol is proposed to possess health benefits and is not psychoactive.

As the opioid crisis rages, solutions are not readily presenting themselves. Will we be on the wrong side of medical history by providing patients with chronic pain access to medical marijuana? Perhaps we can avoid, at least for a short time, the all-too inevitable outcome of chronic pain patients in their 30s: ever-increasing opioid doses with the same amount of pain, frequent emergency department visits, a fractured patient-physician relationship, and drug overdose.

For our patients’ sake, I hope we can bend before we break.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

I have learned a few things in my almost half-century of hurtling through space with all of you on this fragile blue-green rock. My most recent enlightenment is that the universe has a way of flipping our certitude on its head. Mental acrobatics requires flexibility, requiring us to bend so we don’t break.

On July 1, Minnesota began allowing clinicians to certify patients for “intractable pain” as a qualifying condition for the Minnesota Medical Cannabis Program. Recall that medical marijuana is a Schedule I drug, and we cannot prescribe it. These programs are set up in such a way that the only role a clinician plays is to certify patients with qualifying conditions. This allows a patient to pay a registration fee and visit a cannabis patient center, where a pharmacist will recommend cannabis dose and type.

Months before this, I was waxing professorial about our lack of certainty about dosing and efficacy of medical marijuana. Then I met a 30-year-old with chronic back pain.

She had been evaluated by every subspecialist. This patient was taking and failing supertherapeutic doses of NSAIDs, acetaminophen, and gabapentin. No more surgical options existed. She had been removed from opioid contracts for aberrant behavior. She had had a hysterectomy for severe bleeding. She was in pain and asking for help.

She relates to you that street marijuana has helped with the pain, but she is worried about being arrested and losing her job. Do we put her on another opioid contract? Do we throw up our hands in defeat, apologize, and show her the door?

Serendipitously, I ran across a study evaluating the relationship between cannabis use over a 20-year period and health conditions. The study by Madeline Meier, Ph.D., and her colleagues evaluated 1,037 New Zealanders followed into their late 30s. Laboratory measures were available, and tobacco use was determined (JAMA Psychiatry. 2016 Jul 1;73[7]:731-40).

Cannabis was associated with poorer periodontal health, but with no other health conditions in early midlife. In contrast, tobacco use was associated with significant adverse health consequences in multiple domains.

This study looked at smoked cannabis. In contrast, the cannabis that my patient would take is an oil, negating any potential respiratory health issues from by-products of burning. Furthermore, products with higher concentrations of or consisting exclusively of cannabidiol can be selected. Cannabidiol is proposed to possess health benefits and is not psychoactive.

As the opioid crisis rages, solutions are not readily presenting themselves. Will we be on the wrong side of medical history by providing patients with chronic pain access to medical marijuana? Perhaps we can avoid, at least for a short time, the all-too inevitable outcome of chronic pain patients in their 30s: ever-increasing opioid doses with the same amount of pain, frequent emergency department visits, a fractured patient-physician relationship, and drug overdose.

For our patients’ sake, I hope we can bend before we break.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

Despite the lack of clarity about the exact prevalence in youth, particularly prepubertal youth, it’s clear that an increasing number of children and teenagers are presenting to multidisciplinary clinics for evaluation and management of gender identity issues (Pediatrics. 2012 Mar;129[3]:418-25). Recent literature has indicated that the prevalence of individuals overall identifying as transgender and/or experiencing gender dysphoria is about 0.2%-0.3% of the population (JAMA Pediatr. 2016;170[5]:423-4), while being mindful of the variability in the characteristics of the populations included in certain studies.

Although gender variation, in and of itself, is not a disorder, these youth are a considerably underserved and poorly researched population with specific medical and mental health needs. They are at risk for being victims of abuse and developing a range of mental health struggles, including mood disorders, suicidal thinking, self-harming, and anxiety, possibly because of the stresses they experience socially (family rejection, victimization). In addition to these more discrete psychiatric phenomena, co-occurring autism spectrum disorders (or traits thereof) are increasingly being recognized in transgender youth.

Case summary

Maddie is a 20-year-old college sophomore who presents for an autism diagnostic evaluation after being seen by a mental health colleague for consultation regarding medical treatment associated with female-to-male gender transition. In brief, Maddie reports a longstanding history of feeling “socially overwhelmed.” He is an articulate young adult who shares that he’s frequently uncomfortable in social situations, explaining that he has trouble “reading people,” acknowledging a tendency to become overly focused on the details of others and missing the gestalt of interpersonal interactions. Maddie discloses never having close friendships, and although he identifies as lonely, he doesn’t “understand the appeal of casual social interactions.” Maddie and his mother seek an understanding of such social difficulties, wondering about the possibility of Asperger’s syndrome.

Maddie, whose assigned gender at birth was female, now identifies as male. His mother recalls him to have been a precocious preschooler in terms of language development who had no significant developmental delays and became, per report, increasingly withdrawn in elementary school. Over the years, educators have commented repeatedly on the fact that Maddie has needed to work on his “people skills,” with past providers ascribing such struggles to anxiety and social awkwardness that were thought to inherently accompany gender-variant behaviors and thinking. Maddie socially transitioned from a female to male in grade 11 and began taking prescribed testosterone about 4 years ago.

In the interview, Maddie is a hesitant male-appearing individual whose eye contact and spontaneity are limited. He has a guarded manner, and although he is able to answer questions posed to him, rapport is difficult to establish as he appears interpersonally uncomfortable.

Prior to the visit, Maddie’s mother completed the Social Responsiveness Scales, which revealed elevated scores in the area of Social Communication and Social Motivation. Despite appearing cognitively bright and having an array of academic and creative strengths, Maddie’s troubles forming meaningful relationships are striking. Deficits in social-emotional competence are incommensurate with his suspected cognitive abilities, and although he relates learning social skills from film over the years, he endorses pervasively compromised social-communication aptitudes and enduring functional impairments. “I’m always playing catch-up socially,” he shares, wondering how this will affect him in his nursing career.

Discussion

Maddie and his mother participated in an autism diagnostic evaluation, including the administration of the Autism Diagnostic Interview–Revised (ADI-R) and the Autism Diagnostic Observation Schedule (ADOS). The evaluation revealed a profile of social impairments and inflexible thinking dating back to early childhood that supported a diagnosis of an autism spectrum disorder (ASD). Other diagnoses, including anxiety disorders, a depressive disorder, a social pragmatic communication disorder, and a nonverbal learning disorder, were considered, but ultimately it was concluded that ASD best captured Maddie, who also continued to display features consistent with gender dysphoria.

Over the past 30 years, the relationship between gender-related concerns and ASD has begun to be discussed in the scientific literature, beginning with case reports and more recently with a retrospective chart study that yielded results suggesting that subjects diagnosed with ASD were almost eight times more likely to report gender variance than a nonreferred standardization sample of the Child Behavior Checklist (CBCL) (Transgender Health. 2016 Feb;1[1]:63-8). These results echo those of a prior study showing that 7.8% of individuals presenting for an evaluation in a Dutch gender clinic had an ASD diagnosis (J Autism Dev Disord. 2010 Aug;40[8]:930-6).

With the individual prevalences for ASD and gender dysphoria taken into account, these numbers suggest that the prevalence of ASD in gender-dysphoric youth is about four times higher than that found in the general population (Sex Med Rev. 2016;4:3e14). These data raise questions regarding potential shared etiology and the neurobiology between a disorder of social communication and gender identity–related issues; however, to date, despite several theories attempting to explain the connection (the notion of an “extreme male brain,” role of sex hormones, etc.), the relationship remains puzzling. Some have argued that the rigid thinking that can characterize ASD may lead those individuals who display any gender-variant behaviors to automatically identify as the gender opposite their biologic gender, even though they aren’t necessarily experiencing frank gender dysphoria or a core gender identity that is firmly discordant from their anatomical sex. Thinking about the relationship from another perspective, perhaps those with ASD are less aware of the social constructs of gender and are able to express their gender identity (whether it be crossgender or cisgender) more freely and without the worry of how they may be perceived by others. Undoubtedly, a complex interplay between ASD and gender dysphoria/gender-nonconforming behavior is suspected, and more quality research is needed – research that, at a minimum, is informed by the use of representative sample groups drawn from all developmental periods and well-defined diagnostic constructs.

Clinical pearl

Maddie, a transgender man, received a diagnosis of an autism spectrum disorder as a young adult – a full 16 years after the median age of diagnosis (MMWR Surveill Summ. 2016;65[3]:1-23).

The case illustrates some of the difficulties of attempting to parse out the cause of social impairments in an individual who also may have other phenomena that influence interpersonal functioning (attention-deficit/hyperactivity disorder, anxiety, gender dysphoria, etc.) in a developmental manner. Diagnostic “overshadowing” (mistakenly attributing symptoms to a particular condition and paying little attention to other possibilities) is not uncommon in youth with ASD and co-occurring conditions. Given the overlap between gender-nonconforming youth, individuals with gender dysphoria, and ASD, primary care providers may opt to incorporate mental health professionals familiar with ASD into the assessment and care of these children and adolescents. Getting a complete developmental history and paying attention to the possibility of early red flags for ASD can help to elucidate diagnostic possibilities and inform treatment planning. If a co-occurring diagnosis is confirmed, implementation of evidence-based interventions that are provided through the lens of ASD can help to minimize the risk of developing other co-occurring pathology, build resilience, alleviate social impairment, and foster self-advocacy skills in this very vulnerable population. Regardless of whether gender-variant youth and adolescents have an autistic disorder, mental health providers can have an integral role in assisting these individuals and their families to navigate a complicated system of care, address gender dysphoria, and promote healthy identity development (J Am Acad Child Adolesc Psychiatry. 2016 Jun;55[6]:441-3).

Dr. Dickerson, a child and adolescent psychiatrist, is assistant professor of psychiatry at the University of Vermont, where he is director of the autism diagnostic clinic.

Despite the lack of clarity about the exact prevalence in youth, particularly prepubertal youth, it’s clear that an increasing number of children and teenagers are presenting to multidisciplinary clinics for evaluation and management of gender identity issues (Pediatrics. 2012 Mar;129[3]:418-25). Recent literature has indicated that the prevalence of individuals overall identifying as transgender and/or experiencing gender dysphoria is about 0.2%-0.3% of the population (JAMA Pediatr. 2016;170[5]:423-4), while being mindful of the variability in the characteristics of the populations included in certain studies.

Although gender variation, in and of itself, is not a disorder, these youth are a considerably underserved and poorly researched population with specific medical and mental health needs. They are at risk for being victims of abuse and developing a range of mental health struggles, including mood disorders, suicidal thinking, self-harming, and anxiety, possibly because of the stresses they experience socially (family rejection, victimization). In addition to these more discrete psychiatric phenomena, co-occurring autism spectrum disorders (or traits thereof) are increasingly being recognized in transgender youth.

Case summary

Maddie is a 20-year-old college sophomore who presents for an autism diagnostic evaluation after being seen by a mental health colleague for consultation regarding medical treatment associated with female-to-male gender transition. In brief, Maddie reports a longstanding history of feeling “socially overwhelmed.” He is an articulate young adult who shares that he’s frequently uncomfortable in social situations, explaining that he has trouble “reading people,” acknowledging a tendency to become overly focused on the details of others and missing the gestalt of interpersonal interactions. Maddie discloses never having close friendships, and although he identifies as lonely, he doesn’t “understand the appeal of casual social interactions.” Maddie and his mother seek an understanding of such social difficulties, wondering about the possibility of Asperger’s syndrome.

Maddie, whose assigned gender at birth was female, now identifies as male. His mother recalls him to have been a precocious preschooler in terms of language development who had no significant developmental delays and became, per report, increasingly withdrawn in elementary school. Over the years, educators have commented repeatedly on the fact that Maddie has needed to work on his “people skills,” with past providers ascribing such struggles to anxiety and social awkwardness that were thought to inherently accompany gender-variant behaviors and thinking. Maddie socially transitioned from a female to male in grade 11 and began taking prescribed testosterone about 4 years ago.

In the interview, Maddie is a hesitant male-appearing individual whose eye contact and spontaneity are limited. He has a guarded manner, and although he is able to answer questions posed to him, rapport is difficult to establish as he appears interpersonally uncomfortable.

Prior to the visit, Maddie’s mother completed the Social Responsiveness Scales, which revealed elevated scores in the area of Social Communication and Social Motivation. Despite appearing cognitively bright and having an array of academic and creative strengths, Maddie’s troubles forming meaningful relationships are striking. Deficits in social-emotional competence are incommensurate with his suspected cognitive abilities, and although he relates learning social skills from film over the years, he endorses pervasively compromised social-communication aptitudes and enduring functional impairments. “I’m always playing catch-up socially,” he shares, wondering how this will affect him in his nursing career.

