Child Psychiatry Consult

Last week, one of my patients presented with a BMI of 49 and two canes. Knee x-ray shows marked medial compartment narrowing bilaterally. We will inject her knees with steroids, but this will be temporary.

As the obesity epidemic continues to rage, native joints are rapidly being replaced with metal ones. Our pitiful homegrown joints were not designed to carry all this human weight. Joint forces in the hip and knee have been estimated to be 3 times body weight when walking on level ground and 6-10 times body weight when stooping or bending. Combine this with all the ‘screen time’ (average 8 hours a day for U.S. adults) and all the trips to the bathroom from the poorly controlled diabetes, and we are set up for needing a lot more orthopedic surgeons.

So should we push for surgery?

I am reluctant to immediately and eagerly pursue surgery based upon data from Ward et al. elucidating the increased risk for complications after joint surgery among patients with a BMI > 40 (J.Arthroplasty. 2015 Jun 3. pii: S0883-5403(15)00474-X. doi: 10.1016/j.arth.2015.03.045. [Epub ahead of print]). Data from the bariatric literature suggest that the risk of complications following joint replacement is lower if bariatric surgery is performed first. Weight loss as we look toward joint replacement is a good idea for both our orthopedic colleagues and our patients.

So we will work on weight loss first

In patients with osteoarthritis, a moderate amount of weight loss can significantly improve knee function. The short term efficacy of weight loss is comparable to joint replacement. But clinicians need to be wary of the “pain-exercise block”: patients telling us they cannot lose weight because the pain prevents them from exercising. I tell my patients that weight loss and weight maintenance can be managed effectively through dietary modification and that they do not have to run a marathon, they just need to walk if they can. But patients do not always want to hear this. Caloric restriction is psychologically painful for many. I remind them that 30 minutes of exercise can be undone in 30 seconds with a bar of chocolate, so we need to skip the chocolate bar if we do light exercise or forgo exercise altogether. Exercise is important for a million other reasons, but many of our patients can’t engage, especially when presenting with gait assist devices.

My patient and I started the discussion of bariatric surgery. In the meantime, we are going to try a trial of lorcaserin and hope the knees hold out. We are likely going to need more steroids.

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. Follow him on Twitter: @jonebbert.

Last week, one of my patients presented with a BMI of 49 and two canes. Knee x-ray shows marked medial compartment narrowing bilaterally. We will inject her knees with steroids, but this will be temporary.

As the obesity epidemic continues to rage, native joints are rapidly being replaced with metal ones. Our pitiful homegrown joints were not designed to carry all this human weight. Joint forces in the hip and knee have been estimated to be 3 times body weight when walking on level ground and 6-10 times body weight when stooping or bending. Combine this with all the ‘screen time’ (average 8 hours a day for U.S. adults) and all the trips to the bathroom from the poorly controlled diabetes, and we are set up for needing a lot more orthopedic surgeons.

So should we push for surgery?

I am reluctant to immediately and eagerly pursue surgery based upon data from Ward et al. elucidating the increased risk for complications after joint surgery among patients with a BMI > 40 (J.Arthroplasty. 2015 Jun 3. pii: S0883-5403(15)00474-X. doi: 10.1016/j.arth.2015.03.045. [Epub ahead of print]). Data from the bariatric literature suggest that the risk of complications following joint replacement is lower if bariatric surgery is performed first. Weight loss as we look toward joint replacement is a good idea for both our orthopedic colleagues and our patients.

So we will work on weight loss first

In patients with osteoarthritis, a moderate amount of weight loss can significantly improve knee function. The short term efficacy of weight loss is comparable to joint replacement. But clinicians need to be wary of the “pain-exercise block”: patients telling us they cannot lose weight because the pain prevents them from exercising. I tell my patients that weight loss and weight maintenance can be managed effectively through dietary modification and that they do not have to run a marathon, they just need to walk if they can. But patients do not always want to hear this. Caloric restriction is psychologically painful for many. I remind them that 30 minutes of exercise can be undone in 30 seconds with a bar of chocolate, so we need to skip the chocolate bar if we do light exercise or forgo exercise altogether. Exercise is important for a million other reasons, but many of our patients can’t engage, especially when presenting with gait assist devices.

My patient and I started the discussion of bariatric surgery. In the meantime, we are going to try a trial of lorcaserin and hope the knees hold out. We are likely going to need more steroids.

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. Follow him on Twitter: @jonebbert.

Last week, one of my patients presented with a BMI of 49 and two canes. Knee x-ray shows marked medial compartment narrowing bilaterally. We will inject her knees with steroids, but this will be temporary.

As the obesity epidemic continues to rage, native joints are rapidly being replaced with metal ones. Our pitiful homegrown joints were not designed to carry all this human weight. Joint forces in the hip and knee have been estimated to be 3 times body weight when walking on level ground and 6-10 times body weight when stooping or bending. Combine this with all the ‘screen time’ (average 8 hours a day for U.S. adults) and all the trips to the bathroom from the poorly controlled diabetes, and we are set up for needing a lot more orthopedic surgeons.

So should we push for surgery?

I am reluctant to immediately and eagerly pursue surgery based upon data from Ward et al. elucidating the increased risk for complications after joint surgery among patients with a BMI > 40 (J.Arthroplasty. 2015 Jun 3. pii: S0883-5403(15)00474-X. doi: 10.1016/j.arth.2015.03.045. [Epub ahead of print]). Data from the bariatric literature suggest that the risk of complications following joint replacement is lower if bariatric surgery is performed first. Weight loss as we look toward joint replacement is a good idea for both our orthopedic colleagues and our patients.

So we will work on weight loss first

In patients with osteoarthritis, a moderate amount of weight loss can significantly improve knee function. The short term efficacy of weight loss is comparable to joint replacement. But clinicians need to be wary of the “pain-exercise block”: patients telling us they cannot lose weight because the pain prevents them from exercising. I tell my patients that weight loss and weight maintenance can be managed effectively through dietary modification and that they do not have to run a marathon, they just need to walk if they can. But patients do not always want to hear this. Caloric restriction is psychologically painful for many. I remind them that 30 minutes of exercise can be undone in 30 seconds with a bar of chocolate, so we need to skip the chocolate bar if we do light exercise or forgo exercise altogether. Exercise is important for a million other reasons, but many of our patients can’t engage, especially when presenting with gait assist devices.

My patient and I started the discussion of bariatric surgery. In the meantime, we are going to try a trial of lorcaserin and hope the knees hold out. We are likely going to need more steroids.

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. Follow him on Twitter: @jonebbert.

Despite all its glamour and opportunities to write columns like this one, primary care does not attract as many clinicians as it needs to provide for the aging population. Some have proposed that this is because when learners rotate with us, they witness frustration with preauthorizations and physician-patient relationships poisoned by opioid addiction – not the intangible spiritual fulfillment of long-term relationships with people who share their lives with us.

In addition, many primary care providers have other competing interests that take them away from practice. This trend will likely increase as practitioners work beyond the age of 65 years but at reduced hours. These demands naturally decrease patient access and can theoretically lead to dissatisfaction, which is potentially devastating if we are reimbursed based upon satisfaction scores.

So, do reduced hours frustrate patients?

Laura Panattoni, Ph.D., and her colleagues at the Palo Alto Medical Foundation Research Institute, Mountain View, Calif., evaluated the relationship between physicians’ clinical time, continuity of care, access to care, and patient satisfaction with the physician (J. Gen. Intern. Med. 2015;30:327-33). The study was a cross-section survey of physicians in family and internal medicine and their patients.

The investigators found that greater office time was directly associated with increased continuity and access but with lower patient satisfaction scores. Restated, reduced clinical hours were associated with improved patient satisfaction.

These findings are interesting and important at many levels. First, they suggest that clinicians who choose less than a full-time clinical obligation can keep their patients happy. Second, we can hypothesize that what is lost in continuity and access is made up for in effective communication delivered by clinicians who are happy themselves. Third, practice redesign should not require full-time commitment to deliver on the satisfaction side of the equation. The world is clamoring for alternative care models where electronic “touches” alleviate the pressure for “patients in rooms.” Studies have shown that up to 93% of patients would select a physician who allows them to communicate with them electronically. About 450,000 patients will see a doctor through the Internet this year. UnitedHealth Group started covering telemedicine and plans to expand this to 20 million customers next year.

I personally spend one-third of my time seeing patients in rooms, but I am electronically and telephonically accessible to them every day at all times. Maybe this helps keep my patients happy, despite me not being in the office every day.

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. Follow Dr. Ebbert on Twitter @jonebbert.

Despite all its glamour and opportunities to write columns like this one, primary care does not attract as many clinicians as it needs to provide for the aging population. Some have proposed that this is because when learners rotate with us, they witness frustration with preauthorizations and physician-patient relationships poisoned by opioid addiction – not the intangible spiritual fulfillment of long-term relationships with people who share their lives with us.

In addition, many primary care providers have other competing interests that take them away from practice. This trend will likely increase as practitioners work beyond the age of 65 years but at reduced hours. These demands naturally decrease patient access and can theoretically lead to dissatisfaction, which is potentially devastating if we are reimbursed based upon satisfaction scores.

So, do reduced hours frustrate patients?

Laura Panattoni, Ph.D., and her colleagues at the Palo Alto Medical Foundation Research Institute, Mountain View, Calif., evaluated the relationship between physicians’ clinical time, continuity of care, access to care, and patient satisfaction with the physician (J. Gen. Intern. Med. 2015;30:327-33). The study was a cross-section survey of physicians in family and internal medicine and their patients.

The investigators found that greater office time was directly associated with increased continuity and access but with lower patient satisfaction scores. Restated, reduced clinical hours were associated with improved patient satisfaction.

These findings are interesting and important at many levels. First, they suggest that clinicians who choose less than a full-time clinical obligation can keep their patients happy. Second, we can hypothesize that what is lost in continuity and access is made up for in effective communication delivered by clinicians who are happy themselves. Third, practice redesign should not require full-time commitment to deliver on the satisfaction side of the equation. The world is clamoring for alternative care models where electronic “touches” alleviate the pressure for “patients in rooms.” Studies have shown that up to 93% of patients would select a physician who allows them to communicate with them electronically. About 450,000 patients will see a doctor through the Internet this year. UnitedHealth Group started covering telemedicine and plans to expand this to 20 million customers next year.

I personally spend one-third of my time seeing patients in rooms, but I am electronically and telephonically accessible to them every day at all times. Maybe this helps keep my patients happy, despite me not being in the office every day.

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. Follow Dr. Ebbert on Twitter @jonebbert.

Despite all its glamour and opportunities to write columns like this one, primary care does not attract as many clinicians as it needs to provide for the aging population. Some have proposed that this is because when learners rotate with us, they witness frustration with preauthorizations and physician-patient relationships poisoned by opioid addiction – not the intangible spiritual fulfillment of long-term relationships with people who share their lives with us.

In addition, many primary care providers have other competing interests that take them away from practice. This trend will likely increase as practitioners work beyond the age of 65 years but at reduced hours. These demands naturally decrease patient access and can theoretically lead to dissatisfaction, which is potentially devastating if we are reimbursed based upon satisfaction scores.

So, do reduced hours frustrate patients?

Laura Panattoni, Ph.D., and her colleagues at the Palo Alto Medical Foundation Research Institute, Mountain View, Calif., evaluated the relationship between physicians’ clinical time, continuity of care, access to care, and patient satisfaction with the physician (J. Gen. Intern. Med. 2015;30:327-33). The study was a cross-section survey of physicians in family and internal medicine and their patients.

The investigators found that greater office time was directly associated with increased continuity and access but with lower patient satisfaction scores. Restated, reduced clinical hours were associated with improved patient satisfaction.

These findings are interesting and important at many levels. First, they suggest that clinicians who choose less than a full-time clinical obligation can keep their patients happy. Second, we can hypothesize that what is lost in continuity and access is made up for in effective communication delivered by clinicians who are happy themselves. Third, practice redesign should not require full-time commitment to deliver on the satisfaction side of the equation. The world is clamoring for alternative care models where electronic “touches” alleviate the pressure for “patients in rooms.” Studies have shown that up to 93% of patients would select a physician who allows them to communicate with them electronically. About 450,000 patients will see a doctor through the Internet this year. UnitedHealth Group started covering telemedicine and plans to expand this to 20 million customers next year.

I personally spend one-third of my time seeing patients in rooms, but I am electronically and telephonically accessible to them every day at all times. Maybe this helps keep my patients happy, despite me not being in the office every day.

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. Follow Dr. Ebbert on Twitter @jonebbert.

For decades, bullying has been viewed as an unpleasant but generally benign rite of passage that many children experience and overcome without significant consequences. Some high-profile examples of youth suicide coupled with several stunning research studies demonstrating major negative effects of bullying that rival the impact of things like child abuse and out-of-home placement on future physical and mental health, however, have caused many clinicians across specialties to stop and take notice (Lancet Psychiatry 2015;2:524-31). The result has been concerted antibullying efforts from varied sources including the federal government, such as stopbullying.gov, and many professional organizations. Pediatricians are in a prime position both to help individual children and families and to serve as community advocates against this significant public health concern.

Case summary

Jeremy is an 11-year-old boy who has been followed by his pediatrician since birth. He has had few health concerns over the years other than some low levels of anxiety and being somewhat overweight. At an annual checkup, his mother reports that Jeremy has missed much more school this year, often making somewhat vague physical complaints. He also has told his mother that a couple of peers at school are particularly “mean” to him. He doesn’t elaborate and doesn’t want his parents to make “a big deal” about it for fear of causing further embarrassment at school.

Discussion

At least moderate levels of bullying are estimated to occur in about 30% of school-age children, resulting in approximately160,000 lost days of school. Bullying behavior can include anything from name calling to outright physical assault. Online bullying in the form of texts, e-mails, and social media also is increasingly common. School grounds remain the most common site for bullying, and physical appearance is the most common target of bullying behavior. What is thought to separate bullying from other forms of peer conflict is that there exists some sort of power differential between the bully and the victim in terms of physical size, social status, or other features. Some interesting data also suggest some sex differences regarding bullying with boys being more likely to bully children outside of their core group of friends, and girls being more likely to bully individuals within the network of individuals with whom they typically interact.

A key element of helping bullied children involves getting them to talk about the experience with a parent, teacher, physician, or counselor. Some tips that can help get kids to talk include reassurance that the child has control over what will happen with the information (within legal limits) and that no action will be taken without their knowledge and agreement, and having adults relate stories about their own past experience with bullying. Pediatricians also may want to consider opening up the conversation more broadly by asking if bullying is a problem “at your school” rather than in a particular child’s life.

In making an appropriate intervention, parents and physicians may want to differentiate lower levels of bullying (name calling, teasing) from higher levels (overt threats, physical violence, and intimidation), keeping in mind that all forms can be potentially harmful.

For lower-level bullying, the following tips can be helpful to keep in mind in working with kids directly and in helping parents help their children:

1. Don’t underestimate the power of sympathetic listening. Overt expressions to a child that he or she doesn’t deserve this, and that such behaviors are really hurtful can be very important to many kids. Positive experiences with friends and families also can go a long way to counteract a negative encounter with a bully.

2. Coach bully victims about how to respond. The old adage of telling a bully that he or she is hurting your feelings has been replaced with advice to react emotionally as little as possible. Some children also can be helped by rehearsing specific responses or learning to join groups during higher-risk activities.

3. If the bullying is occurring online, encourage kids to save the texts or social media posts if needed as evidence.

4. Consider the option of an anonymous report to a school principal or guidance counselor. While school personnel will be unable to make a direct response, they might be able, for example, to provide more monitoring in high-risk areas such as bathrooms, school buses, or locker rooms.

For higher levels of bullying, it often is important to have more direct involvement with school staff or even the police. Many states now have mandatory bullying prevention and intervention policies. While parents of bullying victims may have strong and natural urges to confront directly the parents of the alleged bully, this step often does not help the situation and often can makes things worse.

Finally, if there is evidence that bullying is having a strong negative impact on the child, a more in-depth evaluation to rule out anxiety disorders, depression, and the presence of any suicidal or homicidal thinking should be strongly considered (JAMA 2001;285:2094-100).

Case follow-up

After reassuring Jeremy that action would not be taken without his consent, the pediatrician was able to elicit more information. She learned that two older boys have been teasing Jeremy in the cafeteria and once took away part of his lunch while telling him he was too fat to need it. After some discussion, the pediatrician agreed to call the school principal to inform the school anonymously about bullying in the cafeteria. The mother, now aware of the situation, was able to offer some support and suggestions such as having lunch in a larger group and sitting at a table that is closer to adult supervision. They agreed to meet again to make sure improvements were occurring.

Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Follow him on Twitter @pedipsych. E-mail him at [email protected].

For decades, bullying has been viewed as an unpleasant but generally benign rite of passage that many children experience and overcome without significant consequences. Some high-profile examples of youth suicide coupled with several stunning research studies demonstrating major negative effects of bullying that rival the impact of things like child abuse and out-of-home placement on future physical and mental health, however, have caused many clinicians across specialties to stop and take notice (Lancet Psychiatry 2015;2:524-31). The result has been concerted antibullying efforts from varied sources including the federal government, such as stopbullying.gov, and many professional organizations. Pediatricians are in a prime position both to help individual children and families and to serve as community advocates against this significant public health concern.

Case summary

Jeremy is an 11-year-old boy who has been followed by his pediatrician since birth. He has had few health concerns over the years other than some low levels of anxiety and being somewhat overweight. At an annual checkup, his mother reports that Jeremy has missed much more school this year, often making somewhat vague physical complaints. He also has told his mother that a couple of peers at school are particularly “mean” to him. He doesn’t elaborate and doesn’t want his parents to make “a big deal” about it for fear of causing further embarrassment at school.

Discussion

At least moderate levels of bullying are estimated to occur in about 30% of school-age children, resulting in approximately160,000 lost days of school. Bullying behavior can include anything from name calling to outright physical assault. Online bullying in the form of texts, e-mails, and social media also is increasingly common. School grounds remain the most common site for bullying, and physical appearance is the most common target of bullying behavior. What is thought to separate bullying from other forms of peer conflict is that there exists some sort of power differential between the bully and the victim in terms of physical size, social status, or other features. Some interesting data also suggest some sex differences regarding bullying with boys being more likely to bully children outside of their core group of friends, and girls being more likely to bully individuals within the network of individuals with whom they typically interact.

A key element of helping bullied children involves getting them to talk about the experience with a parent, teacher, physician, or counselor. Some tips that can help get kids to talk include reassurance that the child has control over what will happen with the information (within legal limits) and that no action will be taken without their knowledge and agreement, and having adults relate stories about their own past experience with bullying. Pediatricians also may want to consider opening up the conversation more broadly by asking if bullying is a problem “at your school” rather than in a particular child’s life.

In making an appropriate intervention, parents and physicians may want to differentiate lower levels of bullying (name calling, teasing) from higher levels (overt threats, physical violence, and intimidation), keeping in mind that all forms can be potentially harmful.

For lower-level bullying, the following tips can be helpful to keep in mind in working with kids directly and in helping parents help their children:

1. Don’t underestimate the power of sympathetic listening. Overt expressions to a child that he or she doesn’t deserve this, and that such behaviors are really hurtful can be very important to many kids. Positive experiences with friends and families also can go a long way to counteract a negative encounter with a bully.

2. Coach bully victims about how to respond. The old adage of telling a bully that he or she is hurting your feelings has been replaced with advice to react emotionally as little as possible. Some children also can be helped by rehearsing specific responses or learning to join groups during higher-risk activities.

3. If the bullying is occurring online, encourage kids to save the texts or social media posts if needed as evidence.

4. Consider the option of an anonymous report to a school principal or guidance counselor. While school personnel will be unable to make a direct response, they might be able, for example, to provide more monitoring in high-risk areas such as bathrooms, school buses, or locker rooms.

For higher levels of bullying, it often is important to have more direct involvement with school staff or even the police. Many states now have mandatory bullying prevention and intervention policies. While parents of bullying victims may have strong and natural urges to confront directly the parents of the alleged bully, this step often does not help the situation and often can makes things worse.

Finally, if there is evidence that bullying is having a strong negative impact on the child, a more in-depth evaluation to rule out anxiety disorders, depression, and the presence of any suicidal or homicidal thinking should be strongly considered (JAMA 2001;285:2094-100).

Case follow-up

After reassuring Jeremy that action would not be taken without his consent, the pediatrician was able to elicit more information. She learned that two older boys have been teasing Jeremy in the cafeteria and once took away part of his lunch while telling him he was too fat to need it. After some discussion, the pediatrician agreed to call the school principal to inform the school anonymously about bullying in the cafeteria. The mother, now aware of the situation, was able to offer some support and suggestions such as having lunch in a larger group and sitting at a table that is closer to adult supervision. They agreed to meet again to make sure improvements were occurring.

Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Follow him on Twitter @pedipsych. E-mail him at [email protected].

For decades, bullying has been viewed as an unpleasant but generally benign rite of passage that many children experience and overcome without significant consequences. Some high-profile examples of youth suicide coupled with several stunning research studies demonstrating major negative effects of bullying that rival the impact of things like child abuse and out-of-home placement on future physical and mental health, however, have caused many clinicians across specialties to stop and take notice (Lancet Psychiatry 2015;2:524-31). The result has been concerted antibullying efforts from varied sources including the federal government, such as stopbullying.gov, and many professional organizations. Pediatricians are in a prime position both to help individual children and families and to serve as community advocates against this significant public health concern.

Case summary

Jeremy is an 11-year-old boy who has been followed by his pediatrician since birth. He has had few health concerns over the years other than some low levels of anxiety and being somewhat overweight. At an annual checkup, his mother reports that Jeremy has missed much more school this year, often making somewhat vague physical complaints. He also has told his mother that a couple of peers at school are particularly “mean” to him. He doesn’t elaborate and doesn’t want his parents to make “a big deal” about it for fear of causing further embarrassment at school.