Discussion

Maddie and his mother participated in an autism diagnostic evaluation, including the administration of the Autism Diagnostic Interview–Revised (ADI-R) and the Autism Diagnostic Observation Schedule (ADOS). The evaluation revealed a profile of social impairments and inflexible thinking dating back to early childhood that supported a diagnosis of an autism spectrum disorder (ASD). Other diagnoses, including anxiety disorders, a depressive disorder, a social pragmatic communication disorder, and a nonverbal learning disorder, were considered, but ultimately it was concluded that ASD best captured Maddie, who also continued to display features consistent with gender dysphoria.

Over the past 30 years, the relationship between gender-related concerns and ASD has begun to be discussed in the scientific literature, beginning with case reports and more recently with a retrospective chart study that yielded results suggesting that subjects diagnosed with ASD were almost eight times more likely to report gender variance than a nonreferred standardization sample of the Child Behavior Checklist (CBCL) (Transgender Health. 2016 Feb;1[1]:63-8). These results echo those of a prior study showing that 7.8% of individuals presenting for an evaluation in a Dutch gender clinic had an ASD diagnosis (J Autism Dev Disord. 2010 Aug;40[8]:930-6).

With the individual prevalences for ASD and gender dysphoria taken into account, these numbers suggest that the prevalence of ASD in gender-dysphoric youth is about four times higher than that found in the general population (Sex Med Rev. 2016;4:3e14). These data raise questions regarding potential shared etiology and the neurobiology between a disorder of social communication and gender identity–related issues; however, to date, despite several theories attempting to explain the connection (the notion of an “extreme male brain,” role of sex hormones, etc.), the relationship remains puzzling. Some have argued that the rigid thinking that can characterize ASD may lead those individuals who display any gender-variant behaviors to automatically identify as the gender opposite their biologic gender, even though they aren’t necessarily experiencing frank gender dysphoria or a core gender identity that is firmly discordant from their anatomical sex. Thinking about the relationship from another perspective, perhaps those with ASD are less aware of the social constructs of gender and are able to express their gender identity (whether it be crossgender or cisgender) more freely and without the worry of how they may be perceived by others. Undoubtedly, a complex interplay between ASD and gender dysphoria/gender-nonconforming behavior is suspected, and more quality research is needed – research that, at a minimum, is informed by the use of representative sample groups drawn from all developmental periods and well-defined diagnostic constructs.

Clinical pearl

Maddie, a transgender man, received a diagnosis of an autism spectrum disorder as a young adult – a full 16 years after the median age of diagnosis (MMWR Surveill Summ. 2016;65[3]:1-23).

The case illustrates some of the difficulties of attempting to parse out the cause of social impairments in an individual who also may have other phenomena that influence interpersonal functioning (attention-deficit/hyperactivity disorder, anxiety, gender dysphoria, etc.) in a developmental manner. Diagnostic “overshadowing” (mistakenly attributing symptoms to a particular condition and paying little attention to other possibilities) is not uncommon in youth with ASD and co-occurring conditions. Given the overlap between gender-nonconforming youth, individuals with gender dysphoria, and ASD, primary care providers may opt to incorporate mental health professionals familiar with ASD into the assessment and care of these children and adolescents. Getting a complete developmental history and paying attention to the possibility of early red flags for ASD can help to elucidate diagnostic possibilities and inform treatment planning. If a co-occurring diagnosis is confirmed, implementation of evidence-based interventions that are provided through the lens of ASD can help to minimize the risk of developing other co-occurring pathology, build resilience, alleviate social impairment, and foster self-advocacy skills in this very vulnerable population. Regardless of whether gender-variant youth and adolescents have an autistic disorder, mental health providers can have an integral role in assisting these individuals and their families to navigate a complicated system of care, address gender dysphoria, and promote healthy identity development (J Am Acad Child Adolesc Psychiatry. 2016 Jun;55[6]:441-3).

Dr. Dickerson, a child and adolescent psychiatrist, is assistant professor of psychiatry at the University of Vermont, where he is director of the autism diagnostic clinic.

Despite the lack of clarity about the exact prevalence in youth, particularly prepubertal youth, it’s clear that an increasing number of children and teenagers are presenting to multidisciplinary clinics for evaluation and management of gender identity issues (Pediatrics. 2012 Mar;129[3]:418-25). Recent literature has indicated that the prevalence of individuals overall identifying as transgender and/or experiencing gender dysphoria is about 0.2%-0.3% of the population (JAMA Pediatr. 2016;170[5]:423-4), while being mindful of the variability in the characteristics of the populations included in certain studies.

Although gender variation, in and of itself, is not a disorder, these youth are a considerably underserved and poorly researched population with specific medical and mental health needs. They are at risk for being victims of abuse and developing a range of mental health struggles, including mood disorders, suicidal thinking, self-harming, and anxiety, possibly because of the stresses they experience socially (family rejection, victimization). In addition to these more discrete psychiatric phenomena, co-occurring autism spectrum disorders (or traits thereof) are increasingly being recognized in transgender youth.

Case summary

Maddie is a 20-year-old college sophomore who presents for an autism diagnostic evaluation after being seen by a mental health colleague for consultation regarding medical treatment associated with female-to-male gender transition. In brief, Maddie reports a longstanding history of feeling “socially overwhelmed.” He is an articulate young adult who shares that he’s frequently uncomfortable in social situations, explaining that he has trouble “reading people,” acknowledging a tendency to become overly focused on the details of others and missing the gestalt of interpersonal interactions. Maddie discloses never having close friendships, and although he identifies as lonely, he doesn’t “understand the appeal of casual social interactions.” Maddie and his mother seek an understanding of such social difficulties, wondering about the possibility of Asperger’s syndrome.

Maddie, whose assigned gender at birth was female, now identifies as male. His mother recalls him to have been a precocious preschooler in terms of language development who had no significant developmental delays and became, per report, increasingly withdrawn in elementary school. Over the years, educators have commented repeatedly on the fact that Maddie has needed to work on his “people skills,” with past providers ascribing such struggles to anxiety and social awkwardness that were thought to inherently accompany gender-variant behaviors and thinking. Maddie socially transitioned from a female to male in grade 11 and began taking prescribed testosterone about 4 years ago.

In the interview, Maddie is a hesitant male-appearing individual whose eye contact and spontaneity are limited. He has a guarded manner, and although he is able to answer questions posed to him, rapport is difficult to establish as he appears interpersonally uncomfortable.

Prior to the visit, Maddie’s mother completed the Social Responsiveness Scales, which revealed elevated scores in the area of Social Communication and Social Motivation. Despite appearing cognitively bright and having an array of academic and creative strengths, Maddie’s troubles forming meaningful relationships are striking. Deficits in social-emotional competence are incommensurate with his suspected cognitive abilities, and although he relates learning social skills from film over the years, he endorses pervasively compromised social-communication aptitudes and enduring functional impairments. “I’m always playing catch-up socially,” he shares, wondering how this will affect him in his nursing career.

Discussion

Maddie and his mother participated in an autism diagnostic evaluation, including the administration of the Autism Diagnostic Interview–Revised (ADI-R) and the Autism Diagnostic Observation Schedule (ADOS). The evaluation revealed a profile of social impairments and inflexible thinking dating back to early childhood that supported a diagnosis of an autism spectrum disorder (ASD). Other diagnoses, including anxiety disorders, a depressive disorder, a social pragmatic communication disorder, and a nonverbal learning disorder, were considered, but ultimately it was concluded that ASD best captured Maddie, who also continued to display features consistent with gender dysphoria.

Over the past 30 years, the relationship between gender-related concerns and ASD has begun to be discussed in the scientific literature, beginning with case reports and more recently with a retrospective chart study that yielded results suggesting that subjects diagnosed with ASD were almost eight times more likely to report gender variance than a nonreferred standardization sample of the Child Behavior Checklist (CBCL) (Transgender Health. 2016 Feb;1[1]:63-8). These results echo those of a prior study showing that 7.8% of individuals presenting for an evaluation in a Dutch gender clinic had an ASD diagnosis (J Autism Dev Disord. 2010 Aug;40[8]:930-6).

With the individual prevalences for ASD and gender dysphoria taken into account, these numbers suggest that the prevalence of ASD in gender-dysphoric youth is about four times higher than that found in the general population (Sex Med Rev. 2016;4:3e14). These data raise questions regarding potential shared etiology and the neurobiology between a disorder of social communication and gender identity–related issues; however, to date, despite several theories attempting to explain the connection (the notion of an “extreme male brain,” role of sex hormones, etc.), the relationship remains puzzling. Some have argued that the rigid thinking that can characterize ASD may lead those individuals who display any gender-variant behaviors to automatically identify as the gender opposite their biologic gender, even though they aren’t necessarily experiencing frank gender dysphoria or a core gender identity that is firmly discordant from their anatomical sex. Thinking about the relationship from another perspective, perhaps those with ASD are less aware of the social constructs of gender and are able to express their gender identity (whether it be crossgender or cisgender) more freely and without the worry of how they may be perceived by others. Undoubtedly, a complex interplay between ASD and gender dysphoria/gender-nonconforming behavior is suspected, and more quality research is needed – research that, at a minimum, is informed by the use of representative sample groups drawn from all developmental periods and well-defined diagnostic constructs.

Clinical pearl

Maddie, a transgender man, received a diagnosis of an autism spectrum disorder as a young adult – a full 16 years after the median age of diagnosis (MMWR Surveill Summ. 2016;65[3]:1-23).

The case illustrates some of the difficulties of attempting to parse out the cause of social impairments in an individual who also may have other phenomena that influence interpersonal functioning (attention-deficit/hyperactivity disorder, anxiety, gender dysphoria, etc.) in a developmental manner. Diagnostic “overshadowing” (mistakenly attributing symptoms to a particular condition and paying little attention to other possibilities) is not uncommon in youth with ASD and co-occurring conditions. Given the overlap between gender-nonconforming youth, individuals with gender dysphoria, and ASD, primary care providers may opt to incorporate mental health professionals familiar with ASD into the assessment and care of these children and adolescents. Getting a complete developmental history and paying attention to the possibility of early red flags for ASD can help to elucidate diagnostic possibilities and inform treatment planning. If a co-occurring diagnosis is confirmed, implementation of evidence-based interventions that are provided through the lens of ASD can help to minimize the risk of developing other co-occurring pathology, build resilience, alleviate social impairment, and foster self-advocacy skills in this very vulnerable population. Regardless of whether gender-variant youth and adolescents have an autistic disorder, mental health providers can have an integral role in assisting these individuals and their families to navigate a complicated system of care, address gender dysphoria, and promote healthy identity development (J Am Acad Child Adolesc Psychiatry. 2016 Jun;55[6]:441-3).

Dr. Dickerson, a child and adolescent psychiatrist, is assistant professor of psychiatry at the University of Vermont, where he is director of the autism diagnostic clinic.

There has been quite a bit of discussion and controversy lately about transgender individuals. The debate has extended to the diagnosis itself and whether it should be maintained as an official entity. The previous edition of the Diagnostic and Statistical Manual included the diagnosis of gender identity disorder, which was modified to the current diagnosis of gender dysphoria that describes individuals who show a persistent desire to be the “other” gender and/or an insistence that their gender is different from their birth sex.

One question at the heart of this discussion is the degree to which psychiatric symptoms and disorders are inherent in the gender dysphoria itself or whether most, if not all, of the noted links to things like anxiety, depression, and suicidal behavior stem from the hostility and abuse that many of these youth endure.

As has been reported in the Pediatric News column LGBT Youth Consult, research is now focusing on the mental health of transgender youth, although the data are not entirely consistent. One recent study of 298 transgender women between the ages of 16 and 29 years, of whom nearly three-quarters had received crossgender hormones, showed quite high rates of psychiatric disorders including depression (35%), anxiety (8%), and substance abuse (11%).¹ Moderate to high levels of suicidality in the past month were found in 20% of the sample. Although one cannot conclude from this study that psychopathology is intrinsic to transgender individuals, it does suggest that difficulties can certainly persist among those who have socially transitioned to their affirmed gender.

In contrast, another study from the TransYouth Project showed much more hopeful results.² In this younger sample of 73 prepubescent children, 70% of whom were natal males and all of whom had been supported in the social transition to their affirmed gender at a relatively young age, levels of depressed symptoms were no different from those in 73 controls, and scores on an anxiety scale were only slightly elevated, but did not reach clinical or even subclinical levels as a group. The authors of this study concluded that psychiatric symptoms are not “synonymous” with being transgender. They suggest that supporting youth in their transition at earlier ages could possibly prevent the occurrence of mental health problems in the future.

There is wide acknowledgment that gender-nonconforming youth are at much heightened risk from what can be vicious and cruel maltreatment from peers and the wider community. Similarly, there is good consensus that “conversion therapy” approaches that actively try to discourage youth from their affirmed gender are misguided and unethical. What remains in question among well-meaning parents and clinicians alike, however, is at what age should social transition be supported and how encompassing should it be with regard to pronoun use, bathroom and dressing room access, clothing, and so on. Studies have shown that gender atypical behavior can be quite common in young children, with the vast majority eventually developing gender identities that are in line with their natal sex. Parents may worry that promoting a premature gender transition might expose their child to bullying and harassment that could otherwise be avoided. On the other hand, parents may worry that not supporting gender transition will be experienced as rejecting and critical, which could lead to increased feelings of depression and isolation. Although both views represent valid concerns, it is probably fair to say that among clinicians and researchers who work with transgender youth, there seems to be some movement toward more active acceptance and encouragement of a child’s gender expression at the time, with the understanding that for many, there can be continued movement in one’s gender “journey” across development.