Discussion

At least moderate levels of bullying are estimated to occur in about 30% of school-age children, resulting in approximately160,000 lost days of school. Bullying behavior can include anything from name calling to outright physical assault. Online bullying in the form of texts, e-mails, and social media also is increasingly common. School grounds remain the most common site for bullying, and physical appearance is the most common target of bullying behavior. What is thought to separate bullying from other forms of peer conflict is that there exists some sort of power differential between the bully and the victim in terms of physical size, social status, or other features. Some interesting data also suggest some sex differences regarding bullying with boys being more likely to bully children outside of their core group of friends, and girls being more likely to bully individuals within the network of individuals with whom they typically interact.

A key element of helping bullied children involves getting them to talk about the experience with a parent, teacher, physician, or counselor. Some tips that can help get kids to talk include reassurance that the child has control over what will happen with the information (within legal limits) and that no action will be taken without their knowledge and agreement, and having adults relate stories about their own past experience with bullying. Pediatricians also may want to consider opening up the conversation more broadly by asking if bullying is a problem “at your school” rather than in a particular child’s life.

In making an appropriate intervention, parents and physicians may want to differentiate lower levels of bullying (name calling, teasing) from higher levels (overt threats, physical violence, and intimidation), keeping in mind that all forms can be potentially harmful.

For lower-level bullying, the following tips can be helpful to keep in mind in working with kids directly and in helping parents help their children:

1. Don’t underestimate the power of sympathetic listening. Overt expressions to a child that he or she doesn’t deserve this, and that such behaviors are really hurtful can be very important to many kids. Positive experiences with friends and families also can go a long way to counteract a negative encounter with a bully.

2. Coach bully victims about how to respond. The old adage of telling a bully that he or she is hurting your feelings has been replaced with advice to react emotionally as little as possible. Some children also can be helped by rehearsing specific responses or learning to join groups during higher-risk activities.

3. If the bullying is occurring online, encourage kids to save the texts or social media posts if needed as evidence.

4. Consider the option of an anonymous report to a school principal or guidance counselor. While school personnel will be unable to make a direct response, they might be able, for example, to provide more monitoring in high-risk areas such as bathrooms, school buses, or locker rooms.

For higher levels of bullying, it often is important to have more direct involvement with school staff or even the police. Many states now have mandatory bullying prevention and intervention policies. While parents of bullying victims may have strong and natural urges to confront directly the parents of the alleged bully, this step often does not help the situation and often can makes things worse.

Finally, if there is evidence that bullying is having a strong negative impact on the child, a more in-depth evaluation to rule out anxiety disorders, depression, and the presence of any suicidal or homicidal thinking should be strongly considered (JAMA 2001;285:2094-100).

Case follow-up

After reassuring Jeremy that action would not be taken without his consent, the pediatrician was able to elicit more information. She learned that two older boys have been teasing Jeremy in the cafeteria and once took away part of his lunch while telling him he was too fat to need it. After some discussion, the pediatrician agreed to call the school principal to inform the school anonymously about bullying in the cafeteria. The mother, now aware of the situation, was able to offer some support and suggestions such as having lunch in a larger group and sitting at a table that is closer to adult supervision. They agreed to meet again to make sure improvements were occurring.

Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Follow him on Twitter @pedipsych. E-mail him at [email protected].

The other day, I received an electronic message that my patient presented to the emergency department following his attempt at lifting a relatively immovable object. The only thing apparently moved by this activity was his intervertebral disk – outward from its usual place and onto a nerve. He was quickly diagnosed with acute sciatica and treated with a healthy dose of steroids.

I enjoyed the subsequent soliloquy of the brilliance and outstanding clinical skill of our emergency department clinicians (which is true, by the way) when I saw him for follow-up. He was markedly improved.

In a moment of introspection, I questioned why we do not tend to use this strategy more in my practice, especially because it worked so well for my patient.

Perhaps it is because we are so used to dealing with medication side effects and the downstream consequences of insulin resistance in primary care that steroids make us squeamish. Perhaps it is also because we tend to see patients later in the course of their disease and think that it is too late for steroids to be beneficial. Maybe we are uncertain of their benefits.

So, how well do they work?

Dr. Harley Goldberg and colleagues recently published data from a randomized clinical trial exploring the efficacy of oral steroids for the treatment of acute sciatica (JAMA 2015;313:1915-23). A total of 269 adults with radicular pain for 3 months or less, an Oswestry Disability Index (ODI) of at least 30, and a herniated disk confirmed on MRI were randomized to prednisone or placebo. The prednisone dose was 60 mg for 5 days, then 40 mg for 5 days, and finally 20 mg for 5 days.

The prednisone group demonstrated significant reduction in the ODI at 3 weeks and 12 months, compared with placebo. No differences in pain or in rates of surgery were observed.

Adverse events were more common with prednisone, the most common being insomnia, increased appetite, and nervousness. No serious adverse events occurred related to treatment, and no differences were observed at 1 year.

The authors point out that the observation of a reduction in disability but no reduction in pain may be related to the fact that as patients improve functionally, they increase activity and experience more pain. Although analyses did not demonstrate a relationship between time until starting the steroids and identified effects of prednisone, clinical sense may press us to want to start them earlier in the course of disease.

Steroids might be a reasonable option in this setting, and combining them with other modalities (e.g., gabapentin) might further improve patients’ functional status and pain. As always, engaging patients in the shared decision making may help manage expectations.

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 disclosures about this article.

The other day, I received an electronic message that my patient presented to the emergency department following his attempt at lifting a relatively immovable object. The only thing apparently moved by this activity was his intervertebral disk – outward from its usual place and onto a nerve. He was quickly diagnosed with acute sciatica and treated with a healthy dose of steroids.

I enjoyed the subsequent soliloquy of the brilliance and outstanding clinical skill of our emergency department clinicians (which is true, by the way) when I saw him for follow-up. He was markedly improved.

In a moment of introspection, I questioned why we do not tend to use this strategy more in my practice, especially because it worked so well for my patient.

Perhaps it is because we are so used to dealing with medication side effects and the downstream consequences of insulin resistance in primary care that steroids make us squeamish. Perhaps it is also because we tend to see patients later in the course of their disease and think that it is too late for steroids to be beneficial. Maybe we are uncertain of their benefits.

So, how well do they work?

Dr. Harley Goldberg and colleagues recently published data from a randomized clinical trial exploring the efficacy of oral steroids for the treatment of acute sciatica (JAMA 2015;313:1915-23). A total of 269 adults with radicular pain for 3 months or less, an Oswestry Disability Index (ODI) of at least 30, and a herniated disk confirmed on MRI were randomized to prednisone or placebo. The prednisone dose was 60 mg for 5 days, then 40 mg for 5 days, and finally 20 mg for 5 days.

The prednisone group demonstrated significant reduction in the ODI at 3 weeks and 12 months, compared with placebo. No differences in pain or in rates of surgery were observed.

Adverse events were more common with prednisone, the most common being insomnia, increased appetite, and nervousness. No serious adverse events occurred related to treatment, and no differences were observed at 1 year.

The authors point out that the observation of a reduction in disability but no reduction in pain may be related to the fact that as patients improve functionally, they increase activity and experience more pain. Although analyses did not demonstrate a relationship between time until starting the steroids and identified effects of prednisone, clinical sense may press us to want to start them earlier in the course of disease.

Steroids might be a reasonable option in this setting, and combining them with other modalities (e.g., gabapentin) might further improve patients’ functional status and pain. As always, engaging patients in the shared decision making may help manage expectations.

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 disclosures about this article.

The other day, I received an electronic message that my patient presented to the emergency department following his attempt at lifting a relatively immovable object. The only thing apparently moved by this activity was his intervertebral disk – outward from its usual place and onto a nerve. He was quickly diagnosed with acute sciatica and treated with a healthy dose of steroids.

I enjoyed the subsequent soliloquy of the brilliance and outstanding clinical skill of our emergency department clinicians (which is true, by the way) when I saw him for follow-up. He was markedly improved.

In a moment of introspection, I questioned why we do not tend to use this strategy more in my practice, especially because it worked so well for my patient.

Perhaps it is because we are so used to dealing with medication side effects and the downstream consequences of insulin resistance in primary care that steroids make us squeamish. Perhaps it is also because we tend to see patients later in the course of their disease and think that it is too late for steroids to be beneficial. Maybe we are uncertain of their benefits.

So, how well do they work?

Dr. Harley Goldberg and colleagues recently published data from a randomized clinical trial exploring the efficacy of oral steroids for the treatment of acute sciatica (JAMA 2015;313:1915-23). A total of 269 adults with radicular pain for 3 months or less, an Oswestry Disability Index (ODI) of at least 30, and a herniated disk confirmed on MRI were randomized to prednisone or placebo. The prednisone dose was 60 mg for 5 days, then 40 mg for 5 days, and finally 20 mg for 5 days.

The prednisone group demonstrated significant reduction in the ODI at 3 weeks and 12 months, compared with placebo. No differences in pain or in rates of surgery were observed.

Adverse events were more common with prednisone, the most common being insomnia, increased appetite, and nervousness. No serious adverse events occurred related to treatment, and no differences were observed at 1 year.

The authors point out that the observation of a reduction in disability but no reduction in pain may be related to the fact that as patients improve functionally, they increase activity and experience more pain. Although analyses did not demonstrate a relationship between time until starting the steroids and identified effects of prednisone, clinical sense may press us to want to start them earlier in the course of disease.

Steroids might be a reasonable option in this setting, and combining them with other modalities (e.g., gabapentin) might further improve patients’ functional status and pain. As always, engaging patients in the shared decision making may help manage expectations.

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 disclosures about this article.

As the obesity epidemic continues to rage unabated and diabetes takes its toll on nerves, I am seeing an increase in diabetic foot ulcers.

Traditionally, we have used topical therapies and dressings and pressure relief through accommodative footwear. This usually produces moderate to no effect in many of my patients. Perhaps this is because we are not monitoring in the clinic every other day, or patients are having a difficult time adhering to the complex wound care regimens we prescribe.

Then along came MIST, a proprietary, noncontact ultrasound device delivering low-frequency/low-intensity ultrasound waves via atomized sterile saline. Researchers at our institution have published data suggesting the efficacy of this treatment.

You’ll notice these data are far from new. Sorry to be late to the party, but what is new is my own case series of patients who have done astoundingly well with this therapy.

MIST Therapy heals by activating fibroblasts, reducing bacterial count, and disrupting that pernicious biofilm. The recommended regimen is three treatments per week, with treatments lasting 3-20 minutes depending on wound size. Larger wounds get longer treatments. Many centers are using this therapy exclusively when more than minimal debridement is required.

The MIST Therapy website suggests that this therapy is associated with a $2,600 cost savings over standard of care (estimated to be $10,300). In March 2013, the American Medical Association approved a CPT I code (97610) for MIST Therapy, which became effective in 2014.

Perhaps this code has resulted in more widespread use. However, my wound care colleagues said they have been using this for years prior to the code being issued, and reimbursement has not been a problem.