Interestingly, these studies are being published in parallel with some neuroimaging research investigating sex differences with regard to the brain. A recent study from the Proceedings of the National Academy of Sciences found that, among many different regions that are known to show some sex differences with regard to size or connectivity to other regions, the typical human brain shows a “mosaic” pattern in which some regions look more typically male while others look more typically female.³

References

1. JAMA Pediatr. 2016 May 1;170(5):481-6.
2. Pediatrics. 2016;137(3):1-8.
3. PNAS. 2015;112(50):15468-73

Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Follow him on Twitter @pedipsych.

There has been quite a bit of discussion and controversy lately about transgender individuals. The debate has extended to the diagnosis itself and whether it should be maintained as an official entity. The previous edition of the Diagnostic and Statistical Manual included the diagnosis of gender identity disorder, which was modified to the current diagnosis of gender dysphoria that describes individuals who show a persistent desire to be the “other” gender and/or an insistence that their gender is different from their birth sex.

One question at the heart of this discussion is the degree to which psychiatric symptoms and disorders are inherent in the gender dysphoria itself or whether most, if not all, of the noted links to things like anxiety, depression, and suicidal behavior stem from the hostility and abuse that many of these youth endure.

As has been reported in the Pediatric News column LGBT Youth Consult, research is now focusing on the mental health of transgender youth, although the data are not entirely consistent. One recent study of 298 transgender women between the ages of 16 and 29 years, of whom nearly three-quarters had received crossgender hormones, showed quite high rates of psychiatric disorders including depression (35%), anxiety (8%), and substance abuse (11%).¹ Moderate to high levels of suicidality in the past month were found in 20% of the sample. Although one cannot conclude from this study that psychopathology is intrinsic to transgender individuals, it does suggest that difficulties can certainly persist among those who have socially transitioned to their affirmed gender.

In contrast, another study from the TransYouth Project showed much more hopeful results.² In this younger sample of 73 prepubescent children, 70% of whom were natal males and all of whom had been supported in the social transition to their affirmed gender at a relatively young age, levels of depressed symptoms were no different from those in 73 controls, and scores on an anxiety scale were only slightly elevated, but did not reach clinical or even subclinical levels as a group. The authors of this study concluded that psychiatric symptoms are not “synonymous” with being transgender. They suggest that supporting youth in their transition at earlier ages could possibly prevent the occurrence of mental health problems in the future.

There is wide acknowledgment that gender-nonconforming youth are at much heightened risk from what can be vicious and cruel maltreatment from peers and the wider community. Similarly, there is good consensus that “conversion therapy” approaches that actively try to discourage youth from their affirmed gender are misguided and unethical. What remains in question among well-meaning parents and clinicians alike, however, is at what age should social transition be supported and how encompassing should it be with regard to pronoun use, bathroom and dressing room access, clothing, and so on. Studies have shown that gender atypical behavior can be quite common in young children, with the vast majority eventually developing gender identities that are in line with their natal sex. Parents may worry that promoting a premature gender transition might expose their child to bullying and harassment that could otherwise be avoided. On the other hand, parents may worry that not supporting gender transition will be experienced as rejecting and critical, which could lead to increased feelings of depression and isolation. Although both views represent valid concerns, it is probably fair to say that among clinicians and researchers who work with transgender youth, there seems to be some movement toward more active acceptance and encouragement of a child’s gender expression at the time, with the understanding that for many, there can be continued movement in one’s gender “journey” across development.

Interestingly, these studies are being published in parallel with some neuroimaging research investigating sex differences with regard to the brain. A recent study from the Proceedings of the National Academy of Sciences found that, among many different regions that are known to show some sex differences with regard to size or connectivity to other regions, the typical human brain shows a “mosaic” pattern in which some regions look more typically male while others look more typically female.³

References

1. JAMA Pediatr. 2016 May 1;170(5):481-6.
2. Pediatrics. 2016;137(3):1-8.
3. PNAS. 2015;112(50):15468-73

Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Follow him on Twitter @pedipsych.

There has been quite a bit of discussion and controversy lately about transgender individuals. The debate has extended to the diagnosis itself and whether it should be maintained as an official entity. The previous edition of the Diagnostic and Statistical Manual included the diagnosis of gender identity disorder, which was modified to the current diagnosis of gender dysphoria that describes individuals who show a persistent desire to be the “other” gender and/or an insistence that their gender is different from their birth sex.

One question at the heart of this discussion is the degree to which psychiatric symptoms and disorders are inherent in the gender dysphoria itself or whether most, if not all, of the noted links to things like anxiety, depression, and suicidal behavior stem from the hostility and abuse that many of these youth endure.

As has been reported in the Pediatric News column LGBT Youth Consult, research is now focusing on the mental health of transgender youth, although the data are not entirely consistent. One recent study of 298 transgender women between the ages of 16 and 29 years, of whom nearly three-quarters had received crossgender hormones, showed quite high rates of psychiatric disorders including depression (35%), anxiety (8%), and substance abuse (11%).¹ Moderate to high levels of suicidality in the past month were found in 20% of the sample. Although one cannot conclude from this study that psychopathology is intrinsic to transgender individuals, it does suggest that difficulties can certainly persist among those who have socially transitioned to their affirmed gender.

In contrast, another study from the TransYouth Project showed much more hopeful results.² In this younger sample of 73 prepubescent children, 70% of whom were natal males and all of whom had been supported in the social transition to their affirmed gender at a relatively young age, levels of depressed symptoms were no different from those in 73 controls, and scores on an anxiety scale were only slightly elevated, but did not reach clinical or even subclinical levels as a group. The authors of this study concluded that psychiatric symptoms are not “synonymous” with being transgender. They suggest that supporting youth in their transition at earlier ages could possibly prevent the occurrence of mental health problems in the future.

There is wide acknowledgment that gender-nonconforming youth are at much heightened risk from what can be vicious and cruel maltreatment from peers and the wider community. Similarly, there is good consensus that “conversion therapy” approaches that actively try to discourage youth from their affirmed gender are misguided and unethical. What remains in question among well-meaning parents and clinicians alike, however, is at what age should social transition be supported and how encompassing should it be with regard to pronoun use, bathroom and dressing room access, clothing, and so on. Studies have shown that gender atypical behavior can be quite common in young children, with the vast majority eventually developing gender identities that are in line with their natal sex. Parents may worry that promoting a premature gender transition might expose their child to bullying and harassment that could otherwise be avoided. On the other hand, parents may worry that not supporting gender transition will be experienced as rejecting and critical, which could lead to increased feelings of depression and isolation. Although both views represent valid concerns, it is probably fair to say that among clinicians and researchers who work with transgender youth, there seems to be some movement toward more active acceptance and encouragement of a child’s gender expression at the time, with the understanding that for many, there can be continued movement in one’s gender “journey” across development.

Interestingly, these studies are being published in parallel with some neuroimaging research investigating sex differences with regard to the brain. A recent study from the Proceedings of the National Academy of Sciences found that, among many different regions that are known to show some sex differences with regard to size or connectivity to other regions, the typical human brain shows a “mosaic” pattern in which some regions look more typically male while others look more typically female.³

References

1. JAMA Pediatr. 2016 May 1;170(5):481-6.
2. Pediatrics. 2016;137(3):1-8.
3. PNAS. 2015;112(50):15468-73

Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Follow him on Twitter @pedipsych.

We are a product of our environment. But we shan’t forget that we are a product of the critical interaction between our environment and our evolutionary biology.

Back when we were roaming the plains searching for food, we likely experienced “forced fasts” (that is, we had no food). Our ancestors who were the best at surviving these periods of scarcity lived to bear us into our current period of staggering abundance. Now, we are the unhealthiest humans in history.

Is part of the answer to our current health problems to return to our roots and ... fast?

In a recent article by Catherine Marinac and her colleagues, patients aged 27-70 years with breast cancer in the Women’s Healthy Eating and Living study were analyzed to uncover the relationship between nightly fasting duration and new primary breast tumors and death (JAMA Oncol. 2016 Mar 31. doi: 10.1001/jamaoncol.2016.0164). Fasting was assessed through use of 24-hour dietary recall.

Fasting less than 13 hours per night was associated with an increased risk of breast cancer, compared with fasting at least 13 hours (hazard ratio, 1.36; 95% confidence interval, 1.05-1.76). Different fasting durations were not associated with breast cancer mortality.

Additional analyses demonstrated that each 2-hour increase in fasting duration was associated with significantly lower hemoglobin A_1c levels and a longer duration of nighttime sleep.

The positive health benefits of fasting have become increasingly “discussed,” albeit commonly on websites advertising for fasting cookbooks. Benefits of fasting include weight loss, improved insulin sensitivity, reductions in inflammation, improved cardiovascular risk factors, enhanced brain function, reductions in Alzheimer’s disease symptoms, and extended life span.

Many of these data are preliminary, and some are based upon animal models, such as the prolonged lifespan. In one study, rats undergoing alternate-day fasting lived 83% longer than rats who were not fasted. Interestingly, human data suggest that food consumption on the nonfasting days does not result in caloric consumption to cover the caloric deficit on the fasted day.

I have to admit that I am intrigued. I am not hearing much discussion about fasting among my colleagues – although a lot them skip meals, I know. But nobody is discussing it as a recommendation to appropriately selected patients (for example, not on insulin) to combat obesity and other diseases. I tried to suggest it to a patient the other day, who had a staggering amount of central adiposity, and he laughed at me. Is the thought of skipping eating for a day so anathema to our modern consumptive culture that we can’t even consider it?

Depending on the type of fasting that one is doing, one does not have to count calories on the fasting days, because there aren’t any. That makes it easy.

In a world of abundance and limitless food options, it may seem strange (self-indulgent?) to fast. But perhaps it will be a key to help us continue the species for a couple more generations.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

We are a product of our environment. But we shan’t forget that we are a product of the critical interaction between our environment and our evolutionary biology.

Back when we were roaming the plains searching for food, we likely experienced “forced fasts” (that is, we had no food). Our ancestors who were the best at surviving these periods of scarcity lived to bear us into our current period of staggering abundance. Now, we are the unhealthiest humans in history.

Is part of the answer to our current health problems to return to our roots and ... fast?

In a recent article by Catherine Marinac and her colleagues, patients aged 27-70 years with breast cancer in the Women’s Healthy Eating and Living study were analyzed to uncover the relationship between nightly fasting duration and new primary breast tumors and death (JAMA Oncol. 2016 Mar 31. doi: 10.1001/jamaoncol.2016.0164). Fasting was assessed through use of 24-hour dietary recall.

Fasting less than 13 hours per night was associated with an increased risk of breast cancer, compared with fasting at least 13 hours (hazard ratio, 1.36; 95% confidence interval, 1.05-1.76). Different fasting durations were not associated with breast cancer mortality.

Additional analyses demonstrated that each 2-hour increase in fasting duration was associated with significantly lower hemoglobin A_1c levels and a longer duration of nighttime sleep.

The positive health benefits of fasting have become increasingly “discussed,” albeit commonly on websites advertising for fasting cookbooks. Benefits of fasting include weight loss, improved insulin sensitivity, reductions in inflammation, improved cardiovascular risk factors, enhanced brain function, reductions in Alzheimer’s disease symptoms, and extended life span.

Many of these data are preliminary, and some are based upon animal models, such as the prolonged lifespan. In one study, rats undergoing alternate-day fasting lived 83% longer than rats who were not fasted. Interestingly, human data suggest that food consumption on the nonfasting days does not result in caloric consumption to cover the caloric deficit on the fasted day.

I have to admit that I am intrigued. I am not hearing much discussion about fasting among my colleagues – although a lot them skip meals, I know. But nobody is discussing it as a recommendation to appropriately selected patients (for example, not on insulin) to combat obesity and other diseases. I tried to suggest it to a patient the other day, who had a staggering amount of central adiposity, and he laughed at me. Is the thought of skipping eating for a day so anathema to our modern consumptive culture that we can’t even consider it?

Depending on the type of fasting that one is doing, one does not have to count calories on the fasting days, because there aren’t any. That makes it easy.

In a world of abundance and limitless food options, it may seem strange (self-indulgent?) to fast. But perhaps it will be a key to help us continue the species for a couple more generations.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

We are a product of our environment. But we shan’t forget that we are a product of the critical interaction between our environment and our evolutionary biology.

Back when we were roaming the plains searching for food, we likely experienced “forced fasts” (that is, we had no food). Our ancestors who were the best at surviving these periods of scarcity lived to bear us into our current period of staggering abundance. Now, we are the unhealthiest humans in history.

Is part of the answer to our current health problems to return to our roots and ... fast?

In a recent article by Catherine Marinac and her colleagues, patients aged 27-70 years with breast cancer in the Women’s Healthy Eating and Living study were analyzed to uncover the relationship between nightly fasting duration and new primary breast tumors and death (JAMA Oncol. 2016 Mar 31. doi: 10.1001/jamaoncol.2016.0164). Fasting was assessed through use of 24-hour dietary recall.

Fasting less than 13 hours per night was associated with an increased risk of breast cancer, compared with fasting at least 13 hours (hazard ratio, 1.36; 95% confidence interval, 1.05-1.76). Different fasting durations were not associated with breast cancer mortality.

Additional analyses demonstrated that each 2-hour increase in fasting duration was associated with significantly lower hemoglobin A_1c levels and a longer duration of nighttime sleep.

The positive health benefits of fasting have become increasingly “discussed,” albeit commonly on websites advertising for fasting cookbooks. Benefits of fasting include weight loss, improved insulin sensitivity, reductions in inflammation, improved cardiovascular risk factors, enhanced brain function, reductions in Alzheimer’s disease symptoms, and extended life span.

Many of these data are preliminary, and some are based upon animal models, such as the prolonged lifespan. In one study, rats undergoing alternate-day fasting lived 83% longer than rats who were not fasted. Interestingly, human data suggest that food consumption on the nonfasting days does not result in caloric consumption to cover the caloric deficit on the fasted day.

I have to admit that I am intrigued. I am not hearing much discussion about fasting among my colleagues – although a lot them skip meals, I know. But nobody is discussing it as a recommendation to appropriately selected patients (for example, not on insulin) to combat obesity and other diseases. I tried to suggest it to a patient the other day, who had a staggering amount of central adiposity, and he laughed at me. Is the thought of skipping eating for a day so anathema to our modern consumptive culture that we can’t even consider it?

Depending on the type of fasting that one is doing, one does not have to count calories on the fasting days, because there aren’t any. That makes it easy.

In a world of abundance and limitless food options, it may seem strange (self-indulgent?) to fast. But perhaps it will be a key to help us continue the species for a couple more generations.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

A tic is described by the DSM-5 as a sudden, rapid, recurrent, nonrhythmic movement or vocalization. Tics are a common occurrence in childhood and can range from mild to severe, transient to chronic, simple to complex. It is not uncommon for parents to ask pediatric care providers when and how to manage tics in children. Here, we present a case to illustrate just such an issue.

Case summary

Adam is an 8-year-old with a previous diagnosis of attention-deficit/hyperactivity disorder (ADHD) who is being seen for follow-up after being started on a stimulant 3 months ago because of declining performance in school and at home, despite adequate accommodations, parent education, and nonpharmacologic treatments. He has done well on a small dose of methylphenidate (0.5 mg/kg per day), but in the context of being asked about other symptoms, his mother, Mary, mentions that she has noticed that Adam is frequently clearing his throat. This began about 6 weeks ago after experiencing allergic rhinitis for almost a week. Since that time, Mary has noticed that he clears his throat as frequently as once every 5 minutes.

The behavior was reported to occur in the classroom, but not nearly with the frequency experienced at home. If asked to not clear his throat, Adam can suppress it. None of his classmates have said anything or appear to have noticed. His parents have never noticed any tics previously. There is a family history of ADHD in his father. There is no other family history of neurodevelopmental disorders, including no obsessive compulsive disorder (OCD), Tourette’s disorder, or other chronic tic disorders. There is nothing else of concern on physical or mental status examination. His mother has concerns that the stimulant medication may be inducing a tic and wonders about stopping it.

Case discussion

Adam has a mild simple vocal tic. The vast majority of tics that develop in childhood will not last the requisite 1 year required to make the diagnosis of a persistent (chronic) motor or vocal tic, nor will they occur with both vocal and motor tics over 1 year required to make the diagnosis of Tourette’s disorder. In the DSM-IV, tics lasting less than 1 year would have been given the diagnosis of transient tic disorder.

In the DSM-5, the diagnosis is now provisional tic disorder because there is no way to tell which tics will be transient and which will be persistent or chronic. Chronic tics occur with a prevalence of between 0.5% and 3%¹, with a male predominance, and are more common in children with ADHD and OCD. In addition, children with chronic tic disorders often have higher incidence of learning problems and, perhaps, autism spectrum disorders. Simple motor and vocal tics (those involving a single muscle group) are more common than complex tics, in which coordinated movements are made. Despite the portrayal in the popular media, it is particularly rare to have complex tics that include copropraxia (an obscene gesture), coprolalia (an obscene movement), echolalia (repeating another’s words), or echopraxia (repeating another’s actions).

Tics tend to have their onset in early school age, with the highest prevalence and severity between the ages of 9 and 12 years.² When present, tics tend to be somewhat suppressed when the child is in school or when the child is engaged in a task. Furthermore, most tics, even when chronic, do not lead to impairment. When impairment does occur, it is often the result of social problems from teasing by peers. Most tics wax and wane over time, but eventually resolve without intervention.

In the case of Adam, there is no clear reason to begin to treat immediately. If one wanted to follow his tics, there are several parent and clinic measures that are available. Taking a history of his case would include ensuring that there are no other predisposing causes and no other psychiatric comorbidities. Induction of tics by the initiation of a stimulant might be considered, although recent data suggest that stimulants are less likely to induce or worsen tics in the course of treatment for ADHD than previously thought.^3,4 If concerned, however, alternative ADHD treatment such as alpha-2 agonist treatment could be considered. Education could be provided to the parents regarding the likelihood of resolution. Should the tics worsen in severity and/or become chronic, there are several behavioral interventions, including habit reversal training and the Comprehensive Behavioral Intervention for Tics, which could be considered as first line.

Medications could be considered if the tics are moderate to severe and behavioral interventions are not sufficient to reduce impairment. The only Food and Drug Administration–approved agents are haloperidol and pimozide, although there is ample support for other agents, and practitioners are most likely to use alternatives, given the side-effect profiles of these typical antipsychotics. Co-occurring symptoms should be considered when thinking about medication. Alpha-2 agonists appear to be most effective in the context of ADHD, while second-generation antipsychotics appear to be more useful if OCD is comorbid. In general, though, in cases like Adam’s, taking a watchful-waiting approach will most often lead to symptom resolution.

References

1. Eur Child Adolesc Psychiatry. 2012 Jan;21(1):5-13.

2. J Am Acad Child Adolesc Psychiatry. 2013 Dec;52(12):1341-59.

3. J Am Acad Child Adolesc Psychiatry. 2015 Sep;54(9):728-36.

4. Cochrane Database Syst Rev. 2011 Apr 13;(4):CD007990.

Dr. Althoff is associate professor of psychiatry, psychology, and pediatrics at the University of Vermont, Burlington. He is director of the division of behavioral genetics and conducts research on the development of self-regulation in children. Email him at [email protected].

A tic is described by the DSM-5 as a sudden, rapid, recurrent, nonrhythmic movement or vocalization. Tics are a common occurrence in childhood and can range from mild to severe, transient to chronic, simple to complex. It is not uncommon for parents to ask pediatric care providers when and how to manage tics in children. Here, we present a case to illustrate just such an issue.

Case summary

Adam is an 8-year-old with a previous diagnosis of attention-deficit/hyperactivity disorder (ADHD) who is being seen for follow-up after being started on a stimulant 3 months ago because of declining performance in school and at home, despite adequate accommodations, parent education, and nonpharmacologic treatments. He has done well on a small dose of methylphenidate (0.5 mg/kg per day), but in the context of being asked about other symptoms, his mother, Mary, mentions that she has noticed that Adam is frequently clearing his throat. This began about 6 weeks ago after experiencing allergic rhinitis for almost a week. Since that time, Mary has noticed that he clears his throat as frequently as once every 5 minutes.

The behavior was reported to occur in the classroom, but not nearly with the frequency experienced at home. If asked to not clear his throat, Adam can suppress it. None of his classmates have said anything or appear to have noticed. His parents have never noticed any tics previously. There is a family history of ADHD in his father. There is no other family history of neurodevelopmental disorders, including no obsessive compulsive disorder (OCD), Tourette’s disorder, or other chronic tic disorders. There is nothing else of concern on physical or mental status examination. His mother has concerns that the stimulant medication may be inducing a tic and wonders about stopping it.

Case discussion

Adam has a mild simple vocal tic. The vast majority of tics that develop in childhood will not last the requisite 1 year required to make the diagnosis of a persistent (chronic) motor or vocal tic, nor will they occur with both vocal and motor tics over 1 year required to make the diagnosis of Tourette’s disorder. In the DSM-IV, tics lasting less than 1 year would have been given the diagnosis of transient tic disorder.

In the DSM-5, the diagnosis is now provisional tic disorder because there is no way to tell which tics will be transient and which will be persistent or chronic. Chronic tics occur with a prevalence of between 0.5% and 3%¹, with a male predominance, and are more common in children with ADHD and OCD. In addition, children with chronic tic disorders often have higher incidence of learning problems and, perhaps, autism spectrum disorders. Simple motor and vocal tics (those involving a single muscle group) are more common than complex tics, in which coordinated movements are made. Despite the portrayal in the popular media, it is particularly rare to have complex tics that include copropraxia (an obscene gesture), coprolalia (an obscene movement), echolalia (repeating another’s words), or echopraxia (repeating another’s actions).

Tics tend to have their onset in early school age, with the highest prevalence and severity between the ages of 9 and 12 years.² When present, tics tend to be somewhat suppressed when the child is in school or when the child is engaged in a task. Furthermore, most tics, even when chronic, do not lead to impairment. When impairment does occur, it is often the result of social problems from teasing by peers. Most tics wax and wane over time, but eventually resolve without intervention.

In the case of Adam, there is no clear reason to begin to treat immediately. If one wanted to follow his tics, there are several parent and clinic measures that are available. Taking a history of his case would include ensuring that there are no other predisposing causes and no other psychiatric comorbidities. Induction of tics by the initiation of a stimulant might be considered, although recent data suggest that stimulants are less likely to induce or worsen tics in the course of treatment for ADHD than previously thought.^3,4 If concerned, however, alternative ADHD treatment such as alpha-2 agonist treatment could be considered. Education could be provided to the parents regarding the likelihood of resolution. Should the tics worsen in severity and/or become chronic, there are several behavioral interventions, including habit reversal training and the Comprehensive Behavioral Intervention for Tics, which could be considered as first line.

Medications could be considered if the tics are moderate to severe and behavioral interventions are not sufficient to reduce impairment. The only Food and Drug Administration–approved agents are haloperidol and pimozide, although there is ample support for other agents, and practitioners are most likely to use alternatives, given the side-effect profiles of these typical antipsychotics. Co-occurring symptoms should be considered when thinking about medication. Alpha-2 agonists appear to be most effective in the context of ADHD, while second-generation antipsychotics appear to be more useful if OCD is comorbid. In general, though, in cases like Adam’s, taking a watchful-waiting approach will most often lead to symptom resolution.

References

1. Eur Child Adolesc Psychiatry. 2012 Jan;21(1):5-13.

2. J Am Acad Child Adolesc Psychiatry. 2013 Dec;52(12):1341-59.

3. J Am Acad Child Adolesc Psychiatry. 2015 Sep;54(9):728-36.

4. Cochrane Database Syst Rev. 2011 Apr 13;(4):CD007990.

Dr. Althoff is associate professor of psychiatry, psychology, and pediatrics at the University of Vermont, Burlington. He is director of the division of behavioral genetics and conducts research on the development of self-regulation in children. Email him at [email protected].

A tic is described by the DSM-5 as a sudden, rapid, recurrent, nonrhythmic movement or vocalization. Tics are a common occurrence in childhood and can range from mild to severe, transient to chronic, simple to complex. It is not uncommon for parents to ask pediatric care providers when and how to manage tics in children. Here, we present a case to illustrate just such an issue.

Case summary

Adam is an 8-year-old with a previous diagnosis of attention-deficit/hyperactivity disorder (ADHD) who is being seen for follow-up after being started on a stimulant 3 months ago because of declining performance in school and at home, despite adequate accommodations, parent education, and nonpharmacologic treatments. He has done well on a small dose of methylphenidate (0.5 mg/kg per day), but in the context of being asked about other symptoms, his mother, Mary, mentions that she has noticed that Adam is frequently clearing his throat. This began about 6 weeks ago after experiencing allergic rhinitis for almost a week. Since that time, Mary has noticed that he clears his throat as frequently as once every 5 minutes.

The behavior was reported to occur in the classroom, but not nearly with the frequency experienced at home. If asked to not clear his throat, Adam can suppress it. None of his classmates have said anything or appear to have noticed. His parents have never noticed any tics previously. There is a family history of ADHD in his father. There is no other family history of neurodevelopmental disorders, including no obsessive compulsive disorder (OCD), Tourette’s disorder, or other chronic tic disorders. There is nothing else of concern on physical or mental status examination. His mother has concerns that the stimulant medication may be inducing a tic and wonders about stopping it.

Case discussion

Adam has a mild simple vocal tic. The vast majority of tics that develop in childhood will not last the requisite 1 year required to make the diagnosis of a persistent (chronic) motor or vocal tic, nor will they occur with both vocal and motor tics over 1 year required to make the diagnosis of Tourette’s disorder. In the DSM-IV, tics lasting less than 1 year would have been given the diagnosis of transient tic disorder.