What I have noticed is how clean and healthy the wounds look very early in the treatment cycle. If you are not adding this therapy to your program for addressing foot ulcers, you need to. Ask your local wound care center about it, and apologize (for me) for being so late to the party.

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 disclosures.

As the obesity epidemic continues to rage unabated and diabetes takes its toll on nerves, I am seeing an increase in diabetic foot ulcers.

Traditionally, we have used topical therapies and dressings and pressure relief through accommodative footwear. This usually produces moderate to no effect in many of my patients. Perhaps this is because we are not monitoring in the clinic every other day, or patients are having a difficult time adhering to the complex wound care regimens we prescribe.

Then along came MIST, a proprietary, noncontact ultrasound device delivering low-frequency/low-intensity ultrasound waves via atomized sterile saline. Researchers at our institution have published data suggesting the efficacy of this treatment.

You’ll notice these data are far from new. Sorry to be late to the party, but what is new is my own case series of patients who have done astoundingly well with this therapy.

MIST Therapy heals by activating fibroblasts, reducing bacterial count, and disrupting that pernicious biofilm. The recommended regimen is three treatments per week, with treatments lasting 3-20 minutes depending on wound size. Larger wounds get longer treatments. Many centers are using this therapy exclusively when more than minimal debridement is required.

The MIST Therapy website suggests that this therapy is associated with a $2,600 cost savings over standard of care (estimated to be $10,300). In March 2013, the American Medical Association approved a CPT I code (97610) for MIST Therapy, which became effective in 2014.

Perhaps this code has resulted in more widespread use. However, my wound care colleagues said they have been using this for years prior to the code being issued, and reimbursement has not been a problem.

What I have noticed is how clean and healthy the wounds look very early in the treatment cycle. If you are not adding this therapy to your program for addressing foot ulcers, you need to. Ask your local wound care center about it, and apologize (for me) for being so late to the party.

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 disclosures.

As the obesity epidemic continues to rage unabated and diabetes takes its toll on nerves, I am seeing an increase in diabetic foot ulcers.

Traditionally, we have used topical therapies and dressings and pressure relief through accommodative footwear. This usually produces moderate to no effect in many of my patients. Perhaps this is because we are not monitoring in the clinic every other day, or patients are having a difficult time adhering to the complex wound care regimens we prescribe.

Then along came MIST, a proprietary, noncontact ultrasound device delivering low-frequency/low-intensity ultrasound waves via atomized sterile saline. Researchers at our institution have published data suggesting the efficacy of this treatment.

You’ll notice these data are far from new. Sorry to be late to the party, but what is new is my own case series of patients who have done astoundingly well with this therapy.

MIST Therapy heals by activating fibroblasts, reducing bacterial count, and disrupting that pernicious biofilm. The recommended regimen is three treatments per week, with treatments lasting 3-20 minutes depending on wound size. Larger wounds get longer treatments. Many centers are using this therapy exclusively when more than minimal debridement is required.

The MIST Therapy website suggests that this therapy is associated with a $2,600 cost savings over standard of care (estimated to be $10,300). In March 2013, the American Medical Association approved a CPT I code (97610) for MIST Therapy, which became effective in 2014.

Perhaps this code has resulted in more widespread use. However, my wound care colleagues said they have been using this for years prior to the code being issued, and reimbursement has not been a problem.

What I have noticed is how clean and healthy the wounds look very early in the treatment cycle. If you are not adding this therapy to your program for addressing foot ulcers, you need to. Ask your local wound care center about it, and apologize (for me) for being so late to the party.

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 disclosures.

Attention deficit/hyperactivity disorder (ADHD) has been identified in children, and appropriate treatments studied now for over half a century. The vast majority of cases that present for treatment do so after the child starts school and concerns are raised about ability to manage academics. Yet, when asked when the symptoms first began, many parents will describe onset prior to the school years – in the preschool period. But identification of ADHD in preschoolers can be difficult because of the developmental changes that are ongoing during the period from 3 to 5 years. Many of the symptoms that one would attribute to ADHD, such as increased motor activity, inattention, and distractibility are commonplace in this age group. Furthermore, some behaviors commonly associated with ADHD, such as emotional lability and obstinacy, are nearly synonymous with being a preschooler. So, how is the diagnosis made? When is it appropriate to treat? And what would that treatment look like? The following case, where symptoms of preschool ADHD go beyond typical development, provides some guides for treatment based on the evolving literature regarding preschool ADHD.

Case Summary

Johnny is a 4-year-old boy who was the product of a complicated pregnancy and delivery. Born at 35 weeks to a 17-year-old mother with a history of tobacco use disorder and depression, he spent several weeks in the special care nursery before leaving the hospital with his mother. His early temperament was described as being “difficult” with frequent episodes of colic and trouble establishing a sleep routine. His father had a history of conduct problems and school failure, and would come in and out of the family for the first 3 years. Lately, he had moved in with Johnny and his mother, and they were trying to “make a go of it.” Johnny had been slightly behind in his developmental milestones – particularly his language – but by 4 years he was able to speak in simple sentences, was able to name his colors, and had started copying circles and squares.

His parents bring Johnny in for an appointment that they made specifically to discuss his activity level and the question of ADHD, which has been brought up by multiple family members and his preschool teacher. They describe some behaviors that you have not heard about previously because they had assumed that “this is what boys did.” At age 3 years, he impulsively ran into the road after being told “no” and was nearly struck by a car. He continually tries to put things into the toaster, and they have had to get “industrial strength” plug covers because he tries to pry them off with a kitchen knife. On multiple occasions, his mother has locked herself in her bedroom because he wouldn’t stop talking to her and she couldn’t stand it anymore. When this happens, she checks often to make sure Johnny is safe, but then calls Johnny’s father home from his job as a delivery driver because she’s at her limit. In fact, Johnny’s father has been called to the preschool to bring Johnny home so many times that his father is in danger of losing his job. While Johnny appears to be a good athlete, he is often picked last for teams because he doesn’t pay attention in the game and likes to “play his own game” of tackling the other children. The stress of raising Johnny is weighing on the parents’ relationship, and Johnny’s father is considering moving out again. The parents ask for an assessment and treatment, preferably with medication.

Case Discussion

Johnny very likely has ADHD. However, to take appropriate caution in the diagnosis, one would consider that he needs to have six of nine criteria of inattention (being careless, difficulty sustaining attention, not listening, not following through, avoiding hard mental tasks, not organizing, losing important items, being easily distractible, and being forgetful) and/or six of nine criteria of hyperactivity/impulsivity (squirming/fidgeting, can’t stay seated, running or climbing excessively, can’t play quietly, “driven by a motor,” talking excessively, blurting out answers, not waiting his turn, and interrupting/intruding on others). As with school-aged ADHD, there need to be symptoms that are frequent (“often”) and that interfere with home, academic, or occupational function. One must take into account the base rate for these symptoms in preschoolers. For example, Willoughby and colleagues (J. Abnorm. Child Psychol. 2012;40:1301-12) demonstrated that at age 4 years, 26.3% of children fidget or squirm, 39.5% act as if “driven by a motor,” 46.3% talk excessively, 28.8% are easily distracted, and 25.4% have difficult waiting their turn. In fact, on average, a 4-year-old will have 1.3 inattentive items and 2.4 hyperactive-impulsive items. Still, Johnny seems to have more than his fair share. This can be validated by a) doing a careful evaluation over time using multiple informants, b) taking a family history, c) looking at developmental signs and ruling out other developmental disorders, d) making physical observations in the office (although these can be deceiving) and e) having the parents and others complete parent and caregiver checklists.

When asking parents and caregivers to complete checklists, it is crucial to make sure that these checklists look for symptoms other than just ADHD, because there are often co-occurring symptoms and disorders. These include oppositional defiant disorder, anxiety, obsessive compulsive disorder, depressive disorders, autism spectrum disorders, trauma, and learning/communication disorders. In fact, the Preschool ADHD Treatment Study (PATS) demonstrated that 71.5% of children with preschool ADHD had at least one other diagnosis and 29.7% had two or more (J. Child Adolesc. Psychopharmacol. 2007;17:563-80). Use of a broad-based instrument that captures all of these domains, in addition to attention, is warranted. In our clinic, we also assess the parents for psychopathology using the same instruments. The reason for this is, first, that family history increases the likelihood of an ADHD diagnosis and, perhaps more importantly, presence of family psychopathology makes treatment more difficult. This is because the treatment you will prescribe is going to actively involve the parents.

The treatment of choice for preschool ADHD, based on practice parameters and expert opinion, is to start with family-based behavioral treatments. There are now several empirically-based treatments that have shown efficacy for the symptoms of inattention and hyperactivity-impulsivity in preschoolers. These include Triple P (“Practitioner’s Manual for Enhanced Triple P” [Brisbane: Families International Publishing, 1998]), The Incredible Years (Webster-Stratton & Hancock, 1998), and the Revised New Forest Parent Program (Daley & Thompson, 2007), among others. If these are not available in your community, other options would be “Helping the noncompliant child: A clinician’s guide to effective parent training,” 2nd ed. (The Guilford Press: New York, 2003) or any other empirically-based parent training program. This is why it is critical to engage the parents in treatment and to refer them for treatment for their own psychopathology, if present. Furthermore, engaging the family in a program of wellness (freedom from substances, enhanced nutrition, avoidance of artificial food coloring, increased exercise), has less of a research base, but the available evidence is that it is helpful.

If medications become necessary because of safety concerns, there are few options that have a Food and Drug Administration indication. Those that do have an indication for disruptive behavior below the age of 5 years (haloperidol, dextroamphetamine, chlorpromazine, and risperidone) should not be considered as first line. The PATS study demonstrated the safety and efficacy of methylphenidate, but with optimal doses lower than those seen in school-aged children (0.7 mg/kg per day) and with increased numbers of adverse effects (11% discontinuing) (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:1284-93; J. Am. Acad. Child Adolesc. Psychiatry 2006;45:1294-303).

Because of the increased amount of side effects, medication treatment cannot be considered as the first treatment. Treatment with nonstimulants is poorly studied. Any treatment with methylphenidate would be considered off-label prescribing, which must be done with great caution and, preferably, in consultation with a child and adolescent psychiatrist.

The diagnosis and management of ADHD in the very young is tricky, but possible. Doing a comprehensive evaluation with information from multiple informants, assessing and treating the parents for psychopathology, engaging the family in wellness, and starting with behavioral management is the way to go. If you feel that medication treatment is necessary for safety of the little ones, it’s best to consult, because none of the medications with FDA indication are likely to be the answer.

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. Dr. Althoff receives no funding from pharmaceutical companies or industry. He has grant funding from the National Institute of General Medical Sciences and the Klingenstein Third Generation Foundation, and is employed, in part, by the nonprofit Research Center for Children, Youth, and Families that develops the Child Behavior Checklist and associated instruments. E-mail him at [email protected].