In the DSM-5, the diagnosis is now provisional tic disorder because there is no way to tell which tics will be transient and which will be persistent or chronic. Chronic tics occur with a prevalence of between 0.5% and 3%¹, with a male predominance, and are more common in children with ADHD and OCD. In addition, children with chronic tic disorders often have higher incidence of learning problems and, perhaps, autism spectrum disorders. Simple motor and vocal tics (those involving a single muscle group) are more common than complex tics, in which coordinated movements are made. Despite the portrayal in the popular media, it is particularly rare to have complex tics that include copropraxia (an obscene gesture), coprolalia (an obscene movement), echolalia (repeating another’s words), or echopraxia (repeating another’s actions).

Tics tend to have their onset in early school age, with the highest prevalence and severity between the ages of 9 and 12 years.² When present, tics tend to be somewhat suppressed when the child is in school or when the child is engaged in a task. Furthermore, most tics, even when chronic, do not lead to impairment. When impairment does occur, it is often the result of social problems from teasing by peers. Most tics wax and wane over time, but eventually resolve without intervention.

In the case of Adam, there is no clear reason to begin to treat immediately. If one wanted to follow his tics, there are several parent and clinic measures that are available. Taking a history of his case would include ensuring that there are no other predisposing causes and no other psychiatric comorbidities. Induction of tics by the initiation of a stimulant might be considered, although recent data suggest that stimulants are less likely to induce or worsen tics in the course of treatment for ADHD than previously thought.^3,4 If concerned, however, alternative ADHD treatment such as alpha-2 agonist treatment could be considered. Education could be provided to the parents regarding the likelihood of resolution. Should the tics worsen in severity and/or become chronic, there are several behavioral interventions, including habit reversal training and the Comprehensive Behavioral Intervention for Tics, which could be considered as first line.

Medications could be considered if the tics are moderate to severe and behavioral interventions are not sufficient to reduce impairment. The only Food and Drug Administration–approved agents are haloperidol and pimozide, although there is ample support for other agents, and practitioners are most likely to use alternatives, given the side-effect profiles of these typical antipsychotics. Co-occurring symptoms should be considered when thinking about medication. Alpha-2 agonists appear to be most effective in the context of ADHD, while second-generation antipsychotics appear to be more useful if OCD is comorbid. In general, though, in cases like Adam’s, taking a watchful-waiting approach will most often lead to symptom resolution.

References

1. Eur Child Adolesc Psychiatry. 2012 Jan;21(1):5-13.

2. J Am Acad Child Adolesc Psychiatry. 2013 Dec;52(12):1341-59.

3. J Am Acad Child Adolesc Psychiatry. 2015 Sep;54(9):728-36.

4. Cochrane Database Syst Rev. 2011 Apr 13;(4):CD007990.

Dr. Althoff is associate professor of psychiatry, psychology, and pediatrics at the University of Vermont, Burlington. He is director of the division of behavioral genetics and conducts research on the development of self-regulation in children. Email him at [email protected].

Sometimes, you come across an article that makes you cringe. After this initial reaction – and if we are up for the challenge – we realize that this information can help us grow by pushing our clinical approach in new directions.

This is the experience I had with an article by Dr. Daniel Bouland and colleagues that explored the ways in which people struggling with addiction obtain prescription medications (J Addict Med. 2015 Jul-Aug;9[4]:281-5).

In this semiquantitative qualitative study, investigators interviewed 36 patients in a residential addiction treatment program who obtained prescriptions from clinicians in support of an addiction. Types of medications obtained by respondents were opioids (97.2%), sedative hypnotics (47.4%), and amphetamines (5.5%).

Patients reported obtaining prescriptions from clinicians because it was perceived to be “legal” – even though 75% of them faked symptoms, several falsified MRI images of an injury, and some used old or forged prescriptions. One patient paid a physician outright for the medication.

Eight percent of patients physically harmed themselves to obtain prescriptions by doing things such as cutting themselves to put blood in the urine, hitting their head against the wall to the point of unconsciousness, and undergoing unnecessary surgery.

Primary care clinicians and pain specialists were viewed as the easiest sources of medication. Most patients used “mom and pop” pharmacies, visited multiple pharmacies, and paid in cash. Importantly, 67% of patients said that an intervention could have changed their behaviors.

I think I knew this, but it challenged me to see it in writing. I appreciated the honesty of these individuals and was struck by the fact that almost two-thirds suggested that an intervention could have transformed them.

But how to start this conversation?

The last time I expressed concern about a patient’s allergy to any pain medication – except oxycodone and the potentially toxic doses of ibuprofen and acetaminophen that didn’t “touch it” – I was the recipient of seething rage and hostility.

Addiction treatment is hard, diagnosing addiction in daily primary care practice is harder, and holding up a mirror to a patient’s prescription drug habits requires protective body armor. That’s why not many of us do it.

So, now that we have guidelines for chronic opioids, we need best practices for acute visits presenting with x-rays of broken animal bones labeled with their name handwritten on duct tape.

Are we up for urine drug screens for every controlled substance prescription on nonestablished patients every time? Probably not, but we have to start somewhere.

At least it might start a conversation when we can say: “We do this for all of our patients, we are not singling you out. Is there anything you would like to talk about before we complete this test?”

Most importantly, once we make a diagnosis of prescription drug abuse, we need resources to which to refer them and health insurance to help cover the cost for this care.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

Sometimes, you come across an article that makes you cringe. After this initial reaction – and if we are up for the challenge – we realize that this information can help us grow by pushing our clinical approach in new directions.

This is the experience I had with an article by Dr. Daniel Bouland and colleagues that explored the ways in which people struggling with addiction obtain prescription medications (J Addict Med. 2015 Jul-Aug;9[4]:281-5).

In this semiquantitative qualitative study, investigators interviewed 36 patients in a residential addiction treatment program who obtained prescriptions from clinicians in support of an addiction. Types of medications obtained by respondents were opioids (97.2%), sedative hypnotics (47.4%), and amphetamines (5.5%).

Patients reported obtaining prescriptions from clinicians because it was perceived to be “legal” – even though 75% of them faked symptoms, several falsified MRI images of an injury, and some used old or forged prescriptions. One patient paid a physician outright for the medication.

Eight percent of patients physically harmed themselves to obtain prescriptions by doing things such as cutting themselves to put blood in the urine, hitting their head against the wall to the point of unconsciousness, and undergoing unnecessary surgery.

Primary care clinicians and pain specialists were viewed as the easiest sources of medication. Most patients used “mom and pop” pharmacies, visited multiple pharmacies, and paid in cash. Importantly, 67% of patients said that an intervention could have changed their behaviors.

I think I knew this, but it challenged me to see it in writing. I appreciated the honesty of these individuals and was struck by the fact that almost two-thirds suggested that an intervention could have transformed them.

But how to start this conversation?

The last time I expressed concern about a patient’s allergy to any pain medication – except oxycodone and the potentially toxic doses of ibuprofen and acetaminophen that didn’t “touch it” – I was the recipient of seething rage and hostility.

Addiction treatment is hard, diagnosing addiction in daily primary care practice is harder, and holding up a mirror to a patient’s prescription drug habits requires protective body armor. That’s why not many of us do it.

So, now that we have guidelines for chronic opioids, we need best practices for acute visits presenting with x-rays of broken animal bones labeled with their name handwritten on duct tape.

Are we up for urine drug screens for every controlled substance prescription on nonestablished patients every time? Probably not, but we have to start somewhere.

At least it might start a conversation when we can say: “We do this for all of our patients, we are not singling you out. Is there anything you would like to talk about before we complete this test?”

Most importantly, once we make a diagnosis of prescription drug abuse, we need resources to which to refer them and health insurance to help cover the cost for this care.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

Sometimes, you come across an article that makes you cringe. After this initial reaction – and if we are up for the challenge – we realize that this information can help us grow by pushing our clinical approach in new directions.

This is the experience I had with an article by Dr. Daniel Bouland and colleagues that explored the ways in which people struggling with addiction obtain prescription medications (J Addict Med. 2015 Jul-Aug;9[4]:281-5).

In this semiquantitative qualitative study, investigators interviewed 36 patients in a residential addiction treatment program who obtained prescriptions from clinicians in support of an addiction. Types of medications obtained by respondents were opioids (97.2%), sedative hypnotics (47.4%), and amphetamines (5.5%).

Patients reported obtaining prescriptions from clinicians because it was perceived to be “legal” – even though 75% of them faked symptoms, several falsified MRI images of an injury, and some used old or forged prescriptions. One patient paid a physician outright for the medication.

Eight percent of patients physically harmed themselves to obtain prescriptions by doing things such as cutting themselves to put blood in the urine, hitting their head against the wall to the point of unconsciousness, and undergoing unnecessary surgery.

Primary care clinicians and pain specialists were viewed as the easiest sources of medication. Most patients used “mom and pop” pharmacies, visited multiple pharmacies, and paid in cash. Importantly, 67% of patients said that an intervention could have changed their behaviors.

I think I knew this, but it challenged me to see it in writing. I appreciated the honesty of these individuals and was struck by the fact that almost two-thirds suggested that an intervention could have transformed them.

But how to start this conversation?

The last time I expressed concern about a patient’s allergy to any pain medication – except oxycodone and the potentially toxic doses of ibuprofen and acetaminophen that didn’t “touch it” – I was the recipient of seething rage and hostility.

Addiction treatment is hard, diagnosing addiction in daily primary care practice is harder, and holding up a mirror to a patient’s prescription drug habits requires protective body armor. That’s why not many of us do it.

So, now that we have guidelines for chronic opioids, we need best practices for acute visits presenting with x-rays of broken animal bones labeled with their name handwritten on duct tape.

Are we up for urine drug screens for every controlled substance prescription on nonestablished patients every time? Probably not, but we have to start somewhere.

At least it might start a conversation when we can say: “We do this for all of our patients, we are not singling you out. Is there anything you would like to talk about before we complete this test?”

Most importantly, once we make a diagnosis of prescription drug abuse, we need resources to which to refer them and health insurance to help cover the cost for this care.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

Introduction

Often, it can be difficult for providers to fully understand why children may be presenting with behavioral problems that appear to be occurring principally in specific environments. Parents may bring their children for an evaluation based upon reports they are receiving from teachers and other school personnel who may be observing more prominent oppositionality, social struggles, troubles following instructions, and frustration intolerance than the parents are experiencing in the home. Additionally, youth may begin to display school refusal and voice strong negative feelings about school. Although at face value, these problems may indicate potential diagnoses like oppositional defiant disorder and attention-deficit/hyperactivity disorder, one also should consider other underlying “non–mental health” issues that could greatly influence school success and present with a range of emotional and behavioral struggles.

Case Summary

Brynn is an animated, social, and strong-willed 4 year-old girl who experienced delays in her receptive and expressive language that prompted her engagement in early intervention around 18 months of age. She and her family continued to receive developmental services over the next few years and, at the age of 3 years, because of ongoing speech and language challenges, she was enrolled in a preschool individualized education program. In her program, Brynn participates in an array of specialized instruction, but her educators comment that she is not making expected academic progress and has troubles “holding onto information,” focusing, and participating meaningfully with peers in a consistent manner.

At times, Brynn can be impulsive, aggressive, and volatile – behavioral traits that mom denies are occurring in the home. A diagnosis of an autism spectrum disorder has been ruled out, and Brynn’s hearing and vision are tested to be normal. Brynn’s mother feels confused by the reports she’s getting from school; “I want Brynn to be happy,” she shares. “I needed special help to read in high school, and I worry about her future.”

Discussion

Learning disorders (or learning disabilities, using educational terminology) are defined as neurologically rooted problems that affect academic achievement via the receiving, processing, or communication of information. They occur in 1 in 10 children (Pediatrics. 2007 Feb;119 Suppl 1:S77-83) and can present with specific problems in reading, writing, and mathematics while having considerable influence on related aptitudes in language, social ability, self-help, and motor functioning. Dyslexia – a developmental reading disorder – is the most common type of learning disorder (LD). Although it’s not clear what causes learning disorders, there are several factors that are thought to play a role in their development, including hereditary factors and problems with pregnancy and birth. Having developmental delays also can place children at risk for having later learning problems that may not be identifiable until a child enters a more structured learning environment. At clinical visits during the preschool years, particularly with a child who may have had earlier developmental concerns, the pediatrician should inquire about a range of “warning signs” that may indicate a need for additional screening and evaluation for specific learning issues.

The National Center for Learning Disabilities offers a range of practical tips for pediatricians who may want to further explore parental and teacher concerns by asking questions related to literacy, writing, language, and social-emotional skills, attention, and gross and fine motor movements in a developmentally informed manner. Further exploring Brynn’s mother’s comments in the context of her daughter not progressing in school revealed a history of difficulty retaining new words, troubles learning colors and shapes, challenges remembering rules, and particular difficulties engaging in group play with other 4-year-olds – all potential signals for a learning disorder. This alerted educators that she may indeed be struggling with issues beyond that of an enduring speech-language delay.

With the suspicion that Brynn was presenting with signs and symptoms suggestive of a learning disorder, her family was educated about the Individuals with Disabilities Education Act, and it was recommended she receive a comprehensive psychoeducational evaluation to further assess her intellectual profile, academic achievement, social functioning, and performance in the classroom using standardized tools. These tools, among other objectives, can help the child’s team offer a more definitive LD diagnosis while informing the potential development of special education supports and assessing for an intellectual disability. The DSM 5 indicates that LD diagnostic criteria are to be met based upon a clinical synthesis of history, school reports, and psychoeducational assessment.

©Bigandt_Photography/Thinkstock

It’s been long established that children with learning problems frequently have co-occurring emotional and behavioral troubles (Arch Dis Child. 1974 Apr; 49[4]:249-56), many of which also should be considered as differential diagnoses in a child with school problems – as such, a complicated interplay of learning disorders and internalizing and externalizing conditions is often appreciated in school-age children with academic difficulties. At times, learning disorders can lead to emotional distress and could also be misdiagnosed as primary emotional and behavioral challenges. Specifically, children with learning problems are at risk for struggling with low self-esteem, loneliness, and anxiety, which also can be associated with mood disorders, school dropout, victimization, and engaging in substance use.

In Brynn’s case, the results of the Teacher Report Forms and Child Behavior Checklists were reviewed, revealing some evidence that she was experiencing clinical-level problems with her attention, but a discrepancy was noted between the teacher and parent report (the teachers endorsing more clinically significant symptoms). Although co-occurring attention-deficit/hyperactivity disorder (ADHD) is not uncommon in children with a learning disorder (Pediatrics. 2011 Mar;127[3]:462-70), we did not feel Brynn met criteria for this. We elected not to provide an ADHD diagnosis but are mindful that her attentional concerns should be closely monitored over time; a diagnosis may be more relevant in the future, perhaps influencing Brynn’s eligibility for services and treatment planning. Furthermore, comorbidity with ADHD is predictive of worse mental health outcomes, compared with learning disabilities presenting without ADHD.

Clinical Pearl

Pediatricians should consider the possibility of a child having a learning disorder in youth who display risk factors (family history of learning concerns, atypical development, prematurity, etc.) and have problems at school. Such problems may be presenting with emotional and behavioral symptoms that could mask a child’s primary learning impairments. Learning disorders also frequently co-occur with psychiatric conditions, but engaging children in effective interventions (school-based supports) could potentially attenuate the risk for the development of mental health problems. Also, promoting emotional wellness and fostering self-worth may improve the academic performance of children with learning disorders.

Dr. Dickerson, a child and adolescent psychiatrist, is an assistant professor of psychiatry at the University of Vermont, Burlington. He is the director of the university’s autism diagnostic clinic. Dr. Dickerson said he had no relevant financial disclosures. Contact Dr. Dickerson at [email protected].

Introduction

Often, it can be difficult for providers to fully understand why children may be presenting with behavioral problems that appear to be occurring principally in specific environments. Parents may bring their children for an evaluation based upon reports they are receiving from teachers and other school personnel who may be observing more prominent oppositionality, social struggles, troubles following instructions, and frustration intolerance than the parents are experiencing in the home. Additionally, youth may begin to display school refusal and voice strong negative feelings about school. Although at face value, these problems may indicate potential diagnoses like oppositional defiant disorder and attention-deficit/hyperactivity disorder, one also should consider other underlying “non–mental health” issues that could greatly influence school success and present with a range of emotional and behavioral struggles.

Case Summary

Brynn is an animated, social, and strong-willed 4 year-old girl who experienced delays in her receptive and expressive language that prompted her engagement in early intervention around 18 months of age. She and her family continued to receive developmental services over the next few years and, at the age of 3 years, because of ongoing speech and language challenges, she was enrolled in a preschool individualized education program. In her program, Brynn participates in an array of specialized instruction, but her educators comment that she is not making expected academic progress and has troubles “holding onto information,” focusing, and participating meaningfully with peers in a consistent manner.

At times, Brynn can be impulsive, aggressive, and volatile – behavioral traits that mom denies are occurring in the home. A diagnosis of an autism spectrum disorder has been ruled out, and Brynn’s hearing and vision are tested to be normal. Brynn’s mother feels confused by the reports she’s getting from school; “I want Brynn to be happy,” she shares. “I needed special help to read in high school, and I worry about her future.”

Discussion

Learning disorders (or learning disabilities, using educational terminology) are defined as neurologically rooted problems that affect academic achievement via the receiving, processing, or communication of information. They occur in 1 in 10 children (Pediatrics. 2007 Feb;119 Suppl 1:S77-83) and can present with specific problems in reading, writing, and mathematics while having considerable influence on related aptitudes in language, social ability, self-help, and motor functioning. Dyslexia – a developmental reading disorder – is the most common type of learning disorder (LD). Although it’s not clear what causes learning disorders, there are several factors that are thought to play a role in their development, including hereditary factors and problems with pregnancy and birth. Having developmental delays also can place children at risk for having later learning problems that may not be identifiable until a child enters a more structured learning environment. At clinical visits during the preschool years, particularly with a child who may have had earlier developmental concerns, the pediatrician should inquire about a range of “warning signs” that may indicate a need for additional screening and evaluation for specific learning issues.

The National Center for Learning Disabilities offers a range of practical tips for pediatricians who may want to further explore parental and teacher concerns by asking questions related to literacy, writing, language, and social-emotional skills, attention, and gross and fine motor movements in a developmentally informed manner. Further exploring Brynn’s mother’s comments in the context of her daughter not progressing in school revealed a history of difficulty retaining new words, troubles learning colors and shapes, challenges remembering rules, and particular difficulties engaging in group play with other 4-year-olds – all potential signals for a learning disorder. This alerted educators that she may indeed be struggling with issues beyond that of an enduring speech-language delay.

With the suspicion that Brynn was presenting with signs and symptoms suggestive of a learning disorder, her family was educated about the Individuals with Disabilities Education Act, and it was recommended she receive a comprehensive psychoeducational evaluation to further assess her intellectual profile, academic achievement, social functioning, and performance in the classroom using standardized tools. These tools, among other objectives, can help the child’s team offer a more definitive LD diagnosis while informing the potential development of special education supports and assessing for an intellectual disability. The DSM 5 indicates that LD diagnostic criteria are to be met based upon a clinical synthesis of history, school reports, and psychoeducational assessment.

©Bigandt_Photography/Thinkstock

It’s been long established that children with learning problems frequently have co-occurring emotional and behavioral troubles (Arch Dis Child. 1974 Apr; 49[4]:249-56), many of which also should be considered as differential diagnoses in a child with school problems – as such, a complicated interplay of learning disorders and internalizing and externalizing conditions is often appreciated in school-age children with academic difficulties. At times, learning disorders can lead to emotional distress and could also be misdiagnosed as primary emotional and behavioral challenges. Specifically, children with learning problems are at risk for struggling with low self-esteem, loneliness, and anxiety, which also can be associated with mood disorders, school dropout, victimization, and engaging in substance use.

In Brynn’s case, the results of the Teacher Report Forms and Child Behavior Checklists were reviewed, revealing some evidence that she was experiencing clinical-level problems with her attention, but a discrepancy was noted between the teacher and parent report (the teachers endorsing more clinically significant symptoms). Although co-occurring attention-deficit/hyperactivity disorder (ADHD) is not uncommon in children with a learning disorder (Pediatrics. 2011 Mar;127[3]:462-70), we did not feel Brynn met criteria for this. We elected not to provide an ADHD diagnosis but are mindful that her attentional concerns should be closely monitored over time; a diagnosis may be more relevant in the future, perhaps influencing Brynn’s eligibility for services and treatment planning. Furthermore, comorbidity with ADHD is predictive of worse mental health outcomes, compared with learning disabilities presenting without ADHD.

Clinical Pearl

Pediatricians should consider the possibility of a child having a learning disorder in youth who display risk factors (family history of learning concerns, atypical development, prematurity, etc.) and have problems at school. Such problems may be presenting with emotional and behavioral symptoms that could mask a child’s primary learning impairments. Learning disorders also frequently co-occur with psychiatric conditions, but engaging children in effective interventions (school-based supports) could potentially attenuate the risk for the development of mental health problems. Also, promoting emotional wellness and fostering self-worth may improve the academic performance of children with learning disorders.

Dr. Dickerson, a child and adolescent psychiatrist, is an assistant professor of psychiatry at the University of Vermont, Burlington. He is the director of the university’s autism diagnostic clinic. Dr. Dickerson said he had no relevant financial disclosures. Contact Dr. Dickerson at [email protected].

Introduction

Often, it can be difficult for providers to fully understand why children may be presenting with behavioral problems that appear to be occurring principally in specific environments. Parents may bring their children for an evaluation based upon reports they are receiving from teachers and other school personnel who may be observing more prominent oppositionality, social struggles, troubles following instructions, and frustration intolerance than the parents are experiencing in the home. Additionally, youth may begin to display school refusal and voice strong negative feelings about school. Although at face value, these problems may indicate potential diagnoses like oppositional defiant disorder and attention-deficit/hyperactivity disorder, one also should consider other underlying “non–mental health” issues that could greatly influence school success and present with a range of emotional and behavioral struggles.

Case Summary

Brynn is an animated, social, and strong-willed 4 year-old girl who experienced delays in her receptive and expressive language that prompted her engagement in early intervention around 18 months of age. She and her family continued to receive developmental services over the next few years and, at the age of 3 years, because of ongoing speech and language challenges, she was enrolled in a preschool individualized education program. In her program, Brynn participates in an array of specialized instruction, but her educators comment that she is not making expected academic progress and has troubles “holding onto information,” focusing, and participating meaningfully with peers in a consistent manner.

At times, Brynn can be impulsive, aggressive, and volatile – behavioral traits that mom denies are occurring in the home. A diagnosis of an autism spectrum disorder has been ruled out, and Brynn’s hearing and vision are tested to be normal. Brynn’s mother feels confused by the reports she’s getting from school; “I want Brynn to be happy,” she shares. “I needed special help to read in high school, and I worry about her future.”

Discussion

Learning disorders (or learning disabilities, using educational terminology) are defined as neurologically rooted problems that affect academic achievement via the receiving, processing, or communication of information. They occur in 1 in 10 children (Pediatrics. 2007 Feb;119 Suppl 1:S77-83) and can present with specific problems in reading, writing, and mathematics while having considerable influence on related aptitudes in language, social ability, self-help, and motor functioning. Dyslexia – a developmental reading disorder – is the most common type of learning disorder (LD). Although it’s not clear what causes learning disorders, there are several factors that are thought to play a role in their development, including hereditary factors and problems with pregnancy and birth. Having developmental delays also can place children at risk for having later learning problems that may not be identifiable until a child enters a more structured learning environment. At clinical visits during the preschool years, particularly with a child who may have had earlier developmental concerns, the pediatrician should inquire about a range of “warning signs” that may indicate a need for additional screening and evaluation for specific learning issues.

The National Center for Learning Disabilities offers a range of practical tips for pediatricians who may want to further explore parental and teacher concerns by asking questions related to literacy, writing, language, and social-emotional skills, attention, and gross and fine motor movements in a developmentally informed manner. Further exploring Brynn’s mother’s comments in the context of her daughter not progressing in school revealed a history of difficulty retaining new words, troubles learning colors and shapes, challenges remembering rules, and particular difficulties engaging in group play with other 4-year-olds – all potential signals for a learning disorder. This alerted educators that she may indeed be struggling with issues beyond that of an enduring speech-language delay.

With the suspicion that Brynn was presenting with signs and symptoms suggestive of a learning disorder, her family was educated about the Individuals with Disabilities Education Act, and it was recommended she receive a comprehensive psychoeducational evaluation to further assess her intellectual profile, academic achievement, social functioning, and performance in the classroom using standardized tools. These tools, among other objectives, can help the child’s team offer a more definitive LD diagnosis while informing the potential development of special education supports and assessing for an intellectual disability. The DSM 5 indicates that LD diagnostic criteria are to be met based upon a clinical synthesis of history, school reports, and psychoeducational assessment.

©Bigandt_Photography/Thinkstock

It’s been long established that children with learning problems frequently have co-occurring emotional and behavioral troubles (Arch Dis Child. 1974 Apr; 49[4]:249-56), many of which also should be considered as differential diagnoses in a child with school problems – as such, a complicated interplay of learning disorders and internalizing and externalizing conditions is often appreciated in school-age children with academic difficulties. At times, learning disorders can lead to emotional distress and could also be misdiagnosed as primary emotional and behavioral challenges. Specifically, children with learning problems are at risk for struggling with low self-esteem, loneliness, and anxiety, which also can be associated with mood disorders, school dropout, victimization, and engaging in substance use.