Attention deficit/hyperactivity disorder (ADHD) has been identified in children, and appropriate treatments studied now for over half a century. The vast majority of cases that present for treatment do so after the child starts school and concerns are raised about ability to manage academics. Yet, when asked when the symptoms first began, many parents will describe onset prior to the school years – in the preschool period. But identification of ADHD in preschoolers can be difficult because of the developmental changes that are ongoing during the period from 3 to 5 years. Many of the symptoms that one would attribute to ADHD, such as increased motor activity, inattention, and distractibility are commonplace in this age group. Furthermore, some behaviors commonly associated with ADHD, such as emotional lability and obstinacy, are nearly synonymous with being a preschooler. So, how is the diagnosis made? When is it appropriate to treat? And what would that treatment look like? The following case, where symptoms of preschool ADHD go beyond typical development, provides some guides for treatment based on the evolving literature regarding preschool ADHD.

Case Summary

Johnny is a 4-year-old boy who was the product of a complicated pregnancy and delivery. Born at 35 weeks to a 17-year-old mother with a history of tobacco use disorder and depression, he spent several weeks in the special care nursery before leaving the hospital with his mother. His early temperament was described as being “difficult” with frequent episodes of colic and trouble establishing a sleep routine. His father had a history of conduct problems and school failure, and would come in and out of the family for the first 3 years. Lately, he had moved in with Johnny and his mother, and they were trying to “make a go of it.” Johnny had been slightly behind in his developmental milestones – particularly his language – but by 4 years he was able to speak in simple sentences, was able to name his colors, and had started copying circles and squares.

His parents bring Johnny in for an appointment that they made specifically to discuss his activity level and the question of ADHD, which has been brought up by multiple family members and his preschool teacher. They describe some behaviors that you have not heard about previously because they had assumed that “this is what boys did.” At age 3 years, he impulsively ran into the road after being told “no” and was nearly struck by a car. He continually tries to put things into the toaster, and they have had to get “industrial strength” plug covers because he tries to pry them off with a kitchen knife. On multiple occasions, his mother has locked herself in her bedroom because he wouldn’t stop talking to her and she couldn’t stand it anymore. When this happens, she checks often to make sure Johnny is safe, but then calls Johnny’s father home from his job as a delivery driver because she’s at her limit. In fact, Johnny’s father has been called to the preschool to bring Johnny home so many times that his father is in danger of losing his job. While Johnny appears to be a good athlete, he is often picked last for teams because he doesn’t pay attention in the game and likes to “play his own game” of tackling the other children. The stress of raising Johnny is weighing on the parents’ relationship, and Johnny’s father is considering moving out again. The parents ask for an assessment and treatment, preferably with medication.

Case Discussion

Johnny very likely has ADHD. However, to take appropriate caution in the diagnosis, one would consider that he needs to have six of nine criteria of inattention (being careless, difficulty sustaining attention, not listening, not following through, avoiding hard mental tasks, not organizing, losing important items, being easily distractible, and being forgetful) and/or six of nine criteria of hyperactivity/impulsivity (squirming/fidgeting, can’t stay seated, running or climbing excessively, can’t play quietly, “driven by a motor,” talking excessively, blurting out answers, not waiting his turn, and interrupting/intruding on others). As with school-aged ADHD, there need to be symptoms that are frequent (“often”) and that interfere with home, academic, or occupational function. One must take into account the base rate for these symptoms in preschoolers. For example, Willoughby and colleagues (J. Abnorm. Child Psychol. 2012;40:1301-12) demonstrated that at age 4 years, 26.3% of children fidget or squirm, 39.5% act as if “driven by a motor,” 46.3% talk excessively, 28.8% are easily distracted, and 25.4% have difficult waiting their turn. In fact, on average, a 4-year-old will have 1.3 inattentive items and 2.4 hyperactive-impulsive items. Still, Johnny seems to have more than his fair share. This can be validated by a) doing a careful evaluation over time using multiple informants, b) taking a family history, c) looking at developmental signs and ruling out other developmental disorders, d) making physical observations in the office (although these can be deceiving) and e) having the parents and others complete parent and caregiver checklists.

When asking parents and caregivers to complete checklists, it is crucial to make sure that these checklists look for symptoms other than just ADHD, because there are often co-occurring symptoms and disorders. These include oppositional defiant disorder, anxiety, obsessive compulsive disorder, depressive disorders, autism spectrum disorders, trauma, and learning/communication disorders. In fact, the Preschool ADHD Treatment Study (PATS) demonstrated that 71.5% of children with preschool ADHD had at least one other diagnosis and 29.7% had two or more (J. Child Adolesc. Psychopharmacol. 2007;17:563-80). Use of a broad-based instrument that captures all of these domains, in addition to attention, is warranted. In our clinic, we also assess the parents for psychopathology using the same instruments. The reason for this is, first, that family history increases the likelihood of an ADHD diagnosis and, perhaps more importantly, presence of family psychopathology makes treatment more difficult. This is because the treatment you will prescribe is going to actively involve the parents.

The treatment of choice for preschool ADHD, based on practice parameters and expert opinion, is to start with family-based behavioral treatments. There are now several empirically-based treatments that have shown efficacy for the symptoms of inattention and hyperactivity-impulsivity in preschoolers. These include Triple P (“Practitioner’s Manual for Enhanced Triple P” [Brisbane: Families International Publishing, 1998]), The Incredible Years (Webster-Stratton & Hancock, 1998), and the Revised New Forest Parent Program (Daley & Thompson, 2007), among others. If these are not available in your community, other options would be “Helping the noncompliant child: A clinician’s guide to effective parent training,” 2nd ed. (The Guilford Press: New York, 2003) or any other empirically-based parent training program. This is why it is critical to engage the parents in treatment and to refer them for treatment for their own psychopathology, if present. Furthermore, engaging the family in a program of wellness (freedom from substances, enhanced nutrition, avoidance of artificial food coloring, increased exercise), has less of a research base, but the available evidence is that it is helpful.

If medications become necessary because of safety concerns, there are few options that have a Food and Drug Administration indication. Those that do have an indication for disruptive behavior below the age of 5 years (haloperidol, dextroamphetamine, chlorpromazine, and risperidone) should not be considered as first line. The PATS study demonstrated the safety and efficacy of methylphenidate, but with optimal doses lower than those seen in school-aged children (0.7 mg/kg per day) and with increased numbers of adverse effects (11% discontinuing) (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:1284-93; J. Am. Acad. Child Adolesc. Psychiatry 2006;45:1294-303).

Because of the increased amount of side effects, medication treatment cannot be considered as the first treatment. Treatment with nonstimulants is poorly studied. Any treatment with methylphenidate would be considered off-label prescribing, which must be done with great caution and, preferably, in consultation with a child and adolescent psychiatrist.

The diagnosis and management of ADHD in the very young is tricky, but possible. Doing a comprehensive evaluation with information from multiple informants, assessing and treating the parents for psychopathology, engaging the family in wellness, and starting with behavioral management is the way to go. If you feel that medication treatment is necessary for safety of the little ones, it’s best to consult, because none of the medications with FDA indication are likely to be the answer.

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. Dr. Althoff receives no funding from pharmaceutical companies or industry. He has grant funding from the National Institute of General Medical Sciences and the Klingenstein Third Generation Foundation, and is employed, in part, by the nonprofit Research Center for Children, Youth, and Families that develops the Child Behavior Checklist and associated instruments. E-mail him at [email protected].

Attention deficit/hyperactivity disorder (ADHD) has been identified in children, and appropriate treatments studied now for over half a century. The vast majority of cases that present for treatment do so after the child starts school and concerns are raised about ability to manage academics. Yet, when asked when the symptoms first began, many parents will describe onset prior to the school years – in the preschool period. But identification of ADHD in preschoolers can be difficult because of the developmental changes that are ongoing during the period from 3 to 5 years. Many of the symptoms that one would attribute to ADHD, such as increased motor activity, inattention, and distractibility are commonplace in this age group. Furthermore, some behaviors commonly associated with ADHD, such as emotional lability and obstinacy, are nearly synonymous with being a preschooler. So, how is the diagnosis made? When is it appropriate to treat? And what would that treatment look like? The following case, where symptoms of preschool ADHD go beyond typical development, provides some guides for treatment based on the evolving literature regarding preschool ADHD.

Case Summary

Johnny is a 4-year-old boy who was the product of a complicated pregnancy and delivery. Born at 35 weeks to a 17-year-old mother with a history of tobacco use disorder and depression, he spent several weeks in the special care nursery before leaving the hospital with his mother. His early temperament was described as being “difficult” with frequent episodes of colic and trouble establishing a sleep routine. His father had a history of conduct problems and school failure, and would come in and out of the family for the first 3 years. Lately, he had moved in with Johnny and his mother, and they were trying to “make a go of it.” Johnny had been slightly behind in his developmental milestones – particularly his language – but by 4 years he was able to speak in simple sentences, was able to name his colors, and had started copying circles and squares.

His parents bring Johnny in for an appointment that they made specifically to discuss his activity level and the question of ADHD, which has been brought up by multiple family members and his preschool teacher. They describe some behaviors that you have not heard about previously because they had assumed that “this is what boys did.” At age 3 years, he impulsively ran into the road after being told “no” and was nearly struck by a car. He continually tries to put things into the toaster, and they have had to get “industrial strength” plug covers because he tries to pry them off with a kitchen knife. On multiple occasions, his mother has locked herself in her bedroom because he wouldn’t stop talking to her and she couldn’t stand it anymore. When this happens, she checks often to make sure Johnny is safe, but then calls Johnny’s father home from his job as a delivery driver because she’s at her limit. In fact, Johnny’s father has been called to the preschool to bring Johnny home so many times that his father is in danger of losing his job. While Johnny appears to be a good athlete, he is often picked last for teams because he doesn’t pay attention in the game and likes to “play his own game” of tackling the other children. The stress of raising Johnny is weighing on the parents’ relationship, and Johnny’s father is considering moving out again. The parents ask for an assessment and treatment, preferably with medication.

Case Discussion

Johnny very likely has ADHD. However, to take appropriate caution in the diagnosis, one would consider that he needs to have six of nine criteria of inattention (being careless, difficulty sustaining attention, not listening, not following through, avoiding hard mental tasks, not organizing, losing important items, being easily distractible, and being forgetful) and/or six of nine criteria of hyperactivity/impulsivity (squirming/fidgeting, can’t stay seated, running or climbing excessively, can’t play quietly, “driven by a motor,” talking excessively, blurting out answers, not waiting his turn, and interrupting/intruding on others). As with school-aged ADHD, there need to be symptoms that are frequent (“often”) and that interfere with home, academic, or occupational function. One must take into account the base rate for these symptoms in preschoolers. For example, Willoughby and colleagues (J. Abnorm. Child Psychol. 2012;40:1301-12) demonstrated that at age 4 years, 26.3% of children fidget or squirm, 39.5% act as if “driven by a motor,” 46.3% talk excessively, 28.8% are easily distracted, and 25.4% have difficult waiting their turn. In fact, on average, a 4-year-old will have 1.3 inattentive items and 2.4 hyperactive-impulsive items. Still, Johnny seems to have more than his fair share. This can be validated by a) doing a careful evaluation over time using multiple informants, b) taking a family history, c) looking at developmental signs and ruling out other developmental disorders, d) making physical observations in the office (although these can be deceiving) and e) having the parents and others complete parent and caregiver checklists.