In Brynn’s case, the results of the Teacher Report Forms and Child Behavior Checklists were reviewed, revealing some evidence that she was experiencing clinical-level problems with her attention, but a discrepancy was noted between the teacher and parent report (the teachers endorsing more clinically significant symptoms). Although co-occurring attention-deficit/hyperactivity disorder (ADHD) is not uncommon in children with a learning disorder (Pediatrics. 2011 Mar;127[3]:462-70), we did not feel Brynn met criteria for this. We elected not to provide an ADHD diagnosis but are mindful that her attentional concerns should be closely monitored over time; a diagnosis may be more relevant in the future, perhaps influencing Brynn’s eligibility for services and treatment planning. Furthermore, comorbidity with ADHD is predictive of worse mental health outcomes, compared with learning disabilities presenting without ADHD.

Clinical Pearl

Pediatricians should consider the possibility of a child having a learning disorder in youth who display risk factors (family history of learning concerns, atypical development, prematurity, etc.) and have problems at school. Such problems may be presenting with emotional and behavioral symptoms that could mask a child’s primary learning impairments. Learning disorders also frequently co-occur with psychiatric conditions, but engaging children in effective interventions (school-based supports) could potentially attenuate the risk for the development of mental health problems. Also, promoting emotional wellness and fostering self-worth may improve the academic performance of children with learning disorders.

Dr. Dickerson, a child and adolescent psychiatrist, is an assistant professor of psychiatry at the University of Vermont, Burlington. He is the director of the university’s autism diagnostic clinic. Dr. Dickerson said he had no relevant financial disclosures. Contact Dr. Dickerson at [email protected].

In the era of individualized (or precision) medicine, we are presented with a unique opportunity to peer into the genetic “maps” of our patients. Through this window, we can envision the self-evident present or predict a possible future.

For the front-line provider, knowing that we could someday have a large amount of these data to deal with can be overwhelming. We may be loath to think that, amongst all the other daily battles we wage with current disease states, we may now need to understand and explain risk for future disease states.

But would we be more likely to use these data if we thought that they would change patient behavior? Maybe.

So does it?

Gareth Hollands, Ph.D., of the University of Cambridge, England, and his colleagues conducted a brilliantly timed and welcome systematic review of the literature assessing the impact of communicating DNA-based disease risk estimates on risk-reducing health behaviors and motivation to engage in such behaviors (BMJ. 2016 Mar 15;352:i1102).

Eighteen studies were found reporting on seven behavioral outcomes, including smoking cessation (six studies, n = 2,663), diet (seven studies, n = 1,784), and physical activity (six studies, n = 1,704). The smoking studies related genetic risk for lung or esophageal cancer; the diet studies related risk for diabetes, obesity, cardiovascular disease, hypertension, hyperlipidemia, and Alzheimer’s disease; and the physical activity studies related risks similar to the diet studies.

No evidence was found that communicating DNA-based risk increased smoking cessation or led to positive changes in diet or physical activity. Nor did the investigators find any effects on motivation to change behavior. Although this information is not motivating to patients, no evidence was found suggesting that it is demotivating, either.

If neither behavior nor motivation is modified by DNA-based risk assessment, what is it good for? As the authors pointed out, this information can be used for clinical risk stratification and for refining screening and treatment procedures.

It’s important to note that this puts the responsibility for the required action in response to DNA data in the hands of medical providers – sadly reminding us that the list of ways to motivate patients to change behavior remains frustratingly short.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

In the era of individualized (or precision) medicine, we are presented with a unique opportunity to peer into the genetic “maps” of our patients. Through this window, we can envision the self-evident present or predict a possible future.

For the front-line provider, knowing that we could someday have a large amount of these data to deal with can be overwhelming. We may be loath to think that, amongst all the other daily battles we wage with current disease states, we may now need to understand and explain risk for future disease states.

But would we be more likely to use these data if we thought that they would change patient behavior? Maybe.

So does it?

Gareth Hollands, Ph.D., of the University of Cambridge, England, and his colleagues conducted a brilliantly timed and welcome systematic review of the literature assessing the impact of communicating DNA-based disease risk estimates on risk-reducing health behaviors and motivation to engage in such behaviors (BMJ. 2016 Mar 15;352:i1102).

Eighteen studies were found reporting on seven behavioral outcomes, including smoking cessation (six studies, n = 2,663), diet (seven studies, n = 1,784), and physical activity (six studies, n = 1,704). The smoking studies related genetic risk for lung or esophageal cancer; the diet studies related risk for diabetes, obesity, cardiovascular disease, hypertension, hyperlipidemia, and Alzheimer’s disease; and the physical activity studies related risks similar to the diet studies.

No evidence was found that communicating DNA-based risk increased smoking cessation or led to positive changes in diet or physical activity. Nor did the investigators find any effects on motivation to change behavior. Although this information is not motivating to patients, no evidence was found suggesting that it is demotivating, either.

If neither behavior nor motivation is modified by DNA-based risk assessment, what is it good for? As the authors pointed out, this information can be used for clinical risk stratification and for refining screening and treatment procedures.

It’s important to note that this puts the responsibility for the required action in response to DNA data in the hands of medical providers – sadly reminding us that the list of ways to motivate patients to change behavior remains frustratingly short.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

In the era of individualized (or precision) medicine, we are presented with a unique opportunity to peer into the genetic “maps” of our patients. Through this window, we can envision the self-evident present or predict a possible future.

For the front-line provider, knowing that we could someday have a large amount of these data to deal with can be overwhelming. We may be loath to think that, amongst all the other daily battles we wage with current disease states, we may now need to understand and explain risk for future disease states.

But would we be more likely to use these data if we thought that they would change patient behavior? Maybe.

So does it?

Gareth Hollands, Ph.D., of the University of Cambridge, England, and his colleagues conducted a brilliantly timed and welcome systematic review of the literature assessing the impact of communicating DNA-based disease risk estimates on risk-reducing health behaviors and motivation to engage in such behaviors (BMJ. 2016 Mar 15;352:i1102).

Eighteen studies were found reporting on seven behavioral outcomes, including smoking cessation (six studies, n = 2,663), diet (seven studies, n = 1,784), and physical activity (six studies, n = 1,704). The smoking studies related genetic risk for lung or esophageal cancer; the diet studies related risk for diabetes, obesity, cardiovascular disease, hypertension, hyperlipidemia, and Alzheimer’s disease; and the physical activity studies related risks similar to the diet studies.

No evidence was found that communicating DNA-based risk increased smoking cessation or led to positive changes in diet or physical activity. Nor did the investigators find any effects on motivation to change behavior. Although this information is not motivating to patients, no evidence was found suggesting that it is demotivating, either.

If neither behavior nor motivation is modified by DNA-based risk assessment, what is it good for? As the authors pointed out, this information can be used for clinical risk stratification and for refining screening and treatment procedures.

It’s important to note that this puts the responsibility for the required action in response to DNA data in the hands of medical providers – sadly reminding us that the list of ways to motivate patients to change behavior remains frustratingly short.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

A fair number of my patients have had or are undergoing bariatric surgery. Disconcertingly, a not insignificant number of them are regaining the weight after surgery. Weight regain will occur in 20% of patients undergoing bariatric surgery after initial weight loss.

When this occurs, not only do we have a patient with an altered gut putting them at risk for nutritional deficiencies if we are not fastidious in our follow-up, but they are discouraged and overweight again.

Add this to the concern that bariatric surgery has been associated with an increase in suicides (2.33-3.63 per 1000 patient-years), and we may have some cause for alarm.

So, what predicts success – and can we facilitate it?

Several factors have been shown to predict successful weight loss after bariatric surgery. An “active coping style” (that is, planning vs. denial) and adherence to follow-up after bariatric surgery have both been shown to be associated with a higher percentage of excess weight loss. Interestingly, psychological burden and motivation have not been associated with weight loss.

In a recent article, Lori Liebl, Ph.D., and her colleagues conducted a qualitative study of the experiences of adults who successfully maintained weight loss after bariatric surgery (J Clin Nurs. 2016 Feb 23. doi: 10.1111/jocn.13129). Success was defined as 50% or more of the excessive weight loss 24 months after bariatric surgery.

The voice of the successful bariatric patient is an interesting and important one. Several themes were identified: 1) taking life back (“I did it for myself”); 2) a new lease on life (“There are things I can do now that I am not exhausted”); 3) the importance of social support; 4) avoiding the negative (terminating unhealthy relationships in which “food is love”); 5) the void (food addiction and sense of loss); 6) fighting food demons; 7) finding the happy weight; and 8) a ripple effect (that is, if you don’t eat it, the rest of family doesn’t, either).

I was left wondering how I can best help my patients using this information.

First, I think the themes can mature our empathy for the struggles that these patients face, and perhaps help us combat bias. Second, I think this knowledge can inform early discussions around what sorts of things need to be lined up for after the procedure, such as social support.

Finally, I think the themes can be universalized and help us counsel patients who may be struggling with weight, but who are otherwise not candidates for bariatric surgery.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

A fair number of my patients have had or are undergoing bariatric surgery. Disconcertingly, a not insignificant number of them are regaining the weight after surgery. Weight regain will occur in 20% of patients undergoing bariatric surgery after initial weight loss.

When this occurs, not only do we have a patient with an altered gut putting them at risk for nutritional deficiencies if we are not fastidious in our follow-up, but they are discouraged and overweight again.

Add this to the concern that bariatric surgery has been associated with an increase in suicides (2.33-3.63 per 1000 patient-years), and we may have some cause for alarm.

So, what predicts success – and can we facilitate it?

Several factors have been shown to predict successful weight loss after bariatric surgery. An “active coping style” (that is, planning vs. denial) and adherence to follow-up after bariatric surgery have both been shown to be associated with a higher percentage of excess weight loss. Interestingly, psychological burden and motivation have not been associated with weight loss.

In a recent article, Lori Liebl, Ph.D., and her colleagues conducted a qualitative study of the experiences of adults who successfully maintained weight loss after bariatric surgery (J Clin Nurs. 2016 Feb 23. doi: 10.1111/jocn.13129). Success was defined as 50% or more of the excessive weight loss 24 months after bariatric surgery.

The voice of the successful bariatric patient is an interesting and important one. Several themes were identified: 1) taking life back (“I did it for myself”); 2) a new lease on life (“There are things I can do now that I am not exhausted”); 3) the importance of social support; 4) avoiding the negative (terminating unhealthy relationships in which “food is love”); 5) the void (food addiction and sense of loss); 6) fighting food demons; 7) finding the happy weight; and 8) a ripple effect (that is, if you don’t eat it, the rest of family doesn’t, either).

I was left wondering how I can best help my patients using this information.

First, I think the themes can mature our empathy for the struggles that these patients face, and perhaps help us combat bias. Second, I think this knowledge can inform early discussions around what sorts of things need to be lined up for after the procedure, such as social support.

Finally, I think the themes can be universalized and help us counsel patients who may be struggling with weight, but who are otherwise not candidates for bariatric surgery.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

A fair number of my patients have had or are undergoing bariatric surgery. Disconcertingly, a not insignificant number of them are regaining the weight after surgery. Weight regain will occur in 20% of patients undergoing bariatric surgery after initial weight loss.

When this occurs, not only do we have a patient with an altered gut putting them at risk for nutritional deficiencies if we are not fastidious in our follow-up, but they are discouraged and overweight again.

Add this to the concern that bariatric surgery has been associated with an increase in suicides (2.33-3.63 per 1000 patient-years), and we may have some cause for alarm.

So, what predicts success – and can we facilitate it?

Several factors have been shown to predict successful weight loss after bariatric surgery. An “active coping style” (that is, planning vs. denial) and adherence to follow-up after bariatric surgery have both been shown to be associated with a higher percentage of excess weight loss. Interestingly, psychological burden and motivation have not been associated with weight loss.

In a recent article, Lori Liebl, Ph.D., and her colleagues conducted a qualitative study of the experiences of adults who successfully maintained weight loss after bariatric surgery (J Clin Nurs. 2016 Feb 23. doi: 10.1111/jocn.13129). Success was defined as 50% or more of the excessive weight loss 24 months after bariatric surgery.

The voice of the successful bariatric patient is an interesting and important one. Several themes were identified: 1) taking life back (“I did it for myself”); 2) a new lease on life (“There are things I can do now that I am not exhausted”); 3) the importance of social support; 4) avoiding the negative (terminating unhealthy relationships in which “food is love”); 5) the void (food addiction and sense of loss); 6) fighting food demons; 7) finding the happy weight; and 8) a ripple effect (that is, if you don’t eat it, the rest of family doesn’t, either).

I was left wondering how I can best help my patients using this information.

First, I think the themes can mature our empathy for the struggles that these patients face, and perhaps help us combat bias. Second, I think this knowledge can inform early discussions around what sorts of things need to be lined up for after the procedure, such as social support.

Finally, I think the themes can be universalized and help us counsel patients who may be struggling with weight, but who are otherwise not candidates for bariatric surgery.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

Emily is a 15-year-old girl who was referred by her pediatrician because of cutting behavior and conflict with her parents. Her parents reported that she has had a high body weight in the obese range since early in life. She had tried various diets without success, and her parents were frustrated with the pediatrician’s emphasis on weight over the years.