When asking parents and caregivers to complete checklists, it is crucial to make sure that these checklists look for symptoms other than just ADHD, because there are often co-occurring symptoms and disorders. These include oppositional defiant disorder, anxiety, obsessive compulsive disorder, depressive disorders, autism spectrum disorders, trauma, and learning/communication disorders. In fact, the Preschool ADHD Treatment Study (PATS) demonstrated that 71.5% of children with preschool ADHD had at least one other diagnosis and 29.7% had two or more (J. Child Adolesc. Psychopharmacol. 2007;17:563-80). Use of a broad-based instrument that captures all of these domains, in addition to attention, is warranted. In our clinic, we also assess the parents for psychopathology using the same instruments. The reason for this is, first, that family history increases the likelihood of an ADHD diagnosis and, perhaps more importantly, presence of family psychopathology makes treatment more difficult. This is because the treatment you will prescribe is going to actively involve the parents.

The treatment of choice for preschool ADHD, based on practice parameters and expert opinion, is to start with family-based behavioral treatments. There are now several empirically-based treatments that have shown efficacy for the symptoms of inattention and hyperactivity-impulsivity in preschoolers. These include Triple P (“Practitioner’s Manual for Enhanced Triple P” [Brisbane: Families International Publishing, 1998]), The Incredible Years (Webster-Stratton & Hancock, 1998), and the Revised New Forest Parent Program (Daley & Thompson, 2007), among others. If these are not available in your community, other options would be “Helping the noncompliant child: A clinician’s guide to effective parent training,” 2nd ed. (The Guilford Press: New York, 2003) or any other empirically-based parent training program. This is why it is critical to engage the parents in treatment and to refer them for treatment for their own psychopathology, if present. Furthermore, engaging the family in a program of wellness (freedom from substances, enhanced nutrition, avoidance of artificial food coloring, increased exercise), has less of a research base, but the available evidence is that it is helpful.

If medications become necessary because of safety concerns, there are few options that have a Food and Drug Administration indication. Those that do have an indication for disruptive behavior below the age of 5 years (haloperidol, dextroamphetamine, chlorpromazine, and risperidone) should not be considered as first line. The PATS study demonstrated the safety and efficacy of methylphenidate, but with optimal doses lower than those seen in school-aged children (0.7 mg/kg per day) and with increased numbers of adverse effects (11% discontinuing) (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:1284-93; J. Am. Acad. Child Adolesc. Psychiatry 2006;45:1294-303).

Because of the increased amount of side effects, medication treatment cannot be considered as the first treatment. Treatment with nonstimulants is poorly studied. Any treatment with methylphenidate would be considered off-label prescribing, which must be done with great caution and, preferably, in consultation with a child and adolescent psychiatrist.

The diagnosis and management of ADHD in the very young is tricky, but possible. Doing a comprehensive evaluation with information from multiple informants, assessing and treating the parents for psychopathology, engaging the family in wellness, and starting with behavioral management is the way to go. If you feel that medication treatment is necessary for safety of the little ones, it’s best to consult, because none of the medications with FDA indication are likely to be the answer.

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. Dr. Althoff receives no funding from pharmaceutical companies or industry. He has grant funding from the National Institute of General Medical Sciences and the Klingenstein Third Generation Foundation, and is employed, in part, by the nonprofit Research Center for Children, Youth, and Families that develops the Child Behavior Checklist and associated instruments. E-mail him at [email protected].

I freely admit I am obsessed with research articles about eating habits. I hold out hope that this will eventually unlock the magic bullet to cure us of the modern plague of obesity. At a certain level, our patients need us to be captivated by such literature. We should feel fairly comfortable with the common knowledge that diets are effective if you stay on them and reducing the caloric density of foods can result in meaningful weight loss.

But what about how quickly we eat? In our fast-paced, heavily caffeinated society, we seem to shovel rather than chew. Ever since I was a medical resident, I have practically inhaled my food. Perchance I am operating under the erroneous and illogical assumption that if I don’t taste the food it won’t register as calories. True science has now enlightened me to the error in my thinking.

Dr. Eric Robinson and his colleagues conducted a brilliant systematic review of the impact of eating rate on energy intake and hunger (Am. J. Clin. Nutr. 2014;100:123-51). They included studies for which there was at least one study arm in which participants ate a meal at a statistically significant slower rate than that of a different arm. Twenty-two studies met the criteria for inclusion.

Available evidence suggests that a slower eating rate is associated with lower intake, compared with faster eating. The effect on caloric intake was observed regardless of the intervention used to modify the eating rate, such as modifying food from soft (fast rate) to hard (slow rate) or verbal instruction. No relationship was observed between eating rate and hunger at the end of the meal or several hours later.

Intriguing to me is the hypothesis that eating rate likely affects intake through the duration and intensity of oral exposure to taste. Previous studies have shown that, when eating rate is held constant, increasing sensory exposure leads to a lower energy intake. This seems to relate to our innate wiring that gives us a “sensory specific satiety.” In my understanding, sensory specific satiety turns off appetitive drive when you have had too much chocolate or too many potato chips and you feel slightly ill. Unfortunately, the food industry is on to this game and they have designed foods to be perfectly balanced to not render satiety. These foods can tragically be eaten ceaselessly.

Take-home message: If your patients cannot control the bad foods they eat, they should try to eat them more slowly.

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.

I freely admit I am obsessed with research articles about eating habits. I hold out hope that this will eventually unlock the magic bullet to cure us of the modern plague of obesity. At a certain level, our patients need us to be captivated by such literature. We should feel fairly comfortable with the common knowledge that diets are effective if you stay on them and reducing the caloric density of foods can result in meaningful weight loss.

But what about how quickly we eat? In our fast-paced, heavily caffeinated society, we seem to shovel rather than chew. Ever since I was a medical resident, I have practically inhaled my food. Perchance I am operating under the erroneous and illogical assumption that if I don’t taste the food it won’t register as calories. True science has now enlightened me to the error in my thinking.

Dr. Eric Robinson and his colleagues conducted a brilliant systematic review of the impact of eating rate on energy intake and hunger (Am. J. Clin. Nutr. 2014;100:123-51). They included studies for which there was at least one study arm in which participants ate a meal at a statistically significant slower rate than that of a different arm. Twenty-two studies met the criteria for inclusion.

Available evidence suggests that a slower eating rate is associated with lower intake, compared with faster eating. The effect on caloric intake was observed regardless of the intervention used to modify the eating rate, such as modifying food from soft (fast rate) to hard (slow rate) or verbal instruction. No relationship was observed between eating rate and hunger at the end of the meal or several hours later.

Intriguing to me is the hypothesis that eating rate likely affects intake through the duration and intensity of oral exposure to taste. Previous studies have shown that, when eating rate is held constant, increasing sensory exposure leads to a lower energy intake. This seems to relate to our innate wiring that gives us a “sensory specific satiety.” In my understanding, sensory specific satiety turns off appetitive drive when you have had too much chocolate or too many potato chips and you feel slightly ill. Unfortunately, the food industry is on to this game and they have designed foods to be perfectly balanced to not render satiety. These foods can tragically be eaten ceaselessly.

Take-home message: If your patients cannot control the bad foods they eat, they should try to eat them more slowly.

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.

I freely admit I am obsessed with research articles about eating habits. I hold out hope that this will eventually unlock the magic bullet to cure us of the modern plague of obesity. At a certain level, our patients need us to be captivated by such literature. We should feel fairly comfortable with the common knowledge that diets are effective if you stay on them and reducing the caloric density of foods can result in meaningful weight loss.

But what about how quickly we eat? In our fast-paced, heavily caffeinated society, we seem to shovel rather than chew. Ever since I was a medical resident, I have practically inhaled my food. Perchance I am operating under the erroneous and illogical assumption that if I don’t taste the food it won’t register as calories. True science has now enlightened me to the error in my thinking.

Dr. Eric Robinson and his colleagues conducted a brilliant systematic review of the impact of eating rate on energy intake and hunger (Am. J. Clin. Nutr. 2014;100:123-51). They included studies for which there was at least one study arm in which participants ate a meal at a statistically significant slower rate than that of a different arm. Twenty-two studies met the criteria for inclusion.

Available evidence suggests that a slower eating rate is associated with lower intake, compared with faster eating. The effect on caloric intake was observed regardless of the intervention used to modify the eating rate, such as modifying food from soft (fast rate) to hard (slow rate) or verbal instruction. No relationship was observed between eating rate and hunger at the end of the meal or several hours later.

Intriguing to me is the hypothesis that eating rate likely affects intake through the duration and intensity of oral exposure to taste. Previous studies have shown that, when eating rate is held constant, increasing sensory exposure leads to a lower energy intake. This seems to relate to our innate wiring that gives us a “sensory specific satiety.” In my understanding, sensory specific satiety turns off appetitive drive when you have had too much chocolate or too many potato chips and you feel slightly ill. Unfortunately, the food industry is on to this game and they have designed foods to be perfectly balanced to not render satiety. These foods can tragically be eaten ceaselessly.

Take-home message: If your patients cannot control the bad foods they eat, they should try to eat them more slowly.

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.

At the risk of stating the obvious, our patients are becoming increasingly complex. Life is prolonged and comorbidities accumulate, creating dizzying laundry lists of medical problems.

Within the context of clinical or, increasingly, nonreimbursed telephonic or electronic visits, we attack the medical problem with the worst severity in an attempt to tamp it down to the level of its comorbid brethren.

Almost without exception, depression rears its ugly head in our sickest patients. Antidepressants will be started and added to the three pages (double-spaced, with 1-inch margins) of medications.

But in all of these patients, are we treating the disease or just the symptom? What if inflammation is causing the depression? Will reduction of inflammation treat the depression?

Dr. Ole Köhler of Aarhus University Hospital, Denmark, and his colleagues conducted a systematic review on the antidepressant effects of anti-inflammatory medications (JAMA Psychiatry 2014;71:1381-91). Fourteen trials informed the meta-analysis, 10 that evaluated NSAID drugs (for example, celecoxib, naproxen, ibuprofen), and 4 that investigated cytokine inhibitors (for example, etanercept, infliximab). Six of the 10 NSAID studies evaluated NSAIDs as monotherapy. All four of the cytokine-inhibitor trials evaluated them as monotherapy. Length of treatment was between 6 and 12 weeks.

The pooled effect suggests that anti-inflammatory treatment reduced depressive symptoms. Celecoxib seemed to have the strongest effect on remission and clinical response. No increase in adverse events was reported.

We know that proinflammatory drugs can induce depression. So the opposite is quite possibly true, and these data suggest it to be so. Findings suggest that reducing the inflammatory state among our patients with depression may be a useful adjunct to antidepressant therapy, at least in the initial period.

Whatever we can do to facilitate depressive symptom relief seems a worthy goal. So, here again, we could tell our patients presenting with depression to take two (with an SSRI, perhaps) and call us in the morning. But how best to do this and in what patients remains uncertain.

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.

At the risk of stating the obvious, our patients are becoming increasingly complex. Life is prolonged and comorbidities accumulate, creating dizzying laundry lists of medical problems.

Within the context of clinical or, increasingly, nonreimbursed telephonic or electronic visits, we attack the medical problem with the worst severity in an attempt to tamp it down to the level of its comorbid brethren.

Almost without exception, depression rears its ugly head in our sickest patients. Antidepressants will be started and added to the three pages (double-spaced, with 1-inch margins) of medications.

But in all of these patients, are we treating the disease or just the symptom? What if inflammation is causing the depression? Will reduction of inflammation treat the depression?

Dr. Ole Köhler of Aarhus University Hospital, Denmark, and his colleagues conducted a systematic review on the antidepressant effects of anti-inflammatory medications (JAMA Psychiatry 2014;71:1381-91). Fourteen trials informed the meta-analysis, 10 that evaluated NSAID drugs (for example, celecoxib, naproxen, ibuprofen), and 4 that investigated cytokine inhibitors (for example, etanercept, infliximab). Six of the 10 NSAID studies evaluated NSAIDs as monotherapy. All four of the cytokine-inhibitor trials evaluated them as monotherapy. Length of treatment was between 6 and 12 weeks.

The pooled effect suggests that anti-inflammatory treatment reduced depressive symptoms. Celecoxib seemed to have the strongest effect on remission and clinical response. No increase in adverse events was reported.

We know that proinflammatory drugs can induce depression. So the opposite is quite possibly true, and these data suggest it to be so. Findings suggest that reducing the inflammatory state among our patients with depression may be a useful adjunct to antidepressant therapy, at least in the initial period.

Whatever we can do to facilitate depressive symptom relief seems a worthy goal. So, here again, we could tell our patients presenting with depression to take two (with an SSRI, perhaps) and call us in the morning. But how best to do this and in what patients remains uncertain.

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.

At the risk of stating the obvious, our patients are becoming increasingly complex. Life is prolonged and comorbidities accumulate, creating dizzying laundry lists of medical problems.

Within the context of clinical or, increasingly, nonreimbursed telephonic or electronic visits, we attack the medical problem with the worst severity in an attempt to tamp it down to the level of its comorbid brethren.

Almost without exception, depression rears its ugly head in our sickest patients. Antidepressants will be started and added to the three pages (double-spaced, with 1-inch margins) of medications.

But in all of these patients, are we treating the disease or just the symptom? What if inflammation is causing the depression? Will reduction of inflammation treat the depression?

Dr. Ole Köhler of Aarhus University Hospital, Denmark, and his colleagues conducted a systematic review on the antidepressant effects of anti-inflammatory medications (JAMA Psychiatry 2014;71:1381-91). Fourteen trials informed the meta-analysis, 10 that evaluated NSAID drugs (for example, celecoxib, naproxen, ibuprofen), and 4 that investigated cytokine inhibitors (for example, etanercept, infliximab). Six of the 10 NSAID studies evaluated NSAIDs as monotherapy. All four of the cytokine-inhibitor trials evaluated them as monotherapy. Length of treatment was between 6 and 12 weeks.

The pooled effect suggests that anti-inflammatory treatment reduced depressive symptoms. Celecoxib seemed to have the strongest effect on remission and clinical response. No increase in adverse events was reported.

We know that proinflammatory drugs can induce depression. So the opposite is quite possibly true, and these data suggest it to be so. Findings suggest that reducing the inflammatory state among our patients with depression may be a useful adjunct to antidepressant therapy, at least in the initial period.

Whatever we can do to facilitate depressive symptom relief seems a worthy goal. So, here again, we could tell our patients presenting with depression to take two (with an SSRI, perhaps) and call us in the morning. But how best to do this and in what patients remains uncertain.

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.

Introduction

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

Case

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

Discussion

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

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

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

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

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

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

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

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

When to consult

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

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

Introduction

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

Case

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

Discussion

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

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

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

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

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

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

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

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

When to consult

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

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

Introduction

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

Case

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

Discussion

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

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

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

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

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

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

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

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

When to consult

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

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

Over the past several years, there has been increasing amounts of research documenting the caregiving challenges that accompany the day-to-day parenting of a child with special health needs and/or chronic medical conditions. Children who are diagnosed with emotional and behavioral problems (ranging from attention-deficit/hyperactivity disorder (ADHD) to autism – which also can be considered chronic conditions), can pose parenting challenges for even the most healthy, supportive, and committed parents. From the point of receiving a diagnosis to daily management of the range of symptoms and attempting to coordinate care with various providers, the emotional stress experienced by caregivers can be quite burdensome and may affect the functioning of the entire family. In an effort to achieve successful treatment outcomes for the child, it’s important to be mindful of this emotional stress and provide parents with tools to foster their own wellness and mental health while mitigating the risk for them developing their own health concerns.

Case summary

Bridget is a 10-year-old girl who presents with her single mother for a psychiatric consultation. Since early childhood, Bridget has demonstrated an array of behaviors that have affected her ability to engage with others socially; she was thought to be a temperamentally shy and sensitive toddler, and in elementary school, her mother describes the emergence of odd mental status changes and accompanying motor movements that were later diagnosed as complex-partial epilepsy. Since this diagnosis at the age of 6 years, despite receiving various antiepileptic treatment, Bridget has continued to present with an intractable seizure disorder. She is now prescribed a combination of benzodiazepines, cannabinoids, and other antiepileptic agents, but still has marked functional impairments. Behaviorally, it appears that Bridget has experienced some regression over the years and has been recently tested to have low-average intelligence and a neurocognitive profile characterized by attentional difficulties, executive impairments, and significant processing deficits.

Because of her complicated presentation, Bridget has been unable to attend school-based academic instruction, and her escalating levels of generalized worry have limited her ability to reliably interact with individuals outside of the family. These challenges also have posed difficulties for providers to perform thorough evaluations and provide Bridget with psychosocial interventions to address her anxiety and self-regulatory deficits. All in all, Bridget is a diagnostically complicated young girl. Her mother wishes to “figure things out,” and acknowledges having trouble managing her daughter’s increasingly defiant and unpredictable behaviors. In the past, setting limits and placing stress on Bridget have been thought to be etiologically related to seizure onset. Additionally, Bridget’s mother has been unable to find her own employment while providing care for her daughter and reports that financially, she isn’t sure how she can make ends meet while providing Bridget with medical marijuana. Bridget’s mother’s composure during the evaluation is applauded (particularly when her daughter’s defiant actions are readily appreciated), but she admits to feeling “exhausted.”

Discussion

Bridget’s case illustrates not only the complexities in attempting to understand and diagnose multifaceted neuropsychiatric phenomena, but also the struggles experienced by families who are challenged economically, socially, psychologically, and emotionally as a result of their child’s difficulties. Although caregiving and parenting is rife with rewarding opportunities for many family members, the provision of such nurturance can undoubtedly place parents at risk for significant hardships. Studies have demonstrated that caregiving demands are associated with poor health outcomes in adult caregivers (Ann. Behav. Med. 1997;19:110-6), and maternal cortisol levels in mothers of older children with autism were found to be significantly lower than normal and the hormonal dysregulation was associated with their child’s behavioral profile. Such findings are similar to those recognized in combat soldiers and others who experience enduring psychological distress (J. Autism Dev. Disord. 2010; 40:457-69).

Upon meeting with Bridget, it became clear that her mother required additional support and services to help care for her daughter’s difficult needs. Through seeking a diagnosis for her daughter, Bridget’s mother also was pursuing an understanding of her daughter’s strengths and struggles, and looking to partner with a provider who might be able to help her navigate the often complicated system of care. By gathering a comprehensive family history (assessing what mom’s vulnerabilities may be for developing her own mental health issues) and thoroughly assessing her current functioning with the Adult Self-Report and the Parenting Stress Index, as a provider, I was better informed to offer family-based treatment recommendations. Through self-reporting, Bridget’s mother endorsed her own mood complaints, occasional substance use, and a constellation of anxiety-based difficulties. We had a thoughtful discussion pertaining to elements of grief, fears, and guilt, which helped to lay the foundation for later exploring how Bridget may best be cared for in the future (such as residential placement). Bridget’s mother shared that she initially felt like a failure for seeking help and not “being able to parent” her daughter; supportive techniques were used to provide her with reassurance and validation.

Using Bridget’s mother’s strengths (resiliency, being a strong advocate for her daughter), other recommendations also were offered to help her to more effectively parent her child and avoid burnout. Not inclusive of suggestions directed towards Bridget individually, these recommendations included:

• Having mom seek her own psychotherapeutic and psychiatric care. Goals of her treatment would be to support her own wellness (through exercise, mindfulness, engagement in positive activities) and focus on developing healthy relationships. By getting her own anxiety under control, assessing her own parenting and coping styles, and additionally obtaining psychoeducation about anxiety disorders in children, mom is primed to develop more successful ways to address Bridget’s defiance and avoid enabling her daughter’s excessive worry while encouraging her to be more socially active.

• Finding respite providers for Bridget. Then mom has more opportunities to seek employment and participate in other out-of-the-home activities.

• Developing a relationship with the school district. This way mom can obtain appropriate supports and accommodations for Bridget to be educated outside the home.

• Exploring community resources through local agencies. This would help mom plan for the future, examine possible sources of financial support, and perhaps most importantly, obtain a treatment team leader and care coordinator.

• Enhancing social supports. This can be done via connections to local support groups.

Clinical pearl

It’s not surprising that parents of children with special needs experience high levels of stress. Be aware of how such stress can affect a parent’s ability to care for their child, and be mindful that a child’s wellness can be significantly mediated by parental wellness and health. When designing treatment plans, routinely assess family caregivers’ stress levels (including that of siblings and fathers) and evaluate other indicators of stress (such as sleep disturbances, weight change, apathy, and expression of negative emotion). Advocate for programs and systems of care that can address both parental and child mental health issues in a coordinated manner that also enhances family cohesion, reduces social isolation, and decreases parental marginalization.

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. Contact Dr. Dickerson at [email protected].

Over the past several years, there has been increasing amounts of research documenting the caregiving challenges that accompany the day-to-day parenting of a child with special health needs and/or chronic medical conditions. Children who are diagnosed with emotional and behavioral problems (ranging from attention-deficit/hyperactivity disorder (ADHD) to autism – which also can be considered chronic conditions), can pose parenting challenges for even the most healthy, supportive, and committed parents. From the point of receiving a diagnosis to daily management of the range of symptoms and attempting to coordinate care with various providers, the emotional stress experienced by caregivers can be quite burdensome and may affect the functioning of the entire family. In an effort to achieve successful treatment outcomes for the child, it’s important to be mindful of this emotional stress and provide parents with tools to foster their own wellness and mental health while mitigating the risk for them developing their own health concerns.

Case summary

Bridget is a 10-year-old girl who presents with her single mother for a psychiatric consultation. Since early childhood, Bridget has demonstrated an array of behaviors that have affected her ability to engage with others socially; she was thought to be a temperamentally shy and sensitive toddler, and in elementary school, her mother describes the emergence of odd mental status changes and accompanying motor movements that were later diagnosed as complex-partial epilepsy. Since this diagnosis at the age of 6 years, despite receiving various antiepileptic treatment, Bridget has continued to present with an intractable seizure disorder. She is now prescribed a combination of benzodiazepines, cannabinoids, and other antiepileptic agents, but still has marked functional impairments. Behaviorally, it appears that Bridget has experienced some regression over the years and has been recently tested to have low-average intelligence and a neurocognitive profile characterized by attentional difficulties, executive impairments, and significant processing deficits.

Because of her complicated presentation, Bridget has been unable to attend school-based academic instruction, and her escalating levels of generalized worry have limited her ability to reliably interact with individuals outside of the family. These challenges also have posed difficulties for providers to perform thorough evaluations and provide Bridget with psychosocial interventions to address her anxiety and self-regulatory deficits. All in all, Bridget is a diagnostically complicated young girl. Her mother wishes to “figure things out,” and acknowledges having trouble managing her daughter’s increasingly defiant and unpredictable behaviors. In the past, setting limits and placing stress on Bridget have been thought to be etiologically related to seizure onset. Additionally, Bridget’s mother has been unable to find her own employment while providing care for her daughter and reports that financially, she isn’t sure how she can make ends meet while providing Bridget with medical marijuana. Bridget’s mother’s composure during the evaluation is applauded (particularly when her daughter’s defiant actions are readily appreciated), but she admits to feeling “exhausted.”

Discussion

Bridget’s case illustrates not only the complexities in attempting to understand and diagnose multifaceted neuropsychiatric phenomena, but also the struggles experienced by families who are challenged economically, socially, psychologically, and emotionally as a result of their child’s difficulties. Although caregiving and parenting is rife with rewarding opportunities for many family members, the provision of such nurturance can undoubtedly place parents at risk for significant hardships. Studies have demonstrated that caregiving demands are associated with poor health outcomes in adult caregivers (Ann. Behav. Med. 1997;19:110-6), and maternal cortisol levels in mothers of older children with autism were found to be significantly lower than normal and the hormonal dysregulation was associated with their child’s behavioral profile. Such findings are similar to those recognized in combat soldiers and others who experience enduring psychological distress (J. Autism Dev. Disord. 2010; 40:457-69).

Upon meeting with Bridget, it became clear that her mother required additional support and services to help care for her daughter’s difficult needs. Through seeking a diagnosis for her daughter, Bridget’s mother also was pursuing an understanding of her daughter’s strengths and struggles, and looking to partner with a provider who might be able to help her navigate the often complicated system of care. By gathering a comprehensive family history (assessing what mom’s vulnerabilities may be for developing her own mental health issues) and thoroughly assessing her current functioning with the Adult Self-Report and the Parenting Stress Index, as a provider, I was better informed to offer family-based treatment recommendations. Through self-reporting, Bridget’s mother endorsed her own mood complaints, occasional substance use, and a constellation of anxiety-based difficulties. We had a thoughtful discussion pertaining to elements of grief, fears, and guilt, which helped to lay the foundation for later exploring how Bridget may best be cared for in the future (such as residential placement). Bridget’s mother shared that she initially felt like a failure for seeking help and not “being able to parent” her daughter; supportive techniques were used to provide her with reassurance and validation.

Using Bridget’s mother’s strengths (resiliency, being a strong advocate for her daughter), other recommendations also were offered to help her to more effectively parent her child and avoid burnout. Not inclusive of suggestions directed towards Bridget individually, these recommendations included:

• Having mom seek her own psychotherapeutic and psychiatric care. Goals of her treatment would be to support her own wellness (through exercise, mindfulness, engagement in positive activities) and focus on developing healthy relationships. By getting her own anxiety under control, assessing her own parenting and coping styles, and additionally obtaining psychoeducation about anxiety disorders in children, mom is primed to develop more successful ways to address Bridget’s defiance and avoid enabling her daughter’s excessive worry while encouraging her to be more socially active.

• Finding respite providers for Bridget. Then mom has more opportunities to seek employment and participate in other out-of-the-home activities.

• Developing a relationship with the school district. This way mom can obtain appropriate supports and accommodations for Bridget to be educated outside the home.

• Exploring community resources through local agencies. This would help mom plan for the future, examine possible sources of financial support, and perhaps most importantly, obtain a treatment team leader and care coordinator.

• Enhancing social supports. This can be done via connections to local support groups.

Clinical pearl

It’s not surprising that parents of children with special needs experience high levels of stress. Be aware of how such stress can affect a parent’s ability to care for their child, and be mindful that a child’s wellness can be significantly mediated by parental wellness and health. When designing treatment plans, routinely assess family caregivers’ stress levels (including that of siblings and fathers) and evaluate other indicators of stress (such as sleep disturbances, weight change, apathy, and expression of negative emotion). Advocate for programs and systems of care that can address both parental and child mental health issues in a coordinated manner that also enhances family cohesion, reduces social isolation, and decreases parental marginalization.

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. Contact Dr. Dickerson at [email protected].

Over the past several years, there has been increasing amounts of research documenting the caregiving challenges that accompany the day-to-day parenting of a child with special health needs and/or chronic medical conditions. Children who are diagnosed with emotional and behavioral problems (ranging from attention-deficit/hyperactivity disorder (ADHD) to autism – which also can be considered chronic conditions), can pose parenting challenges for even the most healthy, supportive, and committed parents. From the point of receiving a diagnosis to daily management of the range of symptoms and attempting to coordinate care with various providers, the emotional stress experienced by caregivers can be quite burdensome and may affect the functioning of the entire family. In an effort to achieve successful treatment outcomes for the child, it’s important to be mindful of this emotional stress and provide parents with tools to foster their own wellness and mental health while mitigating the risk for them developing their own health concerns.

Case summary

Bridget is a 10-year-old girl who presents with her single mother for a psychiatric consultation. Since early childhood, Bridget has demonstrated an array of behaviors that have affected her ability to engage with others socially; she was thought to be a temperamentally shy and sensitive toddler, and in elementary school, her mother describes the emergence of odd mental status changes and accompanying motor movements that were later diagnosed as complex-partial epilepsy. Since this diagnosis at the age of 6 years, despite receiving various antiepileptic treatment, Bridget has continued to present with an intractable seizure disorder. She is now prescribed a combination of benzodiazepines, cannabinoids, and other antiepileptic agents, but still has marked functional impairments. Behaviorally, it appears that Bridget has experienced some regression over the years and has been recently tested to have low-average intelligence and a neurocognitive profile characterized by attentional difficulties, executive impairments, and significant processing deficits.

Because of her complicated presentation, Bridget has been unable to attend school-based academic instruction, and her escalating levels of generalized worry have limited her ability to reliably interact with individuals outside of the family. These challenges also have posed difficulties for providers to perform thorough evaluations and provide Bridget with psychosocial interventions to address her anxiety and self-regulatory deficits. All in all, Bridget is a diagnostically complicated young girl. Her mother wishes to “figure things out,” and acknowledges having trouble managing her daughter’s increasingly defiant and unpredictable behaviors. In the past, setting limits and placing stress on Bridget have been thought to be etiologically related to seizure onset. Additionally, Bridget’s mother has been unable to find her own employment while providing care for her daughter and reports that financially, she isn’t sure how she can make ends meet while providing Bridget with medical marijuana. Bridget’s mother’s composure during the evaluation is applauded (particularly when her daughter’s defiant actions are readily appreciated), but she admits to feeling “exhausted.”

Discussion

Bridget’s case illustrates not only the complexities in attempting to understand and diagnose multifaceted neuropsychiatric phenomena, but also the struggles experienced by families who are challenged economically, socially, psychologically, and emotionally as a result of their child’s difficulties. Although caregiving and parenting is rife with rewarding opportunities for many family members, the provision of such nurturance can undoubtedly place parents at risk for significant hardships. Studies have demonstrated that caregiving demands are associated with poor health outcomes in adult caregivers (Ann. Behav. Med. 1997;19:110-6), and maternal cortisol levels in mothers of older children with autism were found to be significantly lower than normal and the hormonal dysregulation was associated with their child’s behavioral profile. Such findings are similar to those recognized in combat soldiers and others who experience enduring psychological distress (J. Autism Dev. Disord. 2010; 40:457-69).

Upon meeting with Bridget, it became clear that her mother required additional support and services to help care for her daughter’s difficult needs. Through seeking a diagnosis for her daughter, Bridget’s mother also was pursuing an understanding of her daughter’s strengths and struggles, and looking to partner with a provider who might be able to help her navigate the often complicated system of care. By gathering a comprehensive family history (assessing what mom’s vulnerabilities may be for developing her own mental health issues) and thoroughly assessing her current functioning with the Adult Self-Report and the Parenting Stress Index, as a provider, I was better informed to offer family-based treatment recommendations. Through self-reporting, Bridget’s mother endorsed her own mood complaints, occasional substance use, and a constellation of anxiety-based difficulties. We had a thoughtful discussion pertaining to elements of grief, fears, and guilt, which helped to lay the foundation for later exploring how Bridget may best be cared for in the future (such as residential placement). Bridget’s mother shared that she initially felt like a failure for seeking help and not “being able to parent” her daughter; supportive techniques were used to provide her with reassurance and validation.

Using Bridget’s mother’s strengths (resiliency, being a strong advocate for her daughter), other recommendations also were offered to help her to more effectively parent her child and avoid burnout. Not inclusive of suggestions directed towards Bridget individually, these recommendations included:

• Having mom seek her own psychotherapeutic and psychiatric care. Goals of her treatment would be to support her own wellness (through exercise, mindfulness, engagement in positive activities) and focus on developing healthy relationships. By getting her own anxiety under control, assessing her own parenting and coping styles, and additionally obtaining psychoeducation about anxiety disorders in children, mom is primed to develop more successful ways to address Bridget’s defiance and avoid enabling her daughter’s excessive worry while encouraging her to be more socially active.

• Finding respite providers for Bridget. Then mom has more opportunities to seek employment and participate in other out-of-the-home activities.

• Developing a relationship with the school district. This way mom can obtain appropriate supports and accommodations for Bridget to be educated outside the home.

• Exploring community resources through local agencies. This would help mom plan for the future, examine possible sources of financial support, and perhaps most importantly, obtain a treatment team leader and care coordinator.

• Enhancing social supports. This can be done via connections to local support groups.

Clinical pearl

It’s not surprising that parents of children with special needs experience high levels of stress. Be aware of how such stress can affect a parent’s ability to care for their child, and be mindful that a child’s wellness can be significantly mediated by parental wellness and health. When designing treatment plans, routinely assess family caregivers’ stress levels (including that of siblings and fathers) and evaluate other indicators of stress (such as sleep disturbances, weight change, apathy, and expression of negative emotion). Advocate for programs and systems of care that can address both parental and child mental health issues in a coordinated manner that also enhances family cohesion, reduces social isolation, and decreases parental marginalization.

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. Contact Dr. Dickerson at [email protected].