Mood problems had begun when she was in the sixth grade when she began to be severely bullied about her weight. Emily said this time was so difficult that she did not have clear memories of it. She described feeling numb. She began experiencing intense anxiety about school, and she was sometimes reluctant to attend and started cutting herself as a means of managing her emotions. In middle school, she began to fight back and associated herself with a group of “mean girls” who drank. She began having increasing conflict with her parents over the drinking and the cutting.

Discussion

Obesity is an extremely complex issue without simple answers. Severe obesity is correlated with numerous health risks including not only cardiovascular disease, type 2 diabetes, hypertension, and cancer, but also psychiatric problems such as depression, anxiety, body dissatisfaction, eating disorders, and unhealthy weight control behaviors. While some of these issues relate directly to the weight itself, many of the psychiatric concerns stem from society’s extremely harsh response to obesity.

We are all aware that the percentage of overweight and obese children, teens, and adults has increased in the past 50 years, although with some recent stabilization.¹ The rise in obesity is related to societal factors – the prevalence and advertising of nutrient-poor/high-calorie processed foods in the marketplace, the rise of technologies that have decreased the need for movement, increases in portion sizes in restaurants, especially fast food settings, as well as the subsidizing of unhealthy foods, limited access to and greater cost of more nutritious foods, and limited access to exercise opportunities in poorer areas. This is the “obesogenic environment.” As in numerous aspects of health, weight is also influenced by genetics. Those who are genetically more likely to gain weight are the ones who suffer most from these social changes.

The problem is that, except for bariatric surgery, the interventions prescribed for individuals with obesity don’t work for the vast majority of people in the long run. There is an assumption that if the obese would just eat and exercise the way a thin person does, then they would be thin. While there is evidence that lifestyle strategies that induce a negative energy balance through cutting calories (often by 500-1,000) and “programmed exercise” can help some people lose weight over the course of 6 months to a year, longer-term follow-up suggests that most people regain this weight in the long run, at 5 years out. Even the most optimistic estimates suggest that only about one out of five people can maintain weight losses of 10% in the long term with current standard lifestyle interventions.²

©kikkerdirk/Thinkstockphotos.com

There is evidence that someone attaining a particular body mass index (BMI) through dieting is not able to consume as many calories as another person who has always been at that BMI, requiring constant dietary restraint and a very high level of exercise to maintain the weight loss.³ The great majority of people who are unable to lose the weight, or briefly succeed and then gain the weight back or more, are seen as failing by society, by many medical professionals, and by themselves. There is clearly a need to focus more of our efforts on making changes on a societal level.

There also are alternative individual approaches that take the emphasis away from dieting and weight loss and instead focus on body acceptance and self-care. These interventions go by several names including mindful eating, intuitive eating, weight neutral, and “Health at Every Size.” This approach acknowledges the environmental and genetic factors beyond personal control and discusses how society pressures people to be thin. Instead of emphasizing repeated restrictive dieting, these programs stress maximizing health through making sustainable changes to increase activity and nutrition. These programs encourage people to care for themselves now rather than focusing on dieting toward a future weight where one can start enjoying life. Enjoyment of food, taking time to savor food, and being aware of when one is hungry and when not are central. For physical activity, the emphasis is on discovering something that is pleasurable and sustainable, rather than an onerous duty, as a means to an end of weight loss.⁴

Management

For Emily, struggling on the individual level, there is not a neat resolution. Psychotherapy to address anxiety, trauma, and substance abuse is indicated. Psychotherapy also should address Emily’s relationship with her body, as this is at the heart of many of these issues. Acknowledging the powerful stigma that society places on the obese while tolerating and even promoting an obesogenic environment, and the reality that weight loss is in fact extremely difficult, would open the door to a discussion with Emily and her family about what she wants and all her options to find the healthiest and most enjoyable way for her to live her life.

1. Pediatr Clin North Am. 2015 Oct;62(5):1241-61.

2. Annu Rev Nutr. 2001;21:323-41.

3. Am J Clin Nutr. 2005 Jul;82(1 Suppl):222S-225S.

4. Tylka TL, Annunziato RA, Burgard D, et al. “The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss.” J Obes. 2014;2014:983495. doi: 10.1155/2014/983495.

Dr. Hall is an assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington.

Emily is a 15-year-old girl who was referred by her pediatrician because of cutting behavior and conflict with her parents. Her parents reported that she has had a high body weight in the obese range since early in life. She had tried various diets without success, and her parents were frustrated with the pediatrician’s emphasis on weight over the years.

Mood problems had begun when she was in the sixth grade when she began to be severely bullied about her weight. Emily said this time was so difficult that she did not have clear memories of it. She described feeling numb. She began experiencing intense anxiety about school, and she was sometimes reluctant to attend and started cutting herself as a means of managing her emotions. In middle school, she began to fight back and associated herself with a group of “mean girls” who drank. She began having increasing conflict with her parents over the drinking and the cutting.

Discussion

Obesity is an extremely complex issue without simple answers. Severe obesity is correlated with numerous health risks including not only cardiovascular disease, type 2 diabetes, hypertension, and cancer, but also psychiatric problems such as depression, anxiety, body dissatisfaction, eating disorders, and unhealthy weight control behaviors. While some of these issues relate directly to the weight itself, many of the psychiatric concerns stem from society’s extremely harsh response to obesity.

We are all aware that the percentage of overweight and obese children, teens, and adults has increased in the past 50 years, although with some recent stabilization.¹ The rise in obesity is related to societal factors – the prevalence and advertising of nutrient-poor/high-calorie processed foods in the marketplace, the rise of technologies that have decreased the need for movement, increases in portion sizes in restaurants, especially fast food settings, as well as the subsidizing of unhealthy foods, limited access to and greater cost of more nutritious foods, and limited access to exercise opportunities in poorer areas. This is the “obesogenic environment.” As in numerous aspects of health, weight is also influenced by genetics. Those who are genetically more likely to gain weight are the ones who suffer most from these social changes.

The problem is that, except for bariatric surgery, the interventions prescribed for individuals with obesity don’t work for the vast majority of people in the long run. There is an assumption that if the obese would just eat and exercise the way a thin person does, then they would be thin. While there is evidence that lifestyle strategies that induce a negative energy balance through cutting calories (often by 500-1,000) and “programmed exercise” can help some people lose weight over the course of 6 months to a year, longer-term follow-up suggests that most people regain this weight in the long run, at 5 years out. Even the most optimistic estimates suggest that only about one out of five people can maintain weight losses of 10% in the long term with current standard lifestyle interventions.²

©kikkerdirk/Thinkstockphotos.com

There is evidence that someone attaining a particular body mass index (BMI) through dieting is not able to consume as many calories as another person who has always been at that BMI, requiring constant dietary restraint and a very high level of exercise to maintain the weight loss.³ The great majority of people who are unable to lose the weight, or briefly succeed and then gain the weight back or more, are seen as failing by society, by many medical professionals, and by themselves. There is clearly a need to focus more of our efforts on making changes on a societal level.

There also are alternative individual approaches that take the emphasis away from dieting and weight loss and instead focus on body acceptance and self-care. These interventions go by several names including mindful eating, intuitive eating, weight neutral, and “Health at Every Size.” This approach acknowledges the environmental and genetic factors beyond personal control and discusses how society pressures people to be thin. Instead of emphasizing repeated restrictive dieting, these programs stress maximizing health through making sustainable changes to increase activity and nutrition. These programs encourage people to care for themselves now rather than focusing on dieting toward a future weight where one can start enjoying life. Enjoyment of food, taking time to savor food, and being aware of when one is hungry and when not are central. For physical activity, the emphasis is on discovering something that is pleasurable and sustainable, rather than an onerous duty, as a means to an end of weight loss.⁴

Management

For Emily, struggling on the individual level, there is not a neat resolution. Psychotherapy to address anxiety, trauma, and substance abuse is indicated. Psychotherapy also should address Emily’s relationship with her body, as this is at the heart of many of these issues. Acknowledging the powerful stigma that society places on the obese while tolerating and even promoting an obesogenic environment, and the reality that weight loss is in fact extremely difficult, would open the door to a discussion with Emily and her family about what she wants and all her options to find the healthiest and most enjoyable way for her to live her life.

1. Pediatr Clin North Am. 2015 Oct;62(5):1241-61.

2. Annu Rev Nutr. 2001;21:323-41.

3. Am J Clin Nutr. 2005 Jul;82(1 Suppl):222S-225S.

4. Tylka TL, Annunziato RA, Burgard D, et al. “The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss.” J Obes. 2014;2014:983495. doi: 10.1155/2014/983495.

Dr. Hall is an assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington.

Emily is a 15-year-old girl who was referred by her pediatrician because of cutting behavior and conflict with her parents. Her parents reported that she has had a high body weight in the obese range since early in life. She had tried various diets without success, and her parents were frustrated with the pediatrician’s emphasis on weight over the years.

Mood problems had begun when she was in the sixth grade when she began to be severely bullied about her weight. Emily said this time was so difficult that she did not have clear memories of it. She described feeling numb. She began experiencing intense anxiety about school, and she was sometimes reluctant to attend and started cutting herself as a means of managing her emotions. In middle school, she began to fight back and associated herself with a group of “mean girls” who drank. She began having increasing conflict with her parents over the drinking and the cutting.

Discussion

Obesity is an extremely complex issue without simple answers. Severe obesity is correlated with numerous health risks including not only cardiovascular disease, type 2 diabetes, hypertension, and cancer, but also psychiatric problems such as depression, anxiety, body dissatisfaction, eating disorders, and unhealthy weight control behaviors. While some of these issues relate directly to the weight itself, many of the psychiatric concerns stem from society’s extremely harsh response to obesity.

We are all aware that the percentage of overweight and obese children, teens, and adults has increased in the past 50 years, although with some recent stabilization.¹ The rise in obesity is related to societal factors – the prevalence and advertising of nutrient-poor/high-calorie processed foods in the marketplace, the rise of technologies that have decreased the need for movement, increases in portion sizes in restaurants, especially fast food settings, as well as the subsidizing of unhealthy foods, limited access to and greater cost of more nutritious foods, and limited access to exercise opportunities in poorer areas. This is the “obesogenic environment.” As in numerous aspects of health, weight is also influenced by genetics. Those who are genetically more likely to gain weight are the ones who suffer most from these social changes.

The problem is that, except for bariatric surgery, the interventions prescribed for individuals with obesity don’t work for the vast majority of people in the long run. There is an assumption that if the obese would just eat and exercise the way a thin person does, then they would be thin. While there is evidence that lifestyle strategies that induce a negative energy balance through cutting calories (often by 500-1,000) and “programmed exercise” can help some people lose weight over the course of 6 months to a year, longer-term follow-up suggests that most people regain this weight in the long run, at 5 years out. Even the most optimistic estimates suggest that only about one out of five people can maintain weight losses of 10% in the long term with current standard lifestyle interventions.²

©kikkerdirk/Thinkstockphotos.com

There is evidence that someone attaining a particular body mass index (BMI) through dieting is not able to consume as many calories as another person who has always been at that BMI, requiring constant dietary restraint and a very high level of exercise to maintain the weight loss.³ The great majority of people who are unable to lose the weight, or briefly succeed and then gain the weight back or more, are seen as failing by society, by many medical professionals, and by themselves. There is clearly a need to focus more of our efforts on making changes on a societal level.

There also are alternative individual approaches that take the emphasis away from dieting and weight loss and instead focus on body acceptance and self-care. These interventions go by several names including mindful eating, intuitive eating, weight neutral, and “Health at Every Size.” This approach acknowledges the environmental and genetic factors beyond personal control and discusses how society pressures people to be thin. Instead of emphasizing repeated restrictive dieting, these programs stress maximizing health through making sustainable changes to increase activity and nutrition. These programs encourage people to care for themselves now rather than focusing on dieting toward a future weight where one can start enjoying life. Enjoyment of food, taking time to savor food, and being aware of when one is hungry and when not are central. For physical activity, the emphasis is on discovering something that is pleasurable and sustainable, rather than an onerous duty, as a means to an end of weight loss.⁴

Management

For Emily, struggling on the individual level, there is not a neat resolution. Psychotherapy to address anxiety, trauma, and substance abuse is indicated. Psychotherapy also should address Emily’s relationship with her body, as this is at the heart of many of these issues. Acknowledging the powerful stigma that society places on the obese while tolerating and even promoting an obesogenic environment, and the reality that weight loss is in fact extremely difficult, would open the door to a discussion with Emily and her family about what she wants and all her options to find the healthiest and most enjoyable way for her to live her life.

1. Pediatr Clin North Am. 2015 Oct;62(5):1241-61.

2. Annu Rev Nutr. 2001;21:323-41.

3. Am J Clin Nutr. 2005 Jul;82(1 Suppl):222S-225S.

4. Tylka TL, Annunziato RA, Burgard D, et al. “The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss.” J Obes. 2014;2014:983495. doi: 10.1155/2014/983495.

Dr. Hall is an assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington.