Child Psychiatry Consult

Seems that none of my patients sleeps, or at least not very well. Indeed, population-based studies suggest that almost one-third of adults report difficulty initiating or maintaining sleep, waking up too early, and/or nonrestorative or poor quality of sleep.

Light-emitting electronic “e-readers” or “e-books” have exploded as a favorite medium for reading. Many of my patients tell me that when they are unable to sleep, they read. Much of this reading occurs on e-books. But artificial light can produce alerting effects and suppress melatonin. This might be causing or worsening the national insomnia epidemic.

Dr. Anne-Marie Chang and colleagues conducted a randomized, crossover study evaluating the impact of an e-book and a traditional book on sleep (PNAS 2014 Dec. 22 [doi:10.1073/pnas.1418490112]). In the study, 12 healthy young adults were randomized to two conditions: 1) reading an e-book for 4 hours before bedtime; or 2) reading a printed book for 4 hours before bedtime on 5 consecutive evenings. Participants then switched conditions.

The e-book suppressed evening levels of melatonin by 55%, whereas the printed book showed no suppression, and the e-book shifted the melatonin onset to more than 1.5 hours later. Compared with the printed book, the e-book also significantly increased sleep latency (10 minutes longer), decreased REM sleep by11 minutes, decreased evening sleepiness, and increased morning sleepiness.

But not all e-book readers are created equal. Screens of devices used in the current study emit blue light (wavelength 452 nm), the type of light most implicated in melatonin suppression. Newer “e-ink” readers do not emit this light and are “front lit,” with light cast inward rather than outward.

People struggling with insomnia should be encouraged to explore the e-ink options. The table included in the study can provide some guidance as to the type of e-book that may be most beneficial to our sleepy patients.

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. 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.

Seems that none of my patients sleeps, or at least not very well. Indeed, population-based studies suggest that almost one-third of adults report difficulty initiating or maintaining sleep, waking up too early, and/or nonrestorative or poor quality of sleep.

Light-emitting electronic “e-readers” or “e-books” have exploded as a favorite medium for reading. Many of my patients tell me that when they are unable to sleep, they read. Much of this reading occurs on e-books. But artificial light can produce alerting effects and suppress melatonin. This might be causing or worsening the national insomnia epidemic.

Dr. Anne-Marie Chang and colleagues conducted a randomized, crossover study evaluating the impact of an e-book and a traditional book on sleep (PNAS 2014 Dec. 22 [doi:10.1073/pnas.1418490112]). In the study, 12 healthy young adults were randomized to two conditions: 1) reading an e-book for 4 hours before bedtime; or 2) reading a printed book for 4 hours before bedtime on 5 consecutive evenings. Participants then switched conditions.

The e-book suppressed evening levels of melatonin by 55%, whereas the printed book showed no suppression, and the e-book shifted the melatonin onset to more than 1.5 hours later. Compared with the printed book, the e-book also significantly increased sleep latency (10 minutes longer), decreased REM sleep by11 minutes, decreased evening sleepiness, and increased morning sleepiness.

But not all e-book readers are created equal. Screens of devices used in the current study emit blue light (wavelength 452 nm), the type of light most implicated in melatonin suppression. Newer “e-ink” readers do not emit this light and are “front lit,” with light cast inward rather than outward.

People struggling with insomnia should be encouraged to explore the e-ink options. The table included in the study can provide some guidance as to the type of e-book that may be most beneficial to our sleepy patients.

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. 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.

Seems that none of my patients sleeps, or at least not very well. Indeed, population-based studies suggest that almost one-third of adults report difficulty initiating or maintaining sleep, waking up too early, and/or nonrestorative or poor quality of sleep.

Light-emitting electronic “e-readers” or “e-books” have exploded as a favorite medium for reading. Many of my patients tell me that when they are unable to sleep, they read. Much of this reading occurs on e-books. But artificial light can produce alerting effects and suppress melatonin. This might be causing or worsening the national insomnia epidemic.

Dr. Anne-Marie Chang and colleagues conducted a randomized, crossover study evaluating the impact of an e-book and a traditional book on sleep (PNAS 2014 Dec. 22 [doi:10.1073/pnas.1418490112]). In the study, 12 healthy young adults were randomized to two conditions: 1) reading an e-book for 4 hours before bedtime; or 2) reading a printed book for 4 hours before bedtime on 5 consecutive evenings. Participants then switched conditions.

The e-book suppressed evening levels of melatonin by 55%, whereas the printed book showed no suppression, and the e-book shifted the melatonin onset to more than 1.5 hours later. Compared with the printed book, the e-book also significantly increased sleep latency (10 minutes longer), decreased REM sleep by11 minutes, decreased evening sleepiness, and increased morning sleepiness.

But not all e-book readers are created equal. Screens of devices used in the current study emit blue light (wavelength 452 nm), the type of light most implicated in melatonin suppression. Newer “e-ink” readers do not emit this light and are “front lit,” with light cast inward rather than outward.

People struggling with insomnia should be encouraged to explore the e-ink options. The table included in the study can provide some guidance as to the type of e-book that may be most beneficial to our sleepy patients.

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. 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

Both the medical and lay press have directed a lot of attention lately to the treatment of children and adolescents with antipsychotic medications. The literature is clear that the number of children taking this class of medications has risen sharply since their release (Arch. Gen. Psychiatry 2006;63:679-85). What is much less clear is the degree to which this increase represents a reasonable intervention for patients in significant need versus an overuse when other strategies are more appropriate.

Case Summary

Cody is a 6-year-old boy who lives with his younger sister and single mother. The family struggles financially, and the father, who has never had much contact with his son, is currently incarcerated. Since he was a toddler, Cody has been prone to high levels of aggressive behavior and frequent, intense angry outbursts. He was asked to leave his preschool due to his behavior and now is commonly disruptive at school. His pediatrician diagnosed him with attention-deficit/hyperactivity disorder a year ago and began a trial of a psychostimulant, which made him even more irritable, and was discontinued. Cody and his mother now present with concerns that there is “something more” affecting his behavior. The pediatrician now considers whether or not treatment with an antipsychotic medication is reasonable at this point.

Discussion

The above clinical scenario represents a critical and often antagonizing moment in treatment for both the family and the treating physician, yet it is hardly uncommon. The situation often is made more complicated by the fact that what is often the first plan of action, namely referral or consultation with a child psychiatrist, can be very difficult to access.

The American Academy of Child and Adolescent Psychiatry has published online guidelines for the use of antipsychotic medication in youth (http://bit.ly/1eat7e9). Key recommendations and points from this 27-page document and 19 recommendations include the following:

• Patients being considered for treatment with an antipsychotic medication should receive a “meticulous diagnostic assessment” with any medication prescribed being part of a “multidisciplinary” treatment plan (Recommendation 1).

• Prescribers should “regularly check the current literature” regarding the scientific evidence for antipsychotic medication use (Recommendation 2).

• Antipsychotic medications are considered first-line medication treatment for bipolar disorder, schizophrenia, tics/Tourette’s, and autism. (Recommendation 2).

• Antipsychotic medications are not first-line treatment for several other diagnoses and behaviors, including disruptive behavior disorders such as ADHD, aggression, eating disorders, and post-traumatic stress disorder (PTSD). Their use should be considered only after other pharmacologic and nonpharmacologic interventions have failed (Recommendation 2).

• Antipsychotic medications are not advised for preschool-aged patients. (Recommendation 2).

• Dosing should be as low as possible and not exceed the maximum recommended dose for adults (Recommendation 4).

• Simultaneous treatment with multiple antipsychotic medications is not recommended (Recommendation 8).

• Patients should receive regular metabolic monitoring, including lab work, both before and during treatment (Recommendations 11-13).

These are rigorous guidelines that challenge even those who regularly assess and treat children with serious psychiatric disorders. The clinical and legal implications of prescribing antipsychotic medications without adhering to these guidelines will, and probably should, give many physicians pause. Further, the specific point about the need for a thorough psychiatric evaluation underlies the commonly heard recommendation that this class of medicines generally should be avoided by primary care physicians. At the same time, many pediatricians are acutely aware of how dire the clinical situation often is for these families. At this point, it can easily begin to feel very much like a “no-win” situation.

Here are some thoughts that may be useful to consider in these moments:

• Remember that many non-MD mental health professionals can offer a lot of help. Although they can’t do the prescribing themselves, referral to a psychologist or another type of therapist can be useful in getting information about a patient’s diagnosis and the degree to which nonpharmacologic options have been exhausted. If the patient is already seeing a therapist, it is certainly worthwhile to seek their advice as to whether or not antipsychotic medications are now reasonable to consider.

• Look for opportunities to talk “curbside” to a child psychiatrist. Most of us are keenly aware of how inadequate access is to child psychiatry and want to help. Indeed, many states now have specific brief consultation programs in place.

• Get the lab work. A recent study in Pediatrics reported that a baseline glucose was obtained in only 11% of youth receiving antipsychotic medication treatment (Pediatrics 2014;134:e1308-14). In addition to providing important information, this step signals to everyone involved that the decision to use these medications is not something to be taken lightly.

Case follow-up

Cody’s pediatrician decides to get a diagnostic evaluation from a psychologist, who confirms the ADHD diagnosis without associated conditions such as bipolar disorder. The psychologist recommends a course of therapy to build regulatory skills for Cody and provide the mother with some parent behavioral guidance about how to best manage Cody’s challenges and encourage health-promoting behaviors such as physical activity, reading, and a regular sleep routine. The pediatrician decides to try a second line ADHD medication, guanfacine, and the school also begins to institute an incentive plan to reinforce positive behavior. In combination, these efforts significantly reduce the level of aggression and dysregulated behavior.

Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Rettew said he has no relevant financial disclosures. Follow him on Twitter @pedipsych.

Introduction

Both the medical and lay press have directed a lot of attention lately to the treatment of children and adolescents with antipsychotic medications. The literature is clear that the number of children taking this class of medications has risen sharply since their release (Arch. Gen. Psychiatry 2006;63:679-85). What is much less clear is the degree to which this increase represents a reasonable intervention for patients in significant need versus an overuse when other strategies are more appropriate.

Case Summary

Cody is a 6-year-old boy who lives with his younger sister and single mother. The family struggles financially, and the father, who has never had much contact with his son, is currently incarcerated. Since he was a toddler, Cody has been prone to high levels of aggressive behavior and frequent, intense angry outbursts. He was asked to leave his preschool due to his behavior and now is commonly disruptive at school. His pediatrician diagnosed him with attention-deficit/hyperactivity disorder a year ago and began a trial of a psychostimulant, which made him even more irritable, and was discontinued. Cody and his mother now present with concerns that there is “something more” affecting his behavior. The pediatrician now considers whether or not treatment with an antipsychotic medication is reasonable at this point.

Discussion

The above clinical scenario represents a critical and often antagonizing moment in treatment for both the family and the treating physician, yet it is hardly uncommon. The situation often is made more complicated by the fact that what is often the first plan of action, namely referral or consultation with a child psychiatrist, can be very difficult to access.

The American Academy of Child and Adolescent Psychiatry has published online guidelines for the use of antipsychotic medication in youth (http://bit.ly/1eat7e9). Key recommendations and points from this 27-page document and 19 recommendations include the following:

• Patients being considered for treatment with an antipsychotic medication should receive a “meticulous diagnostic assessment” with any medication prescribed being part of a “multidisciplinary” treatment plan (Recommendation 1).

• Prescribers should “regularly check the current literature” regarding the scientific evidence for antipsychotic medication use (Recommendation 2).

• Antipsychotic medications are considered first-line medication treatment for bipolar disorder, schizophrenia, tics/Tourette’s, and autism. (Recommendation 2).

• Antipsychotic medications are not first-line treatment for several other diagnoses and behaviors, including disruptive behavior disorders such as ADHD, aggression, eating disorders, and post-traumatic stress disorder (PTSD). Their use should be considered only after other pharmacologic and nonpharmacologic interventions have failed (Recommendation 2).

• Antipsychotic medications are not advised for preschool-aged patients. (Recommendation 2).

• Dosing should be as low as possible and not exceed the maximum recommended dose for adults (Recommendation 4).

• Simultaneous treatment with multiple antipsychotic medications is not recommended (Recommendation 8).

• Patients should receive regular metabolic monitoring, including lab work, both before and during treatment (Recommendations 11-13).

These are rigorous guidelines that challenge even those who regularly assess and treat children with serious psychiatric disorders. The clinical and legal implications of prescribing antipsychotic medications without adhering to these guidelines will, and probably should, give many physicians pause. Further, the specific point about the need for a thorough psychiatric evaluation underlies the commonly heard recommendation that this class of medicines generally should be avoided by primary care physicians. At the same time, many pediatricians are acutely aware of how dire the clinical situation often is for these families. At this point, it can easily begin to feel very much like a “no-win” situation.

Here are some thoughts that may be useful to consider in these moments:

• Remember that many non-MD mental health professionals can offer a lot of help. Although they can’t do the prescribing themselves, referral to a psychologist or another type of therapist can be useful in getting information about a patient’s diagnosis and the degree to which nonpharmacologic options have been exhausted. If the patient is already seeing a therapist, it is certainly worthwhile to seek their advice as to whether or not antipsychotic medications are now reasonable to consider.

• Look for opportunities to talk “curbside” to a child psychiatrist. Most of us are keenly aware of how inadequate access is to child psychiatry and want to help. Indeed, many states now have specific brief consultation programs in place.

• Get the lab work. A recent study in Pediatrics reported that a baseline glucose was obtained in only 11% of youth receiving antipsychotic medication treatment (Pediatrics 2014;134:e1308-14). In addition to providing important information, this step signals to everyone involved that the decision to use these medications is not something to be taken lightly.

Case follow-up

Cody’s pediatrician decides to get a diagnostic evaluation from a psychologist, who confirms the ADHD diagnosis without associated conditions such as bipolar disorder. The psychologist recommends a course of therapy to build regulatory skills for Cody and provide the mother with some parent behavioral guidance about how to best manage Cody’s challenges and encourage health-promoting behaviors such as physical activity, reading, and a regular sleep routine. The pediatrician decides to try a second line ADHD medication, guanfacine, and the school also begins to institute an incentive plan to reinforce positive behavior. In combination, these efforts significantly reduce the level of aggression and dysregulated behavior.

Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Rettew said he has no relevant financial disclosures. Follow him on Twitter @pedipsych.

Introduction

Both the medical and lay press have directed a lot of attention lately to the treatment of children and adolescents with antipsychotic medications. The literature is clear that the number of children taking this class of medications has risen sharply since their release (Arch. Gen. Psychiatry 2006;63:679-85). What is much less clear is the degree to which this increase represents a reasonable intervention for patients in significant need versus an overuse when other strategies are more appropriate.

Case Summary

Cody is a 6-year-old boy who lives with his younger sister and single mother. The family struggles financially, and the father, who has never had much contact with his son, is currently incarcerated. Since he was a toddler, Cody has been prone to high levels of aggressive behavior and frequent, intense angry outbursts. He was asked to leave his preschool due to his behavior and now is commonly disruptive at school. His pediatrician diagnosed him with attention-deficit/hyperactivity disorder a year ago and began a trial of a psychostimulant, which made him even more irritable, and was discontinued. Cody and his mother now present with concerns that there is “something more” affecting his behavior. The pediatrician now considers whether or not treatment with an antipsychotic medication is reasonable at this point.

Discussion

The above clinical scenario represents a critical and often antagonizing moment in treatment for both the family and the treating physician, yet it is hardly uncommon. The situation often is made more complicated by the fact that what is often the first plan of action, namely referral or consultation with a child psychiatrist, can be very difficult to access.

The American Academy of Child and Adolescent Psychiatry has published online guidelines for the use of antipsychotic medication in youth (http://bit.ly/1eat7e9). Key recommendations and points from this 27-page document and 19 recommendations include the following:

• Patients being considered for treatment with an antipsychotic medication should receive a “meticulous diagnostic assessment” with any medication prescribed being part of a “multidisciplinary” treatment plan (Recommendation 1).

• Prescribers should “regularly check the current literature” regarding the scientific evidence for antipsychotic medication use (Recommendation 2).

• Antipsychotic medications are considered first-line medication treatment for bipolar disorder, schizophrenia, tics/Tourette’s, and autism. (Recommendation 2).

• Antipsychotic medications are not first-line treatment for several other diagnoses and behaviors, including disruptive behavior disorders such as ADHD, aggression, eating disorders, and post-traumatic stress disorder (PTSD). Their use should be considered only after other pharmacologic and nonpharmacologic interventions have failed (Recommendation 2).

• Antipsychotic medications are not advised for preschool-aged patients. (Recommendation 2).

• Dosing should be as low as possible and not exceed the maximum recommended dose for adults (Recommendation 4).

• Simultaneous treatment with multiple antipsychotic medications is not recommended (Recommendation 8).

• Patients should receive regular metabolic monitoring, including lab work, both before and during treatment (Recommendations 11-13).

These are rigorous guidelines that challenge even those who regularly assess and treat children with serious psychiatric disorders. The clinical and legal implications of prescribing antipsychotic medications without adhering to these guidelines will, and probably should, give many physicians pause. Further, the specific point about the need for a thorough psychiatric evaluation underlies the commonly heard recommendation that this class of medicines generally should be avoided by primary care physicians. At the same time, many pediatricians are acutely aware of how dire the clinical situation often is for these families. At this point, it can easily begin to feel very much like a “no-win” situation.

Here are some thoughts that may be useful to consider in these moments:

• Remember that many non-MD mental health professionals can offer a lot of help. Although they can’t do the prescribing themselves, referral to a psychologist or another type of therapist can be useful in getting information about a patient’s diagnosis and the degree to which nonpharmacologic options have been exhausted. If the patient is already seeing a therapist, it is certainly worthwhile to seek their advice as to whether or not antipsychotic medications are now reasonable to consider.

• Look for opportunities to talk “curbside” to a child psychiatrist. Most of us are keenly aware of how inadequate access is to child psychiatry and want to help. Indeed, many states now have specific brief consultation programs in place.

• Get the lab work. A recent study in Pediatrics reported that a baseline glucose was obtained in only 11% of youth receiving antipsychotic medication treatment (Pediatrics 2014;134:e1308-14). In addition to providing important information, this step signals to everyone involved that the decision to use these medications is not something to be taken lightly.

Case follow-up

Cody’s pediatrician decides to get a diagnostic evaluation from a psychologist, who confirms the ADHD diagnosis without associated conditions such as bipolar disorder. The psychologist recommends a course of therapy to build regulatory skills for Cody and provide the mother with some parent behavioral guidance about how to best manage Cody’s challenges and encourage health-promoting behaviors such as physical activity, reading, and a regular sleep routine. The pediatrician decides to try a second line ADHD medication, guanfacine, and the school also begins to institute an incentive plan to reinforce positive behavior. In combination, these efforts significantly reduce the level of aggression and dysregulated behavior.

Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Rettew said he has no relevant financial disclosures. Follow him on Twitter @pedipsych.

While typing this column, I could not recall the last time I saw a patient with “tennis elbow” (lateral epicondylitis) from actual tennis. Lateral epicondylitis peaks between the ages of 30 and 65 years and affects about 1.3% of this group – the vast majority of whom, I am quite suddenly convinced, do not play tennis. Pain is worse with wrist extension and typically affects the dominant hand. The most likely etiology is repeated microtrauma.

The examination is straightforward and about 90% will recover by 1 year without a surgical procedure. The unhappy customers who darken our doorways with worsening or nonimproving symptoms are the ones who make us wonder if we gave them effective conservative measures to begin with.

So what conservative measures are effective?

Sims and colleagues published a meta-analysis evaluating nonsurgical treatments for lateral epicondylitis. The review involved 58 studies (Hand 2014.9:419-46).

The investigators concluded that steroid injections provide relief only for the short term. The authors suggest that this may related to lateral epicondylitis being caused by repeated microtrauma rather than inflammation (perhaps this is why NSAIDs are not always beneficial either). Botulinum A, which works by paralyzing the extensor muscles, thereby allowing them to heal, is comparable to steroids. But patients may not love the experience of extensor muscle paralysis. Prolotherapy, injection of osmotics or irritants to promote inflammation in the target tissue, is also comparable to steroids. Platelet-rich plasma or autologous blood injections have uncertain relative benefit compared to steroids. Bracing with a counterforce brace (i.e., “tennis elbow strap”) or wrist extension splint, physical therapy, and shock wave therapy do not lessen pain or improve function in a dependable way.

This review leaves primary care clinicians who are uncomfortable injecting steroids into the arm with not much in the way of clearly effective evidence-based therapies. Personally, I ask my Ortho Hand colleagues to help me with the injection part. But only when patients fail to respond to what I give them.

So if this is a self-limited disease that gets better in 12-18 months, should we just be offering nothing more than activity modification? Patients will not accept this. My read on the data Sims collected is that there weren’t any quality studies comparing the elbow strap to offering nothing and patients tended to improve with it – although admittedly not clearly more than other therapies such as strengthening exercises. So for now, I will continue to recommend: 1) the elbow strap; 2) home exercises, and 3) lots and lots of reassurance. It’s all I got to give.

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. 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.

While typing this column, I could not recall the last time I saw a patient with “tennis elbow” (lateral epicondylitis) from actual tennis. Lateral epicondylitis peaks between the ages of 30 and 65 years and affects about 1.3% of this group – the vast majority of whom, I am quite suddenly convinced, do not play tennis. Pain is worse with wrist extension and typically affects the dominant hand. The most likely etiology is repeated microtrauma.

The examination is straightforward and about 90% will recover by 1 year without a surgical procedure. The unhappy customers who darken our doorways with worsening or nonimproving symptoms are the ones who make us wonder if we gave them effective conservative measures to begin with.

So what conservative measures are effective?

Sims and colleagues published a meta-analysis evaluating nonsurgical treatments for lateral epicondylitis. The review involved 58 studies (Hand 2014.9:419-46).

The investigators concluded that steroid injections provide relief only for the short term. The authors suggest that this may related to lateral epicondylitis being caused by repeated microtrauma rather than inflammation (perhaps this is why NSAIDs are not always beneficial either). Botulinum A, which works by paralyzing the extensor muscles, thereby allowing them to heal, is comparable to steroids. But patients may not love the experience of extensor muscle paralysis. Prolotherapy, injection of osmotics or irritants to promote inflammation in the target tissue, is also comparable to steroids. Platelet-rich plasma or autologous blood injections have uncertain relative benefit compared to steroids. Bracing with a counterforce brace (i.e., “tennis elbow strap”) or wrist extension splint, physical therapy, and shock wave therapy do not lessen pain or improve function in a dependable way.

This review leaves primary care clinicians who are uncomfortable injecting steroids into the arm with not much in the way of clearly effective evidence-based therapies. Personally, I ask my Ortho Hand colleagues to help me with the injection part. But only when patients fail to respond to what I give them.

So if this is a self-limited disease that gets better in 12-18 months, should we just be offering nothing more than activity modification? Patients will not accept this. My read on the data Sims collected is that there weren’t any quality studies comparing the elbow strap to offering nothing and patients tended to improve with it – although admittedly not clearly more than other therapies such as strengthening exercises. So for now, I will continue to recommend: 1) the elbow strap; 2) home exercises, and 3) lots and lots of reassurance. It’s all I got to give.

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. 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.

While typing this column, I could not recall the last time I saw a patient with “tennis elbow” (lateral epicondylitis) from actual tennis. Lateral epicondylitis peaks between the ages of 30 and 65 years and affects about 1.3% of this group – the vast majority of whom, I am quite suddenly convinced, do not play tennis. Pain is worse with wrist extension and typically affects the dominant hand. The most likely etiology is repeated microtrauma.

The examination is straightforward and about 90% will recover by 1 year without a surgical procedure. The unhappy customers who darken our doorways with worsening or nonimproving symptoms are the ones who make us wonder if we gave them effective conservative measures to begin with.

So what conservative measures are effective?

Sims and colleagues published a meta-analysis evaluating nonsurgical treatments for lateral epicondylitis. The review involved 58 studies (Hand 2014.9:419-46).

The investigators concluded that steroid injections provide relief only for the short term. The authors suggest that this may related to lateral epicondylitis being caused by repeated microtrauma rather than inflammation (perhaps this is why NSAIDs are not always beneficial either). Botulinum A, which works by paralyzing the extensor muscles, thereby allowing them to heal, is comparable to steroids. But patients may not love the experience of extensor muscle paralysis. Prolotherapy, injection of osmotics or irritants to promote inflammation in the target tissue, is also comparable to steroids. Platelet-rich plasma or autologous blood injections have uncertain relative benefit compared to steroids. Bracing with a counterforce brace (i.e., “tennis elbow strap”) or wrist extension splint, physical therapy, and shock wave therapy do not lessen pain or improve function in a dependable way.

This review leaves primary care clinicians who are uncomfortable injecting steroids into the arm with not much in the way of clearly effective evidence-based therapies. Personally, I ask my Ortho Hand colleagues to help me with the injection part. But only when patients fail to respond to what I give them.

So if this is a self-limited disease that gets better in 12-18 months, should we just be offering nothing more than activity modification? Patients will not accept this. My read on the data Sims collected is that there weren’t any quality studies comparing the elbow strap to offering nothing and patients tended to improve with it – although admittedly not clearly more than other therapies such as strengthening exercises. So for now, I will continue to recommend: 1) the elbow strap; 2) home exercises, and 3) lots and lots of reassurance. It’s all I got to give.

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. 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

Parents sometimes come to clinicians with concerns about their children’s moods and behaviors, hoping for a rapid fix of the problem. Most child psychiatric issues can’t be fixed with just medication and respond better with psychotherapy or a combination of psychotherapy and medication. In the past 30 years, tremendous strides have been made in studying the effectiveness of psychotherapeutic interventions among youth.

Case Summary

Katy is a 10-year-old girl who gets into arguments with her mother every day after school because she wants to walk to her grandmother’s house not far away. She was exposed to severe domestic violence by her father against her mother when she was 5 years old, and she has nightmares that cause her to wake up often at night, a fear of men, and rapid mood shifts into sudden rage as well as oppositional behavior with her mother. Her mother also has significant fears and views the world as a very unsafe place. She is worried that Katy has bipolar disorder because of her daughter’s rapid mood changes.

Discussion

While Katy has angry outbursts at times, she does not present with clear-cut episodes of elevated mood along with other symptoms of bipolar disorder, particularly grandiosity. Instead her presentation raises the possibility of post-traumatic stress disorder (PTSD) with nightmares, a fear of men who likely trigger past memories, and sudden mood shifts. Her mother also may have some elements of PTSD, which may be complicating Katy’s presentation. No medication interventions so far have demonstrated significant benefit in youth with PTSD. If further evaluation confirms PTSD, what sort of therapy should be sought for Katy?

A large number of websites now list evidence-based treatments, although many of those require that the creators of the treatment apply for inclusion, and do not address the issue of varying levels of evidence. The American Psychological Association has a website entitled Effective Child Therapy, which discusses psychotherapeutic interventions for various diagnostic areas in youth and the varying levels of evidence for such treatments based on the types and numbers of studies that support them. The website also has an excellent video resource library.

Trauma-focused cognitive-behavioral therapy has numerous studies supporting its efficacy for a wide range of traumas and includes work with both the parent and the child to address the ways the trauma can affect their interaction. This would be an excellent choice for Katy and her mother. Other therapies that have supporting research include child-parent psychotherapy, eye movement desensitization and reprocessing therapy, resilient peer treatment, child-centered therapy, and family therapy for PTSD. Treatments have usually been designed for specific ages, so it is important to consider whether the intervention fits the age of the child.

The extent to which evidence-based treatments are available in the community is variable. However, pediatricians can play a significant role in the availability of these interventions by being aware of which ones are most strongly supported, asking the therapists to whom they refer what their experience is with such interventions, and encouraging training in their offices and communities. Therapists should be comfortable describing exactly how much training they have had in a certain area, for instance, extensive training through their professional education or one or several postgraduate trainings, preferably with follow-up consultation with an experienced practitioner while they are seeing their first cases with a particular intervention.

There is controversy about evidence-based treatment among some psychotherapists who argue that the strict requirements of the research setting make the results inapplicable to the complexity of patients seen in typical clinical settings. In fact, many of the treatments, including trauma-focused cognitive-behavioral therapy, work very well in complex families. Certainly there is much more to learn about how to help patients who don’t respond to certain types of therapy or how to engage families who are reluctant to participate in treatment, but the treatments that we know work are clearly what we should choose first.

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

Introduction

Parents sometimes come to clinicians with concerns about their children’s moods and behaviors, hoping for a rapid fix of the problem. Most child psychiatric issues can’t be fixed with just medication and respond better with psychotherapy or a combination of psychotherapy and medication. In the past 30 years, tremendous strides have been made in studying the effectiveness of psychotherapeutic interventions among youth.

Case Summary

Katy is a 10-year-old girl who gets into arguments with her mother every day after school because she wants to walk to her grandmother’s house not far away. She was exposed to severe domestic violence by her father against her mother when she was 5 years old, and she has nightmares that cause her to wake up often at night, a fear of men, and rapid mood shifts into sudden rage as well as oppositional behavior with her mother. Her mother also has significant fears and views the world as a very unsafe place. She is worried that Katy has bipolar disorder because of her daughter’s rapid mood changes.

Discussion

While Katy has angry outbursts at times, she does not present with clear-cut episodes of elevated mood along with other symptoms of bipolar disorder, particularly grandiosity. Instead her presentation raises the possibility of post-traumatic stress disorder (PTSD) with nightmares, a fear of men who likely trigger past memories, and sudden mood shifts. Her mother also may have some elements of PTSD, which may be complicating Katy’s presentation. No medication interventions so far have demonstrated significant benefit in youth with PTSD. If further evaluation confirms PTSD, what sort of therapy should be sought for Katy?

A large number of websites now list evidence-based treatments, although many of those require that the creators of the treatment apply for inclusion, and do not address the issue of varying levels of evidence. The American Psychological Association has a website entitled Effective Child Therapy, which discusses psychotherapeutic interventions for various diagnostic areas in youth and the varying levels of evidence for such treatments based on the types and numbers of studies that support them. The website also has an excellent video resource library.

Trauma-focused cognitive-behavioral therapy has numerous studies supporting its efficacy for a wide range of traumas and includes work with both the parent and the child to address the ways the trauma can affect their interaction. This would be an excellent choice for Katy and her mother. Other therapies that have supporting research include child-parent psychotherapy, eye movement desensitization and reprocessing therapy, resilient peer treatment, child-centered therapy, and family therapy for PTSD. Treatments have usually been designed for specific ages, so it is important to consider whether the intervention fits the age of the child.

The extent to which evidence-based treatments are available in the community is variable. However, pediatricians can play a significant role in the availability of these interventions by being aware of which ones are most strongly supported, asking the therapists to whom they refer what their experience is with such interventions, and encouraging training in their offices and communities. Therapists should be comfortable describing exactly how much training they have had in a certain area, for instance, extensive training through their professional education or one or several postgraduate trainings, preferably with follow-up consultation with an experienced practitioner while they are seeing their first cases with a particular intervention.

There is controversy about evidence-based treatment among some psychotherapists who argue that the strict requirements of the research setting make the results inapplicable to the complexity of patients seen in typical clinical settings. In fact, many of the treatments, including trauma-focused cognitive-behavioral therapy, work very well in complex families. Certainly there is much more to learn about how to help patients who don’t respond to certain types of therapy or how to engage families who are reluctant to participate in treatment, but the treatments that we know work are clearly what we should choose first.

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

Introduction

Parents sometimes come to clinicians with concerns about their children’s moods and behaviors, hoping for a rapid fix of the problem. Most child psychiatric issues can’t be fixed with just medication and respond better with psychotherapy or a combination of psychotherapy and medication. In the past 30 years, tremendous strides have been made in studying the effectiveness of psychotherapeutic interventions among youth.

Case Summary

Katy is a 10-year-old girl who gets into arguments with her mother every day after school because she wants to walk to her grandmother’s house not far away. She was exposed to severe domestic violence by her father against her mother when she was 5 years old, and she has nightmares that cause her to wake up often at night, a fear of men, and rapid mood shifts into sudden rage as well as oppositional behavior with her mother. Her mother also has significant fears and views the world as a very unsafe place. She is worried that Katy has bipolar disorder because of her daughter’s rapid mood changes.

Discussion

While Katy has angry outbursts at times, she does not present with clear-cut episodes of elevated mood along with other symptoms of bipolar disorder, particularly grandiosity. Instead her presentation raises the possibility of post-traumatic stress disorder (PTSD) with nightmares, a fear of men who likely trigger past memories, and sudden mood shifts. Her mother also may have some elements of PTSD, which may be complicating Katy’s presentation. No medication interventions so far have demonstrated significant benefit in youth with PTSD. If further evaluation confirms PTSD, what sort of therapy should be sought for Katy?

A large number of websites now list evidence-based treatments, although many of those require that the creators of the treatment apply for inclusion, and do not address the issue of varying levels of evidence. The American Psychological Association has a website entitled Effective Child Therapy, which discusses psychotherapeutic interventions for various diagnostic areas in youth and the varying levels of evidence for such treatments based on the types and numbers of studies that support them. The website also has an excellent video resource library.

Trauma-focused cognitive-behavioral therapy has numerous studies supporting its efficacy for a wide range of traumas and includes work with both the parent and the child to address the ways the trauma can affect their interaction. This would be an excellent choice for Katy and her mother. Other therapies that have supporting research include child-parent psychotherapy, eye movement desensitization and reprocessing therapy, resilient peer treatment, child-centered therapy, and family therapy for PTSD. Treatments have usually been designed for specific ages, so it is important to consider whether the intervention fits the age of the child.

The extent to which evidence-based treatments are available in the community is variable. However, pediatricians can play a significant role in the availability of these interventions by being aware of which ones are most strongly supported, asking the therapists to whom they refer what their experience is with such interventions, and encouraging training in their offices and communities. Therapists should be comfortable describing exactly how much training they have had in a certain area, for instance, extensive training through their professional education or one or several postgraduate trainings, preferably with follow-up consultation with an experienced practitioner while they are seeing their first cases with a particular intervention.

There is controversy about evidence-based treatment among some psychotherapists who argue that the strict requirements of the research setting make the results inapplicable to the complexity of patients seen in typical clinical settings. In fact, many of the treatments, including trauma-focused cognitive-behavioral therapy, work very well in complex families. Certainly there is much more to learn about how to help patients who don’t respond to certain types of therapy or how to engage families who are reluctant to participate in treatment, but the treatments that we know work are clearly what we should choose first.

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

Most of my counseling to patients about lowering blood pressure through self management is heavy on weight loss and light on dietary causes of high blood pressure – other than the obvious ones that make people gain weight.

Denial of the effects of dietary salt on blood pressure is not the issue. Rather, it is a time-hewn lack of confidence in the ability of patients to significantly and consistently modify their diet. Part of this may also relate to our inability to provide useful lifestyle tips on how to do so, other than the obvious referral to a dietitian. Telling them not to eat out does not solve this problem, because they can just as easily add salt at home.

However, a recent meta-analysis evaluating the effect of salt substitutes on blood pressure has reinvigorated my desire to counsel my patients on blood pressure self-management.

In this study, the investigators sought randomized, controlled trials with interventions lasting at least 6 months in duration (Am. J. Clin. Nutr. 2014;100:1448-54). Six cohorts were identified in the literature involving a total of 1,974 participants. Included studies took place in China and the Netherlands. Three studies used 65% NaCl/25% KCl/10% MgSO₂, one used 41% NaCl/41% KCl/17% magnesium salt/trace minerals, and one used 65% NaCl/30% KCl/5% calcium salt and folic acid.

Salt substitutes had significant effects on systolic blood pressure with a mean difference of –4.9 mm Hg and on diastolic blood pressure with a mean difference of –1.5 mm Hg.

Overall, one may not be impressed with a 5–mm Hg change in systolic blood pressure. But this is the mean difference – and we presume population heterogeneity in response to salt substitution, such that some patients will respond to a higher degree than this and some to a lower degree. But we do not know which ones are which.

Population interventions aimed at reducing salt intake have been shown to be effective. The Finnish government, for example, collaborated with private industry and was able to achieve reductions in sodium content of food. That initiative resulted in a 33% reduction in the population’s average salt intake, a greater than 10–mm Hg decrease in the population average of both systolic BP and diastolic BP, and a 75%-80% decrease in both stroke and coronary artery disease mortality. Australia, Japan, and the United Kingdom were able to do similar things.

Because we are unlikely to ever see such organized political will exercised in the United States, it seems reasonable to recommend salt substitutes to our patients on an individual level. Adverse effects have been noted with salt substitutes in patients with kidney disease, however, which will have to be considered in that specific population of patients.

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. 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.

Most of my counseling to patients about lowering blood pressure through self management is heavy on weight loss and light on dietary causes of high blood pressure – other than the obvious ones that make people gain weight.

Denial of the effects of dietary salt on blood pressure is not the issue. Rather, it is a time-hewn lack of confidence in the ability of patients to significantly and consistently modify their diet. Part of this may also relate to our inability to provide useful lifestyle tips on how to do so, other than the obvious referral to a dietitian. Telling them not to eat out does not solve this problem, because they can just as easily add salt at home.

However, a recent meta-analysis evaluating the effect of salt substitutes on blood pressure has reinvigorated my desire to counsel my patients on blood pressure self-management.

In this study, the investigators sought randomized, controlled trials with interventions lasting at least 6 months in duration (Am. J. Clin. Nutr. 2014;100:1448-54). Six cohorts were identified in the literature involving a total of 1,974 participants. Included studies took place in China and the Netherlands. Three studies used 65% NaCl/25% KCl/10% MgSO₂, one used 41% NaCl/41% KCl/17% magnesium salt/trace minerals, and one used 65% NaCl/30% KCl/5% calcium salt and folic acid.

Salt substitutes had significant effects on systolic blood pressure with a mean difference of –4.9 mm Hg and on diastolic blood pressure with a mean difference of –1.5 mm Hg.

Overall, one may not be impressed with a 5–mm Hg change in systolic blood pressure. But this is the mean difference – and we presume population heterogeneity in response to salt substitution, such that some patients will respond to a higher degree than this and some to a lower degree. But we do not know which ones are which.

Population interventions aimed at reducing salt intake have been shown to be effective. The Finnish government, for example, collaborated with private industry and was able to achieve reductions in sodium content of food. That initiative resulted in a 33% reduction in the population’s average salt intake, a greater than 10–mm Hg decrease in the population average of both systolic BP and diastolic BP, and a 75%-80% decrease in both stroke and coronary artery disease mortality. Australia, Japan, and the United Kingdom were able to do similar things.

Because we are unlikely to ever see such organized political will exercised in the United States, it seems reasonable to recommend salt substitutes to our patients on an individual level. Adverse effects have been noted with salt substitutes in patients with kidney disease, however, which will have to be considered in that specific population of patients.

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. 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.

Most of my counseling to patients about lowering blood pressure through self management is heavy on weight loss and light on dietary causes of high blood pressure – other than the obvious ones that make people gain weight.

Denial of the effects of dietary salt on blood pressure is not the issue. Rather, it is a time-hewn lack of confidence in the ability of patients to significantly and consistently modify their diet. Part of this may also relate to our inability to provide useful lifestyle tips on how to do so, other than the obvious referral to a dietitian. Telling them not to eat out does not solve this problem, because they can just as easily add salt at home.

However, a recent meta-analysis evaluating the effect of salt substitutes on blood pressure has reinvigorated my desire to counsel my patients on blood pressure self-management.

In this study, the investigators sought randomized, controlled trials with interventions lasting at least 6 months in duration (Am. J. Clin. Nutr. 2014;100:1448-54). Six cohorts were identified in the literature involving a total of 1,974 participants. Included studies took place in China and the Netherlands. Three studies used 65% NaCl/25% KCl/10% MgSO₂, one used 41% NaCl/41% KCl/17% magnesium salt/trace minerals, and one used 65% NaCl/30% KCl/5% calcium salt and folic acid.

Salt substitutes had significant effects on systolic blood pressure with a mean difference of –4.9 mm Hg and on diastolic blood pressure with a mean difference of –1.5 mm Hg.

Overall, one may not be impressed with a 5–mm Hg change in systolic blood pressure. But this is the mean difference – and we presume population heterogeneity in response to salt substitution, such that some patients will respond to a higher degree than this and some to a lower degree. But we do not know which ones are which.

Population interventions aimed at reducing salt intake have been shown to be effective. The Finnish government, for example, collaborated with private industry and was able to achieve reductions in sodium content of food. That initiative resulted in a 33% reduction in the population’s average salt intake, a greater than 10–mm Hg decrease in the population average of both systolic BP and diastolic BP, and a 75%-80% decrease in both stroke and coronary artery disease mortality. Australia, Japan, and the United Kingdom were able to do similar things.

Because we are unlikely to ever see such organized political will exercised in the United States, it seems reasonable to recommend salt substitutes to our patients on an individual level. Adverse effects have been noted with salt substitutes in patients with kidney disease, however, which will have to be considered in that specific population of patients.

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. 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.

SAN DIEGO – Exposure to common household pesticides called pyrethroids almost tripled the odds of attention-deficit/hyperactivity disorder in boys, but not in girls, authors of a large cross-sectional study reported.

The results resemble findings from prior studies of mice, lead investigator Dr. Melissa L. Wagner-Schuman said in an interview. “Pyrethroids are the most commonly used pesticides for residential pest control and public health,” she and her associates said. “Given the growing use of pyrethroids and the perception that they are a safer insecticide alternative, our results may be of considerable public health import.”

Attention-deficit/hyperactivity disorder is more than twice as prevalent in boys as in girls, according to CDC data. The disorder is “highly heritable,” but environmental factors also play a role, the researchers said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

For the study, the investigators analyzed National Health and Nutrition Examination Survey data from 2001 to 2002 from 687 children aged 8-18 years. Children were categorized as having ADHD if they met DSM-IV criteria for the disorder on the Diagnostic Interview Schedule for Children caregiver module, had a diagnosis of ADHD reported by their caregivers, or both, the researchers said. Pyrethroid exposure was assessed by testing urine samples for a metabolite of several pyrethroids called 3-phenoxybenzoic acid (3-PBA), they noted.

Boys who had detectable levels of 3-PBA were 2.95 times more likely to have ADHD than were boys who lacked evidence of pyrethroid exposure (95% confidence interval, 1.07-8.08), said Dr. Wagner-Schuman, a pediatrics resident at Cincinnati Children’s Hospital Medical Center. “Effects in girls were smaller and nonsignificant,” she and her associates reported (adjusted odds ratio for girls with detectable biomarker levels, 1.54; 95% CI, 0.32-7.33). The analysis controlled for age; race or ethnicity; income; health insurance status; prenatal tobacco exposure; blood lead levels; urine organophosphate metabolite levels; and urine creatinine level.

Also in boys but not in girls, the odds of ADHD increased linearly with rising 3-PBA levels and did not plateau, the researchers reported.

In the mouse studies, pyrethroid exposure was found to trigger abnormalities in the dopamine system, which produced an “ADHD phenotype,” the investigators said. “Male animals appear to have a heightened vulnerability to exposure,” they added. Other studies have shown that prenatal pyrethroid exposure in humans can increase the risk of neurodevelopmental problems, the investigators noted.

The analysis was limited by its cross-sectional design, Dr. Wagner-Schuman said. Future studies should serially quantify pyrethroid exposure over time, she added.

The National Institute of Environmental Health Sciences funded the research. One coauthor reported having served as a consultant and expert witness for the California Attorney General’s Office, and having consulted for the California Department of Toxic Substances Control and the U.S. Environmental Protection Agency. The other investigators declared no conflicts of interest.

SAN DIEGO – Exposure to common household pesticides called pyrethroids almost tripled the odds of attention-deficit/hyperactivity disorder in boys, but not in girls, authors of a large cross-sectional study reported.

The results resemble findings from prior studies of mice, lead investigator Dr. Melissa L. Wagner-Schuman said in an interview. “Pyrethroids are the most commonly used pesticides for residential pest control and public health,” she and her associates said. “Given the growing use of pyrethroids and the perception that they are a safer insecticide alternative, our results may be of considerable public health import.”

Attention-deficit/hyperactivity disorder is more than twice as prevalent in boys as in girls, according to CDC data. The disorder is “highly heritable,” but environmental factors also play a role, the researchers said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

For the study, the investigators analyzed National Health and Nutrition Examination Survey data from 2001 to 2002 from 687 children aged 8-18 years. Children were categorized as having ADHD if they met DSM-IV criteria for the disorder on the Diagnostic Interview Schedule for Children caregiver module, had a diagnosis of ADHD reported by their caregivers, or both, the researchers said. Pyrethroid exposure was assessed by testing urine samples for a metabolite of several pyrethroids called 3-phenoxybenzoic acid (3-PBA), they noted.

Boys who had detectable levels of 3-PBA were 2.95 times more likely to have ADHD than were boys who lacked evidence of pyrethroid exposure (95% confidence interval, 1.07-8.08), said Dr. Wagner-Schuman, a pediatrics resident at Cincinnati Children’s Hospital Medical Center. “Effects in girls were smaller and nonsignificant,” she and her associates reported (adjusted odds ratio for girls with detectable biomarker levels, 1.54; 95% CI, 0.32-7.33). The analysis controlled for age; race or ethnicity; income; health insurance status; prenatal tobacco exposure; blood lead levels; urine organophosphate metabolite levels; and urine creatinine level.

Also in boys but not in girls, the odds of ADHD increased linearly with rising 3-PBA levels and did not plateau, the researchers reported.

In the mouse studies, pyrethroid exposure was found to trigger abnormalities in the dopamine system, which produced an “ADHD phenotype,” the investigators said. “Male animals appear to have a heightened vulnerability to exposure,” they added. Other studies have shown that prenatal pyrethroid exposure in humans can increase the risk of neurodevelopmental problems, the investigators noted.

The analysis was limited by its cross-sectional design, Dr. Wagner-Schuman said. Future studies should serially quantify pyrethroid exposure over time, she added.

The National Institute of Environmental Health Sciences funded the research. One coauthor reported having served as a consultant and expert witness for the California Attorney General’s Office, and having consulted for the California Department of Toxic Substances Control and the U.S. Environmental Protection Agency. The other investigators declared no conflicts of interest.

SAN DIEGO – Exposure to common household pesticides called pyrethroids almost tripled the odds of attention-deficit/hyperactivity disorder in boys, but not in girls, authors of a large cross-sectional study reported.

The results resemble findings from prior studies of mice, lead investigator Dr. Melissa L. Wagner-Schuman said in an interview. “Pyrethroids are the most commonly used pesticides for residential pest control and public health,” she and her associates said. “Given the growing use of pyrethroids and the perception that they are a safer insecticide alternative, our results may be of considerable public health import.”

Attention-deficit/hyperactivity disorder is more than twice as prevalent in boys as in girls, according to CDC data. The disorder is “highly heritable,” but environmental factors also play a role, the researchers said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

For the study, the investigators analyzed National Health and Nutrition Examination Survey data from 2001 to 2002 from 687 children aged 8-18 years. Children were categorized as having ADHD if they met DSM-IV criteria for the disorder on the Diagnostic Interview Schedule for Children caregiver module, had a diagnosis of ADHD reported by their caregivers, or both, the researchers said. Pyrethroid exposure was assessed by testing urine samples for a metabolite of several pyrethroids called 3-phenoxybenzoic acid (3-PBA), they noted.

Boys who had detectable levels of 3-PBA were 2.95 times more likely to have ADHD than were boys who lacked evidence of pyrethroid exposure (95% confidence interval, 1.07-8.08), said Dr. Wagner-Schuman, a pediatrics resident at Cincinnati Children’s Hospital Medical Center. “Effects in girls were smaller and nonsignificant,” she and her associates reported (adjusted odds ratio for girls with detectable biomarker levels, 1.54; 95% CI, 0.32-7.33). The analysis controlled for age; race or ethnicity; income; health insurance status; prenatal tobacco exposure; blood lead levels; urine organophosphate metabolite levels; and urine creatinine level.

Also in boys but not in girls, the odds of ADHD increased linearly with rising 3-PBA levels and did not plateau, the researchers reported.

In the mouse studies, pyrethroid exposure was found to trigger abnormalities in the dopamine system, which produced an “ADHD phenotype,” the investigators said. “Male animals appear to have a heightened vulnerability to exposure,” they added. Other studies have shown that prenatal pyrethroid exposure in humans can increase the risk of neurodevelopmental problems, the investigators noted.

The analysis was limited by its cross-sectional design, Dr. Wagner-Schuman said. Future studies should serially quantify pyrethroid exposure over time, she added.

The National Institute of Environmental Health Sciences funded the research. One coauthor reported having served as a consultant and expert witness for the California Attorney General’s Office, and having consulted for the California Department of Toxic Substances Control and the U.S. Environmental Protection Agency. The other investigators declared no conflicts of interest.

One of the greatest challenges you may face as a pediatrician is in helping your patients and families navigate the mental health system. Nearly 20% of children will experience a psychiatric illness before they turn 18, and a quarter of those will go on to experience a persistent or severe psychiatric illness. Whether a patient is experiencing symptoms that are mild or severe, their parents are likely to come to you first for an assessment and for help in finding a referral to the appropriate specialist.

Unlike the smooth process to refer to a neurologist or orthopedist, accessing treatment for mental health problems is often confusing and frustrating. Because of reimbursement that is below the cost of providing care, many community hospitals have closed their divisions of child and adolescent psychiatry, and academic medical centers often have a long wait for a provider. If you go through a patient’s insurance, usually the list of providers is woefully out-of-date, with most of them not accepting new referrals or insurance or both. If mental health services are “carved out” to cut costs, the primary insurer has no direct control of mental health services, and the carve out company is looking for providers willing to accept lower reimbursement and limit longer-term treatments. Faced with reimbursement and administrative demands by the carve out company, child psychiatrists, psychologists, and social workers that once staffed these services have chosen fee-for-service private offices that do not accept any insurance, leaving many communities without access to adequate resources. In private practice, these providers are busy, face no administrative demands to justify their work, and earn two or three times what insurers reimburse.

So families often turn to their schools and their pediatricians when faced with a mood, anxiety, or behavioral problem. While there is no straightforward solution to this problem of access, we have put together a “road map” to what services might be available and to help you in your approach to these patients.

It is first important to consider that mental health and developmental questions are now a major part of pediatric primary care. The majority of your visits will be well child care and psychosocial. So a part, maybe a third or half of mental health concerns might now be considered a routine part of primary care. Many practices are now doing psychosocial screening and more states are mandating reimbursement of this screening. Typically screening includes a CHATfor autism (Checklist for Autism in Toddlers), a developmental screen if indicated, a Pediatric Symptom Checklist for school-age children and adolescents, a Hamilton Rating Scale for Depression in adolescents, and a CRAFFTfor adolescent substance abuse. Some practices include a Hamilton or other depression screen for mothers of newborns and toddlers as maternal depression has a serious impact on the child and is responsive to treatment. If screening is reimbursed, some of that money could go to fund an on-site social worker, who can also bill for patient contact services, and thus provide the practice with an on-site mental health presence at break-even cost. This social worker may be expert in referring to local resources, may be trained in psychotherapy, or may even lead groups for parents of recent divorce, new mothers, facing attention-deficit/hyperactivity disorder (ADHD), etc.

The best place to start for a family with psychosocial concerns is to do a brief review of your patient’s day to day functioning – school, friends, family, activities, and mood. What is your best assessment of the problem, how much of the child and family’s life is affected, and how severe is the problem? There are many mental health problems for which the first-line treatment is a trial of medication according to an algorithm that you can use following American Academy of Pediatrics guidelines. For example, if considering stimulant treatment for a 7-year-old with possible attention difficulties, you can use broad screening instruments like the Pediatric Symptom Checklist or Childhood Behavior Checklist as well as the Vanderbilt Assessment Scales or Conners questionnaire that are specific for ADHD. Many pediatricians also are comfortable treating adolescent depression with medication and with comanagement from a social worker with a master’s degree or a doctorate level psychologist. Of course, treating depression requires a more careful interview, consideration of suicide risk, and more frequent follow-up visits.

As first-line treatment for depression and anxiety usually starts with psychotherapy, it is important to consider how you will access this component of mental health care. For those that don’t have a licensed clinical social worker on-site providing cognitive-behavioral therapy, many busy pediatric practices will establish a relationship with a therapist or group that has agreed to accept their referrals and accepts insurance reimbursement. If you are not fortunate enough to already have such a relationship, it can be fruitful to speak with colleagues in a busier practice about whom they use. It also can be fruitful to reach out to the graduate programs in psychology (PhD or PsyD programs) or social work in your community, to find out if they have a referral service or would like to connect recent graduates trying to establish themselves with referring pediatricians. Having a resource located in your office (employed by you or renting space) is ideal.

When a patient is presenting with a more complex set of symptoms or fails to respond to your initial treatments, then you will want to locate an appropriate referral to a child psychiatrist. If your group is affiliated with an academic medical center, find out what the procedure is for referring to their child psychiatrists or to the child psychiatry trainees. Often there is easy availability early in the academic year (summer), when children are less likely to present with problems and a new crop of trainees has arrived. Academic medical centers also will often be a hub for a lot of research activity, and research programs are usually eager to enroll patients without regard to their insurance. Good studies will provide patients with a formalized assessment that will clarify the diagnostic picture, ensuring that a child is on the path to the right treatment. Cultivating a connection with the research coordinator can ensure that your group knows about opportunities for free care that is easier to access than most.

Many states require schools to provide testing to clarify whether psychiatric symptoms, developmental issues, or learning disabilities are affecting a student’s ability to perform in school. Your office can educate parents that they should go to the school with their concerns and request a formal assessment. If testing indicates a condition, the school system is often required to provide appropriate educational services, such as tutoring for learning disabilities, occupational therapy, and social skills support for children on the autism spectrum, and even counseling for children with anxiety, mood, and behavioral issues. Often, the school psychologist or social worker will be a valuable resource in providing direct care to children or helping you and the parents identify excellent treaters in the community. For children with severe and persistent psychiatric illness, many states require that schools provide or pay for the services that are necessary to educate each child. This can mean anything from paying for an after school social skills group to paying for a therapeutic boarding school. In these cases, it is often helpful to have established a relationship with an educational consultant. These are usually social workers with expertise in mental health issues and the state’s educational system and regulations, and they will partner with parents for a modest fee to educate and empower parents so that they might get appropriate services from their schools. Again, it can be fruitful to speak with trusted colleagues and find one who has identified a local consultant that they trust.

Some states and counties have tried to address the problem of accessing psychiatric care for children, but often these are programs that have not been adequately marketed to pediatricians or families, so they may be under utilized. In Massachusetts and Connecticut, there is the state Child Psychiatry Access Project, which provides all pediatricians with free access to a consulting child psychiatrist by phone. It requires that pediatricians are willing to treat children themselves with the support and guidance of a consulting child psychiatrist, but it will also provide a face-to-face diagnostic evaluation of that child by a child psychiatrist so that they can in turn provide the best guidance to the pediatrician. And it provides a care coordinator who will help to identify appropriate treaters, such as a cognitive-behavioral therapist or a psychopharmacologist who accept the family’s insurance, when the pediatrician is unable to provide the recommended treatment. An online investigation through your state’s or county’s Office of Mental Health or your local Medical Society can help your office identify what resources may exist in your community.

Finally, your most critical task after a parent has come to you with concerns about their child’s mood, thinking, or behavior, may be in educating and supporting those parents. Prepare the parents by explaining to them how the mental health system is more fragmented and frustrating than most other medical specialties. Remind them that psychiatric symptoms and illnesses are eminently treatable, and it will be worth patiently navigating this complex system to eventually access the right care for their child. It can be helpful to suggest to them that if they can possibly afford to pay out-of-pocket for the appropriate care, it will make excellent treatment much easier to access in a timely way. It can be meaningful for parents to hear from you that it is worthwhile for them to call or write their insurance company and complain if that company has restricted access to child psychiatric care. They are, after all, the customers of their insurance company, and it is the silence, shame, and stigma surrounding psychiatric illness that has enabled insurance companies to restrict access to effective care. Finally, it can be very powerful to connect parents with support or advocacy organizations that will help them in navigating this system and in speaking up to their insurance companies, state health, or education agencies or in the press in ways that will diminish the stigma that still surrounds these problems. The National Alliance on Mental Illness (www.nami.org), The Bazelon Center for Mental Health Law (www.bazelon.org), and the American Academy of Child and Adolescent Psychiatry (www.aacap.org) all have excellent online resources that also help identify local organizations and resources for parents. If insurance companies refused to pay for potentially life-saving chemotherapy for a pediatric cancer, you can imagine that there would be many parents protesting to those insurers, to the news, and even to their local or state governments. Mental health care should be no different, as the problems can be as disabling and life-threatening and effective treatments and even cures exist.

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

One of the greatest challenges you may face as a pediatrician is in helping your patients and families navigate the mental health system. Nearly 20% of children will experience a psychiatric illness before they turn 18, and a quarter of those will go on to experience a persistent or severe psychiatric illness. Whether a patient is experiencing symptoms that are mild or severe, their parents are likely to come to you first for an assessment and for help in finding a referral to the appropriate specialist.

Unlike the smooth process to refer to a neurologist or orthopedist, accessing treatment for mental health problems is often confusing and frustrating. Because of reimbursement that is below the cost of providing care, many community hospitals have closed their divisions of child and adolescent psychiatry, and academic medical centers often have a long wait for a provider. If you go through a patient’s insurance, usually the list of providers is woefully out-of-date, with most of them not accepting new referrals or insurance or both. If mental health services are “carved out” to cut costs, the primary insurer has no direct control of mental health services, and the carve out company is looking for providers willing to accept lower reimbursement and limit longer-term treatments. Faced with reimbursement and administrative demands by the carve out company, child psychiatrists, psychologists, and social workers that once staffed these services have chosen fee-for-service private offices that do not accept any insurance, leaving many communities without access to adequate resources. In private practice, these providers are busy, face no administrative demands to justify their work, and earn two or three times what insurers reimburse.

So families often turn to their schools and their pediatricians when faced with a mood, anxiety, or behavioral problem. While there is no straightforward solution to this problem of access, we have put together a “road map” to what services might be available and to help you in your approach to these patients.

It is first important to consider that mental health and developmental questions are now a major part of pediatric primary care. The majority of your visits will be well child care and psychosocial. So a part, maybe a third or half of mental health concerns might now be considered a routine part of primary care. Many practices are now doing psychosocial screening and more states are mandating reimbursement of this screening. Typically screening includes a CHATfor autism (Checklist for Autism in Toddlers), a developmental screen if indicated, a Pediatric Symptom Checklist for school-age children and adolescents, a Hamilton Rating Scale for Depression in adolescents, and a CRAFFTfor adolescent substance abuse. Some practices include a Hamilton or other depression screen for mothers of newborns and toddlers as maternal depression has a serious impact on the child and is responsive to treatment. If screening is reimbursed, some of that money could go to fund an on-site social worker, who can also bill for patient contact services, and thus provide the practice with an on-site mental health presence at break-even cost. This social worker may be expert in referring to local resources, may be trained in psychotherapy, or may even lead groups for parents of recent divorce, new mothers, facing attention-deficit/hyperactivity disorder (ADHD), etc.

The best place to start for a family with psychosocial concerns is to do a brief review of your patient’s day to day functioning – school, friends, family, activities, and mood. What is your best assessment of the problem, how much of the child and family’s life is affected, and how severe is the problem? There are many mental health problems for which the first-line treatment is a trial of medication according to an algorithm that you can use following American Academy of Pediatrics guidelines. For example, if considering stimulant treatment for a 7-year-old with possible attention difficulties, you can use broad screening instruments like the Pediatric Symptom Checklist or Childhood Behavior Checklist as well as the Vanderbilt Assessment Scales or Conners questionnaire that are specific for ADHD. Many pediatricians also are comfortable treating adolescent depression with medication and with comanagement from a social worker with a master’s degree or a doctorate level psychologist. Of course, treating depression requires a more careful interview, consideration of suicide risk, and more frequent follow-up visits.

As first-line treatment for depression and anxiety usually starts with psychotherapy, it is important to consider how you will access this component of mental health care. For those that don’t have a licensed clinical social worker on-site providing cognitive-behavioral therapy, many busy pediatric practices will establish a relationship with a therapist or group that has agreed to accept their referrals and accepts insurance reimbursement. If you are not fortunate enough to already have such a relationship, it can be fruitful to speak with colleagues in a busier practice about whom they use. It also can be fruitful to reach out to the graduate programs in psychology (PhD or PsyD programs) or social work in your community, to find out if they have a referral service or would like to connect recent graduates trying to establish themselves with referring pediatricians. Having a resource located in your office (employed by you or renting space) is ideal.

When a patient is presenting with a more complex set of symptoms or fails to respond to your initial treatments, then you will want to locate an appropriate referral to a child psychiatrist. If your group is affiliated with an academic medical center, find out what the procedure is for referring to their child psychiatrists or to the child psychiatry trainees. Often there is easy availability early in the academic year (summer), when children are less likely to present with problems and a new crop of trainees has arrived. Academic medical centers also will often be a hub for a lot of research activity, and research programs are usually eager to enroll patients without regard to their insurance. Good studies will provide patients with a formalized assessment that will clarify the diagnostic picture, ensuring that a child is on the path to the right treatment. Cultivating a connection with the research coordinator can ensure that your group knows about opportunities for free care that is easier to access than most.

Many states require schools to provide testing to clarify whether psychiatric symptoms, developmental issues, or learning disabilities are affecting a student’s ability to perform in school. Your office can educate parents that they should go to the school with their concerns and request a formal assessment. If testing indicates a condition, the school system is often required to provide appropriate educational services, such as tutoring for learning disabilities, occupational therapy, and social skills support for children on the autism spectrum, and even counseling for children with anxiety, mood, and behavioral issues. Often, the school psychologist or social worker will be a valuable resource in providing direct care to children or helping you and the parents identify excellent treaters in the community. For children with severe and persistent psychiatric illness, many states require that schools provide or pay for the services that are necessary to educate each child. This can mean anything from paying for an after school social skills group to paying for a therapeutic boarding school. In these cases, it is often helpful to have established a relationship with an educational consultant. These are usually social workers with expertise in mental health issues and the state’s educational system and regulations, and they will partner with parents for a modest fee to educate and empower parents so that they might get appropriate services from their schools. Again, it can be fruitful to speak with trusted colleagues and find one who has identified a local consultant that they trust.

Some states and counties have tried to address the problem of accessing psychiatric care for children, but often these are programs that have not been adequately marketed to pediatricians or families, so they may be under utilized. In Massachusetts and Connecticut, there is the state Child Psychiatry Access Project, which provides all pediatricians with free access to a consulting child psychiatrist by phone. It requires that pediatricians are willing to treat children themselves with the support and guidance of a consulting child psychiatrist, but it will also provide a face-to-face diagnostic evaluation of that child by a child psychiatrist so that they can in turn provide the best guidance to the pediatrician. And it provides a care coordinator who will help to identify appropriate treaters, such as a cognitive-behavioral therapist or a psychopharmacologist who accept the family’s insurance, when the pediatrician is unable to provide the recommended treatment. An online investigation through your state’s or county’s Office of Mental Health or your local Medical Society can help your office identify what resources may exist in your community.

Finally, your most critical task after a parent has come to you with concerns about their child’s mood, thinking, or behavior, may be in educating and supporting those parents. Prepare the parents by explaining to them how the mental health system is more fragmented and frustrating than most other medical specialties. Remind them that psychiatric symptoms and illnesses are eminently treatable, and it will be worth patiently navigating this complex system to eventually access the right care for their child. It can be helpful to suggest to them that if they can possibly afford to pay out-of-pocket for the appropriate care, it will make excellent treatment much easier to access in a timely way. It can be meaningful for parents to hear from you that it is worthwhile for them to call or write their insurance company and complain if that company has restricted access to child psychiatric care. They are, after all, the customers of their insurance company, and it is the silence, shame, and stigma surrounding psychiatric illness that has enabled insurance companies to restrict access to effective care. Finally, it can be very powerful to connect parents with support or advocacy organizations that will help them in navigating this system and in speaking up to their insurance companies, state health, or education agencies or in the press in ways that will diminish the stigma that still surrounds these problems. The National Alliance on Mental Illness (www.nami.org), The Bazelon Center for Mental Health Law (www.bazelon.org), and the American Academy of Child and Adolescent Psychiatry (www.aacap.org) all have excellent online resources that also help identify local organizations and resources for parents. If insurance companies refused to pay for potentially life-saving chemotherapy for a pediatric cancer, you can imagine that there would be many parents protesting to those insurers, to the news, and even to their local or state governments. Mental health care should be no different, as the problems can be as disabling and life-threatening and effective treatments and even cures exist.

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

One of the greatest challenges you may face as a pediatrician is in helping your patients and families navigate the mental health system. Nearly 20% of children will experience a psychiatric illness before they turn 18, and a quarter of those will go on to experience a persistent or severe psychiatric illness. Whether a patient is experiencing symptoms that are mild or severe, their parents are likely to come to you first for an assessment and for help in finding a referral to the appropriate specialist.

Unlike the smooth process to refer to a neurologist or orthopedist, accessing treatment for mental health problems is often confusing and frustrating. Because of reimbursement that is below the cost of providing care, many community hospitals have closed their divisions of child and adolescent psychiatry, and academic medical centers often have a long wait for a provider. If you go through a patient’s insurance, usually the list of providers is woefully out-of-date, with most of them not accepting new referrals or insurance or both. If mental health services are “carved out” to cut costs, the primary insurer has no direct control of mental health services, and the carve out company is looking for providers willing to accept lower reimbursement and limit longer-term treatments. Faced with reimbursement and administrative demands by the carve out company, child psychiatrists, psychologists, and social workers that once staffed these services have chosen fee-for-service private offices that do not accept any insurance, leaving many communities without access to adequate resources. In private practice, these providers are busy, face no administrative demands to justify their work, and earn two or three times what insurers reimburse.

So families often turn to their schools and their pediatricians when faced with a mood, anxiety, or behavioral problem. While there is no straightforward solution to this problem of access, we have put together a “road map” to what services might be available and to help you in your approach to these patients.

It is first important to consider that mental health and developmental questions are now a major part of pediatric primary care. The majority of your visits will be well child care and psychosocial. So a part, maybe a third or half of mental health concerns might now be considered a routine part of primary care. Many practices are now doing psychosocial screening and more states are mandating reimbursement of this screening. Typically screening includes a CHATfor autism (Checklist for Autism in Toddlers), a developmental screen if indicated, a Pediatric Symptom Checklist for school-age children and adolescents, a Hamilton Rating Scale for Depression in adolescents, and a CRAFFTfor adolescent substance abuse. Some practices include a Hamilton or other depression screen for mothers of newborns and toddlers as maternal depression has a serious impact on the child and is responsive to treatment. If screening is reimbursed, some of that money could go to fund an on-site social worker, who can also bill for patient contact services, and thus provide the practice with an on-site mental health presence at break-even cost. This social worker may be expert in referring to local resources, may be trained in psychotherapy, or may even lead groups for parents of recent divorce, new mothers, facing attention-deficit/hyperactivity disorder (ADHD), etc.

The best place to start for a family with psychosocial concerns is to do a brief review of your patient’s day to day functioning – school, friends, family, activities, and mood. What is your best assessment of the problem, how much of the child and family’s life is affected, and how severe is the problem? There are many mental health problems for which the first-line treatment is a trial of medication according to an algorithm that you can use following American Academy of Pediatrics guidelines. For example, if considering stimulant treatment for a 7-year-old with possible attention difficulties, you can use broad screening instruments like the Pediatric Symptom Checklist or Childhood Behavior Checklist as well as the Vanderbilt Assessment Scales or Conners questionnaire that are specific for ADHD. Many pediatricians also are comfortable treating adolescent depression with medication and with comanagement from a social worker with a master’s degree or a doctorate level psychologist. Of course, treating depression requires a more careful interview, consideration of suicide risk, and more frequent follow-up visits.

As first-line treatment for depression and anxiety usually starts with psychotherapy, it is important to consider how you will access this component of mental health care. For those that don’t have a licensed clinical social worker on-site providing cognitive-behavioral therapy, many busy pediatric practices will establish a relationship with a therapist or group that has agreed to accept their referrals and accepts insurance reimbursement. If you are not fortunate enough to already have such a relationship, it can be fruitful to speak with colleagues in a busier practice about whom they use. It also can be fruitful to reach out to the graduate programs in psychology (PhD or PsyD programs) or social work in your community, to find out if they have a referral service or would like to connect recent graduates trying to establish themselves with referring pediatricians. Having a resource located in your office (employed by you or renting space) is ideal.

When a patient is presenting with a more complex set of symptoms or fails to respond to your initial treatments, then you will want to locate an appropriate referral to a child psychiatrist. If your group is affiliated with an academic medical center, find out what the procedure is for referring to their child psychiatrists or to the child psychiatry trainees. Often there is easy availability early in the academic year (summer), when children are less likely to present with problems and a new crop of trainees has arrived. Academic medical centers also will often be a hub for a lot of research activity, and research programs are usually eager to enroll patients without regard to their insurance. Good studies will provide patients with a formalized assessment that will clarify the diagnostic picture, ensuring that a child is on the path to the right treatment. Cultivating a connection with the research coordinator can ensure that your group knows about opportunities for free care that is easier to access than most.

Many states require schools to provide testing to clarify whether psychiatric symptoms, developmental issues, or learning disabilities are affecting a student’s ability to perform in school. Your office can educate parents that they should go to the school with their concerns and request a formal assessment. If testing indicates a condition, the school system is often required to provide appropriate educational services, such as tutoring for learning disabilities, occupational therapy, and social skills support for children on the autism spectrum, and even counseling for children with anxiety, mood, and behavioral issues. Often, the school psychologist or social worker will be a valuable resource in providing direct care to children or helping you and the parents identify excellent treaters in the community. For children with severe and persistent psychiatric illness, many states require that schools provide or pay for the services that are necessary to educate each child. This can mean anything from paying for an after school social skills group to paying for a therapeutic boarding school. In these cases, it is often helpful to have established a relationship with an educational consultant. These are usually social workers with expertise in mental health issues and the state’s educational system and regulations, and they will partner with parents for a modest fee to educate and empower parents so that they might get appropriate services from their schools. Again, it can be fruitful to speak with trusted colleagues and find one who has identified a local consultant that they trust.

Some states and counties have tried to address the problem of accessing psychiatric care for children, but often these are programs that have not been adequately marketed to pediatricians or families, so they may be under utilized. In Massachusetts and Connecticut, there is the state Child Psychiatry Access Project, which provides all pediatricians with free access to a consulting child psychiatrist by phone. It requires that pediatricians are willing to treat children themselves with the support and guidance of a consulting child psychiatrist, but it will also provide a face-to-face diagnostic evaluation of that child by a child psychiatrist so that they can in turn provide the best guidance to the pediatrician. And it provides a care coordinator who will help to identify appropriate treaters, such as a cognitive-behavioral therapist or a psychopharmacologist who accept the family’s insurance, when the pediatrician is unable to provide the recommended treatment. An online investigation through your state’s or county’s Office of Mental Health or your local Medical Society can help your office identify what resources may exist in your community.

Finally, your most critical task after a parent has come to you with concerns about their child’s mood, thinking, or behavior, may be in educating and supporting those parents. Prepare the parents by explaining to them how the mental health system is more fragmented and frustrating than most other medical specialties. Remind them that psychiatric symptoms and illnesses are eminently treatable, and it will be worth patiently navigating this complex system to eventually access the right care for their child. It can be helpful to suggest to them that if they can possibly afford to pay out-of-pocket for the appropriate care, it will make excellent treatment much easier to access in a timely way. It can be meaningful for parents to hear from you that it is worthwhile for them to call or write their insurance company and complain if that company has restricted access to child psychiatric care. They are, after all, the customers of their insurance company, and it is the silence, shame, and stigma surrounding psychiatric illness that has enabled insurance companies to restrict access to effective care. Finally, it can be very powerful to connect parents with support or advocacy organizations that will help them in navigating this system and in speaking up to their insurance companies, state health, or education agencies or in the press in ways that will diminish the stigma that still surrounds these problems. The National Alliance on Mental Illness (www.nami.org), The Bazelon Center for Mental Health Law (www.bazelon.org), and the American Academy of Child and Adolescent Psychiatry (www.aacap.org) all have excellent online resources that also help identify local organizations and resources for parents. If insurance companies refused to pay for potentially life-saving chemotherapy for a pediatric cancer, you can imagine that there would be many parents protesting to those insurers, to the news, and even to their local or state governments. Mental health care should be no different, as the problems can be as disabling and life-threatening and effective treatments and even cures exist.

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

Fecal incontinence is a devastating and isolating condition. Sales of adult diapers are a $7 billion global market and the fastest-growing household products business. Which is where a lot of our patients with this condition remain – at home.

Fecal incontinence (FI) is a condition characterized by continuous or recurrent uncontrolled passage of fecal material. The prevalence may be as high as 15%. Risk factors include physical disabilities, dementia, diabetes, urinary incontinence, chronic diarrhea, and multiparity. One-third of patients will talk to us about it. Which for some of us may be suitable, given our inability to offer good treatments.

If patients do mention it, evaluation involves taking a good history. We need to differentiate incontinence from fecal urgency and frequency. Anorectal examination should look for a bilateral anal wink (absence suggests nerve damage). Some form of endoscopic examination should be performed in most patients. Further evaluation/referral will be based upon findings.

Treatment includes improving stool consistency (e.g., fiber for loose stool) and reducing frequency (e.g., loperamide for diarrhea), and this is generally where I start. Hyoscyamine may be helpful for post-meal leakage. Scheduled defecation and amitriptyline may be of benefit to some patients.

Dr. Henri Damon of Hospices Civils de Lyon, France, and his colleagues conducted a multicenter study of perineal retraining for FI (Dig. Liver Dis. 2014;46:237-42). The intervention included perineal retraining and biofeedback. The protocol was based upon 20 sessions of 30 minutes performed within a 4-month period. The intervention was standardized. Eighty patients were included in the control group, with 77 in the biofeedback group.

The success rate was significantly higher in the biofeedback group (57% vs. 37%; P < .021). Stool frequency, leakage, and urgency significantly decreased. Perineal retraining was significantly associated with a higher chance of self-rated improvement.

The take-home message is that perineal retraining is an effective component of FI treatment. Combining it with improved perianal skin hygiene, bowel habit ritualization, and the addition of fiber as a bulking agent and loperamide for diarrhea offers the greatest hope for patients suffering from this challenging condition.

Our job is to figure out where and how our patients can access the level of expertise needed to do the training.

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. 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.

Fecal incontinence is a devastating and isolating condition. Sales of adult diapers are a $7 billion global market and the fastest-growing household products business. Which is where a lot of our patients with this condition remain – at home.

Fecal incontinence (FI) is a condition characterized by continuous or recurrent uncontrolled passage of fecal material. The prevalence may be as high as 15%. Risk factors include physical disabilities, dementia, diabetes, urinary incontinence, chronic diarrhea, and multiparity. One-third of patients will talk to us about it. Which for some of us may be suitable, given our inability to offer good treatments.

If patients do mention it, evaluation involves taking a good history. We need to differentiate incontinence from fecal urgency and frequency. Anorectal examination should look for a bilateral anal wink (absence suggests nerve damage). Some form of endoscopic examination should be performed in most patients. Further evaluation/referral will be based upon findings.

Treatment includes improving stool consistency (e.g., fiber for loose stool) and reducing frequency (e.g., loperamide for diarrhea), and this is generally where I start. Hyoscyamine may be helpful for post-meal leakage. Scheduled defecation and amitriptyline may be of benefit to some patients.

Dr. Henri Damon of Hospices Civils de Lyon, France, and his colleagues conducted a multicenter study of perineal retraining for FI (Dig. Liver Dis. 2014;46:237-42). The intervention included perineal retraining and biofeedback. The protocol was based upon 20 sessions of 30 minutes performed within a 4-month period. The intervention was standardized. Eighty patients were included in the control group, with 77 in the biofeedback group.

The success rate was significantly higher in the biofeedback group (57% vs. 37%; P < .021). Stool frequency, leakage, and urgency significantly decreased. Perineal retraining was significantly associated with a higher chance of self-rated improvement.

The take-home message is that perineal retraining is an effective component of FI treatment. Combining it with improved perianal skin hygiene, bowel habit ritualization, and the addition of fiber as a bulking agent and loperamide for diarrhea offers the greatest hope for patients suffering from this challenging condition.

Our job is to figure out where and how our patients can access the level of expertise needed to do the training.

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. 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.

Fecal incontinence is a devastating and isolating condition. Sales of adult diapers are a $7 billion global market and the fastest-growing household products business. Which is where a lot of our patients with this condition remain – at home.

Fecal incontinence (FI) is a condition characterized by continuous or recurrent uncontrolled passage of fecal material. The prevalence may be as high as 15%. Risk factors include physical disabilities, dementia, diabetes, urinary incontinence, chronic diarrhea, and multiparity. One-third of patients will talk to us about it. Which for some of us may be suitable, given our inability to offer good treatments.

If patients do mention it, evaluation involves taking a good history. We need to differentiate incontinence from fecal urgency and frequency. Anorectal examination should look for a bilateral anal wink (absence suggests nerve damage). Some form of endoscopic examination should be performed in most patients. Further evaluation/referral will be based upon findings.

Treatment includes improving stool consistency (e.g., fiber for loose stool) and reducing frequency (e.g., loperamide for diarrhea), and this is generally where I start. Hyoscyamine may be helpful for post-meal leakage. Scheduled defecation and amitriptyline may be of benefit to some patients.

Dr. Henri Damon of Hospices Civils de Lyon, France, and his colleagues conducted a multicenter study of perineal retraining for FI (Dig. Liver Dis. 2014;46:237-42). The intervention included perineal retraining and biofeedback. The protocol was based upon 20 sessions of 30 minutes performed within a 4-month period. The intervention was standardized. Eighty patients were included in the control group, with 77 in the biofeedback group.

The success rate was significantly higher in the biofeedback group (57% vs. 37%; P < .021). Stool frequency, leakage, and urgency significantly decreased. Perineal retraining was significantly associated with a higher chance of self-rated improvement.

The take-home message is that perineal retraining is an effective component of FI treatment. Combining it with improved perianal skin hygiene, bowel habit ritualization, and the addition of fiber as a bulking agent and loperamide for diarrhea offers the greatest hope for patients suffering from this challenging condition.

Our job is to figure out where and how our patients can access the level of expertise needed to do the training.

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. 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.

SAN DIEGO – Only 1% of families that filled out psychosocial screening questionnaires during medical appointments later sought free mental health consultations, the same rate as for families that were not screened, investigators reported.

“Unless large controlled trials are able to show a process and an outcome benefit, it may be preferable to invest in providing mental health treatment” instead of screening, concluded lead investigator Brianna J. Lewis of the Mount Sinai School of Medicine, New York, and her associates. The researchers presented the findings at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

The study was a post-hoc analysis of data on 3,143 patient encounters at a pediatric allergy clinic in New York City between March and September 2013. Two to five days a week, the investigators had asked children aged 8 years and older and their parents to fill out one-page questionnaires about problems such as distress, anxiety, bullying, and quality-of-life issues. They did not screen patients on the other days, “creating a naturalistic opportunity to compare between screened and nonscreened cohorts,” they added. Because screening was part of regular care, participants did not need to provide informed consent, which eliminated the possibility of selection bias, the researchers said.

In all, 6.1% of families who underwent screening were referred to a mental health consultation, but only 1% followed up, even though consults were offered for free and without third-party billing, the researchers said. The follow-up rate also was 1% for the 1,972 families that were not screened. Among the families who pursued a follow-up consult, 56% of the screened group and 67% of the unscreened group received a psychiatric diagnosis (P = 0.26), Ms. Lewis and her associates reported.

Past studies by the investigators showed that screening children and adults during medical care appointments is “hard to justify,” they noted.

The Jaffe Family Foundation, Pine/Segal Family, and Vanech Family Foundation supported the research. The investigators declared no conflicts of interest.

SAN DIEGO – Only 1% of families that filled out psychosocial screening questionnaires during medical appointments later sought free mental health consultations, the same rate as for families that were not screened, investigators reported.

“Unless large controlled trials are able to show a process and an outcome benefit, it may be preferable to invest in providing mental health treatment” instead of screening, concluded lead investigator Brianna J. Lewis of the Mount Sinai School of Medicine, New York, and her associates. The researchers presented the findings at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

The study was a post-hoc analysis of data on 3,143 patient encounters at a pediatric allergy clinic in New York City between March and September 2013. Two to five days a week, the investigators had asked children aged 8 years and older and their parents to fill out one-page questionnaires about problems such as distress, anxiety, bullying, and quality-of-life issues. They did not screen patients on the other days, “creating a naturalistic opportunity to compare between screened and nonscreened cohorts,” they added. Because screening was part of regular care, participants did not need to provide informed consent, which eliminated the possibility of selection bias, the researchers said.

In all, 6.1% of families who underwent screening were referred to a mental health consultation, but only 1% followed up, even though consults were offered for free and without third-party billing, the researchers said. The follow-up rate also was 1% for the 1,972 families that were not screened. Among the families who pursued a follow-up consult, 56% of the screened group and 67% of the unscreened group received a psychiatric diagnosis (P = 0.26), Ms. Lewis and her associates reported.

Past studies by the investigators showed that screening children and adults during medical care appointments is “hard to justify,” they noted.

The Jaffe Family Foundation, Pine/Segal Family, and Vanech Family Foundation supported the research. The investigators declared no conflicts of interest.

SAN DIEGO – Only 1% of families that filled out psychosocial screening questionnaires during medical appointments later sought free mental health consultations, the same rate as for families that were not screened, investigators reported.

“Unless large controlled trials are able to show a process and an outcome benefit, it may be preferable to invest in providing mental health treatment” instead of screening, concluded lead investigator Brianna J. Lewis of the Mount Sinai School of Medicine, New York, and her associates. The researchers presented the findings at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

The study was a post-hoc analysis of data on 3,143 patient encounters at a pediatric allergy clinic in New York City between March and September 2013. Two to five days a week, the investigators had asked children aged 8 years and older and their parents to fill out one-page questionnaires about problems such as distress, anxiety, bullying, and quality-of-life issues. They did not screen patients on the other days, “creating a naturalistic opportunity to compare between screened and nonscreened cohorts,” they added. Because screening was part of regular care, participants did not need to provide informed consent, which eliminated the possibility of selection bias, the researchers said.

In all, 6.1% of families who underwent screening were referred to a mental health consultation, but only 1% followed up, even though consults were offered for free and without third-party billing, the researchers said. The follow-up rate also was 1% for the 1,972 families that were not screened. Among the families who pursued a follow-up consult, 56% of the screened group and 67% of the unscreened group received a psychiatric diagnosis (P = 0.26), Ms. Lewis and her associates reported.

Past studies by the investigators showed that screening children and adults during medical care appointments is “hard to justify,” they noted.

The Jaffe Family Foundation, Pine/Segal Family, and Vanech Family Foundation supported the research. The investigators declared no conflicts of interest.

Introduction

Autism spectrum disorder is a neurodevelopmental condition characterized by a heterogeneous grouping of social-communication impairments and behavioral phenomena that are observed in early development and often accompanied by an array of co-occurring issues. The prevalence of autism spectrum disorder (ASD) has risen markedly in the last several years (1 in 68 per a 2014 CDC estimate), and the evidence base for early intervention and other treatment strategies supports the idea that a timely and appropriate diagnosis is critical for promoting positive outcomes for children and their families.

With ASD, there can be wide variety in a young child’s presenting symptoms. Although some youth clearly manifest the hallmark features of ASD, ever-changing development, complicated cognitive profiles, family difficulties, co-occurring mental health problems, and evolving nosology (such as DSM changes) can contribute to the difficulty providers encounter in fully interpreting and identifying ASD symptoms in the course of a typical primary care visit. This case example outlines assessment and diagnostic strategies that may help pediatricians to better understand the complexities of diagnosis, assessment, and treatment for children suspected of having ASD. Ideally, a diagnostic evaluation would quickly follow a standardized screening tool that is positive for concern for ASD (such as the Modified Checklist for Autism in Toddlers – Revised) between the ages of 18 and 24 months.

Case summary

Everett is a 4-year-old boy who presents to an autism diagnostic clinic after his parents expressed concerns about his behavior. Everett is described to be a rigid, stubborn, strong-willed, and easily frustrated boy who began to exhibit aggressive behaviors at 18 months of age. He continues to have almost daily temper tantrums. Notably, Everett did not begin to use single words with communicative intent until he was 24 months old. He will often repeat words nonfunctionally and utter nonsensical verbalizations while spinning in circles and rocking back and forth. Everett enjoys being around peers but has difficulties engaging appropriately with other children, exhibiting poor physical boundaries. Everett’s hearing and vision were previously tested to be without deficit, and there is no history of seizure activity or indication of an underlying metabolic disorder.

Discussion

Everett presents with some signs and symptoms to suggest ASD (namely his communication and language impairments accompanied by some atypical social relatedness and repetitive behaviors). His presentation, however, has many characteristics that while common to ASD are not entirely specific to the diagnosis in a preschooler, and could occur with other disorders. For example, Everett’s social difficulties could be the result of an emerging behavioral disorder (an oppositional defiant disorder) or a primary expressive language disorder, which may manifest with frustration intolerance due to communication difficulties.

With children like Everett, a comprehensive autism diagnostic assessment should be obtained and preferably be comprised of a minimum of two components – a caregiver interview and an observational assessment ideally conducted by an experienced clinical interdisciplinary team. Additionally, evaluations of adaptive skills, cognitive profile, family functioning, social-emotional/behavioral functioning, and sensory issues can be useful to inform treatment planning and diagnosis. Ultimately, the diagnosis of ASD is made after clinicians integrate available information and fully consider the range of differential diagnoses. Clinicians who may participate in the diagnostic process include developmental pediatricians, child psychiatrists, clinical psychologists, speech-language pathologists, and other allied health professionals.

Clinical guidelines suggest that gathering a thorough developmental history, assessing for the characteristic impairments that support an ASD diagnosis, and establishing current levels of functioning can be performed using the semistructured Autism Diagnostic Interview – Revised (ADI-R) with primary caregivers. Information about a child’s social interactions also can be obtained with the use of the Social Responsiveness Scale (SRS), which can yield multi-informant data that helps to capture a youth’s functioning and peer interactions in different settings, including home and school.

The observational assessment ideally utilizes the Autism Diagnostic Observation Schedule (ADOS), a standardized instrument that can evaluate domains of reciprocal social interaction, communication, restricted interests, and repetitive behaviors in a developmentally informed manner. Clinicians should be mindful that certain behaviors may not be displayed during the diagnostic evaluation, and as such, scoring on the ADOS should be integrated with other sources of information and interpreted within a developmental framework; no single result on one instrument is sufficient to make or break an autism diagnosis.

The above-mentioned tools were used in Everett’s assessment. Appraising the collected data, his scoring on the ADOS suggested an autism diagnosis, but information from the ADI-R and SRS were not conclusive. To further evaluate Everett, we incorporated a broad developmental evaluation tool, the Mullen Scales of Early Learning, which provided us with a lens through which to interpret his profile of impairments and strengths. Everett scored with average to above-average skills across all domains, which helped us conceptualize that his social, language, and behavioral struggles were not the result of a global developmental delay or intellectual disability.

Additionally, Everett’s family completed the Vineland Adaptive Behavior Scales (his adaptive socialization skills were a relative weakness, and motor skills were a strength) and Child Behavior Checklists, which revealed the endorsement of emotionally reactive and aggressive behavior symptoms from both parents. Everett’s parents’ mental wellness was assessed with Adult Behavior Checklists in order to provide informed family-based treatment recommendations.

In Everett’s evaluation, enduring challenges in the core symptom domains characterizing ASD were noted. His atypical social affect, limited social awareness, and repetitive patterns of behavior provided evidence that Everett met diagnostic criteria for ASD. Also noted were protective factors that promoted his well-being (he’s verbal, has the capacity to play imaginatively, presents with a supportive family, and demonstrates no significant cognitive deficiencies), which were incorporated into our treatment recommendations. Recommendations included enrollment in structured educational and behavioral interventions, and corresponding parent training treatments to help his caregivers manage his disruptive behaviors while reducing the risk for the development of further emotional/behavioral problems in the future.

Everett’s ASD diagnosis also warranted a referral for genetic testing and/or counseling to help the family to obtain information about the etiology of the disorder, screen for other conditions, and help guide appropriate medical management. There were no other indications to pursue additional medical, imaging, or neurological consultations.

Clinical pearl

For some children, the diagnosis of ASD is unclear. Problems arise in making an accurate diagnosis for a variety of reasons, and fully appreciating a child’s (or adolescent’s) developmental challenges can be difficult, especially given the considerable symptom overlap ASD has with other learning, medical, cognitive, or mental health diagnoses. These children require a diagnostic evaluation using a family-focused and culturally sensitive multidisciplinary approach that incorporates standardized tools. As a primary care provider, it can often be difficult to tease out symptoms and have the time to do a thorough assessment; primary providers should be aware of their local assessment expert resources and referral options.

Jeremiah Dickerson, M.D., a child and adolescent psychiatrist, is an assistant professor of psychiatry at the University of Vermont. Dr. Dickerson is the director of the university’s autism diagnostic clinic. Contact Dr. Dickerson at [email protected].

Introduction

Autism spectrum disorder is a neurodevelopmental condition characterized by a heterogeneous grouping of social-communication impairments and behavioral phenomena that are observed in early development and often accompanied by an array of co-occurring issues. The prevalence of autism spectrum disorder (ASD) has risen markedly in the last several years (1 in 68 per a 2014 CDC estimate), and the evidence base for early intervention and other treatment strategies supports the idea that a timely and appropriate diagnosis is critical for promoting positive outcomes for children and their families.

With ASD, there can be wide variety in a young child’s presenting symptoms. Although some youth clearly manifest the hallmark features of ASD, ever-changing development, complicated cognitive profiles, family difficulties, co-occurring mental health problems, and evolving nosology (such as DSM changes) can contribute to the difficulty providers encounter in fully interpreting and identifying ASD symptoms in the course of a typical primary care visit. This case example outlines assessment and diagnostic strategies that may help pediatricians to better understand the complexities of diagnosis, assessment, and treatment for children suspected of having ASD. Ideally, a diagnostic evaluation would quickly follow a standardized screening tool that is positive for concern for ASD (such as the Modified Checklist for Autism in Toddlers – Revised) between the ages of 18 and 24 months.

Case summary

Everett is a 4-year-old boy who presents to an autism diagnostic clinic after his parents expressed concerns about his behavior. Everett is described to be a rigid, stubborn, strong-willed, and easily frustrated boy who began to exhibit aggressive behaviors at 18 months of age. He continues to have almost daily temper tantrums. Notably, Everett did not begin to use single words with communicative intent until he was 24 months old. He will often repeat words nonfunctionally and utter nonsensical verbalizations while spinning in circles and rocking back and forth. Everett enjoys being around peers but has difficulties engaging appropriately with other children, exhibiting poor physical boundaries. Everett’s hearing and vision were previously tested to be without deficit, and there is no history of seizure activity or indication of an underlying metabolic disorder.

Discussion

Everett presents with some signs and symptoms to suggest ASD (namely his communication and language impairments accompanied by some atypical social relatedness and repetitive behaviors). His presentation, however, has many characteristics that while common to ASD are not entirely specific to the diagnosis in a preschooler, and could occur with other disorders. For example, Everett’s social difficulties could be the result of an emerging behavioral disorder (an oppositional defiant disorder) or a primary expressive language disorder, which may manifest with frustration intolerance due to communication difficulties.

With children like Everett, a comprehensive autism diagnostic assessment should be obtained and preferably be comprised of a minimum of two components – a caregiver interview and an observational assessment ideally conducted by an experienced clinical interdisciplinary team. Additionally, evaluations of adaptive skills, cognitive profile, family functioning, social-emotional/behavioral functioning, and sensory issues can be useful to inform treatment planning and diagnosis. Ultimately, the diagnosis of ASD is made after clinicians integrate available information and fully consider the range of differential diagnoses. Clinicians who may participate in the diagnostic process include developmental pediatricians, child psychiatrists, clinical psychologists, speech-language pathologists, and other allied health professionals.

Clinical guidelines suggest that gathering a thorough developmental history, assessing for the characteristic impairments that support an ASD diagnosis, and establishing current levels of functioning can be performed using the semistructured Autism Diagnostic Interview – Revised (ADI-R) with primary caregivers. Information about a child’s social interactions also can be obtained with the use of the Social Responsiveness Scale (SRS), which can yield multi-informant data that helps to capture a youth’s functioning and peer interactions in different settings, including home and school.

The observational assessment ideally utilizes the Autism Diagnostic Observation Schedule (ADOS), a standardized instrument that can evaluate domains of reciprocal social interaction, communication, restricted interests, and repetitive behaviors in a developmentally informed manner. Clinicians should be mindful that certain behaviors may not be displayed during the diagnostic evaluation, and as such, scoring on the ADOS should be integrated with other sources of information and interpreted within a developmental framework; no single result on one instrument is sufficient to make or break an autism diagnosis.

The above-mentioned tools were used in Everett’s assessment. Appraising the collected data, his scoring on the ADOS suggested an autism diagnosis, but information from the ADI-R and SRS were not conclusive. To further evaluate Everett, we incorporated a broad developmental evaluation tool, the Mullen Scales of Early Learning, which provided us with a lens through which to interpret his profile of impairments and strengths. Everett scored with average to above-average skills across all domains, which helped us conceptualize that his social, language, and behavioral struggles were not the result of a global developmental delay or intellectual disability.

Additionally, Everett’s family completed the Vineland Adaptive Behavior Scales (his adaptive socialization skills were a relative weakness, and motor skills were a strength) and Child Behavior Checklists, which revealed the endorsement of emotionally reactive and aggressive behavior symptoms from both parents. Everett’s parents’ mental wellness was assessed with Adult Behavior Checklists in order to provide informed family-based treatment recommendations.

In Everett’s evaluation, enduring challenges in the core symptom domains characterizing ASD were noted. His atypical social affect, limited social awareness, and repetitive patterns of behavior provided evidence that Everett met diagnostic criteria for ASD. Also noted were protective factors that promoted his well-being (he’s verbal, has the capacity to play imaginatively, presents with a supportive family, and demonstrates no significant cognitive deficiencies), which were incorporated into our treatment recommendations. Recommendations included enrollment in structured educational and behavioral interventions, and corresponding parent training treatments to help his caregivers manage his disruptive behaviors while reducing the risk for the development of further emotional/behavioral problems in the future.

Everett’s ASD diagnosis also warranted a referral for genetic testing and/or counseling to help the family to obtain information about the etiology of the disorder, screen for other conditions, and help guide appropriate medical management. There were no other indications to pursue additional medical, imaging, or neurological consultations.

Clinical pearl

For some children, the diagnosis of ASD is unclear. Problems arise in making an accurate diagnosis for a variety of reasons, and fully appreciating a child’s (or adolescent’s) developmental challenges can be difficult, especially given the considerable symptom overlap ASD has with other learning, medical, cognitive, or mental health diagnoses. These children require a diagnostic evaluation using a family-focused and culturally sensitive multidisciplinary approach that incorporates standardized tools. As a primary care provider, it can often be difficult to tease out symptoms and have the time to do a thorough assessment; primary providers should be aware of their local assessment expert resources and referral options.

Jeremiah Dickerson, M.D., a child and adolescent psychiatrist, is an assistant professor of psychiatry at the University of Vermont. Dr. Dickerson is the director of the university’s autism diagnostic clinic. Contact Dr. Dickerson at [email protected].

Introduction

Autism spectrum disorder is a neurodevelopmental condition characterized by a heterogeneous grouping of social-communication impairments and behavioral phenomena that are observed in early development and often accompanied by an array of co-occurring issues. The prevalence of autism spectrum disorder (ASD) has risen markedly in the last several years (1 in 68 per a 2014 CDC estimate), and the evidence base for early intervention and other treatment strategies supports the idea that a timely and appropriate diagnosis is critical for promoting positive outcomes for children and their families.

With ASD, there can be wide variety in a young child’s presenting symptoms. Although some youth clearly manifest the hallmark features of ASD, ever-changing development, complicated cognitive profiles, family difficulties, co-occurring mental health problems, and evolving nosology (such as DSM changes) can contribute to the difficulty providers encounter in fully interpreting and identifying ASD symptoms in the course of a typical primary care visit. This case example outlines assessment and diagnostic strategies that may help pediatricians to better understand the complexities of diagnosis, assessment, and treatment for children suspected of having ASD. Ideally, a diagnostic evaluation would quickly follow a standardized screening tool that is positive for concern for ASD (such as the Modified Checklist for Autism in Toddlers – Revised) between the ages of 18 and 24 months.

Case summary

Everett is a 4-year-old boy who presents to an autism diagnostic clinic after his parents expressed concerns about his behavior. Everett is described to be a rigid, stubborn, strong-willed, and easily frustrated boy who began to exhibit aggressive behaviors at 18 months of age. He continues to have almost daily temper tantrums. Notably, Everett did not begin to use single words with communicative intent until he was 24 months old. He will often repeat words nonfunctionally and utter nonsensical verbalizations while spinning in circles and rocking back and forth. Everett enjoys being around peers but has difficulties engaging appropriately with other children, exhibiting poor physical boundaries. Everett’s hearing and vision were previously tested to be without deficit, and there is no history of seizure activity or indication of an underlying metabolic disorder.

Discussion

Everett presents with some signs and symptoms to suggest ASD (namely his communication and language impairments accompanied by some atypical social relatedness and repetitive behaviors). His presentation, however, has many characteristics that while common to ASD are not entirely specific to the diagnosis in a preschooler, and could occur with other disorders. For example, Everett’s social difficulties could be the result of an emerging behavioral disorder (an oppositional defiant disorder) or a primary expressive language disorder, which may manifest with frustration intolerance due to communication difficulties.

With children like Everett, a comprehensive autism diagnostic assessment should be obtained and preferably be comprised of a minimum of two components – a caregiver interview and an observational assessment ideally conducted by an experienced clinical interdisciplinary team. Additionally, evaluations of adaptive skills, cognitive profile, family functioning, social-emotional/behavioral functioning, and sensory issues can be useful to inform treatment planning and diagnosis. Ultimately, the diagnosis of ASD is made after clinicians integrate available information and fully consider the range of differential diagnoses. Clinicians who may participate in the diagnostic process include developmental pediatricians, child psychiatrists, clinical psychologists, speech-language pathologists, and other allied health professionals.

Clinical guidelines suggest that gathering a thorough developmental history, assessing for the characteristic impairments that support an ASD diagnosis, and establishing current levels of functioning can be performed using the semistructured Autism Diagnostic Interview – Revised (ADI-R) with primary caregivers. Information about a child’s social interactions also can be obtained with the use of the Social Responsiveness Scale (SRS), which can yield multi-informant data that helps to capture a youth’s functioning and peer interactions in different settings, including home and school.

The observational assessment ideally utilizes the Autism Diagnostic Observation Schedule (ADOS), a standardized instrument that can evaluate domains of reciprocal social interaction, communication, restricted interests, and repetitive behaviors in a developmentally informed manner. Clinicians should be mindful that certain behaviors may not be displayed during the diagnostic evaluation, and as such, scoring on the ADOS should be integrated with other sources of information and interpreted within a developmental framework; no single result on one instrument is sufficient to make or break an autism diagnosis.

The above-mentioned tools were used in Everett’s assessment. Appraising the collected data, his scoring on the ADOS suggested an autism diagnosis, but information from the ADI-R and SRS were not conclusive. To further evaluate Everett, we incorporated a broad developmental evaluation tool, the Mullen Scales of Early Learning, which provided us with a lens through which to interpret his profile of impairments and strengths. Everett scored with average to above-average skills across all domains, which helped us conceptualize that his social, language, and behavioral struggles were not the result of a global developmental delay or intellectual disability.

Additionally, Everett’s family completed the Vineland Adaptive Behavior Scales (his adaptive socialization skills were a relative weakness, and motor skills were a strength) and Child Behavior Checklists, which revealed the endorsement of emotionally reactive and aggressive behavior symptoms from both parents. Everett’s parents’ mental wellness was assessed with Adult Behavior Checklists in order to provide informed family-based treatment recommendations.

In Everett’s evaluation, enduring challenges in the core symptom domains characterizing ASD were noted. His atypical social affect, limited social awareness, and repetitive patterns of behavior provided evidence that Everett met diagnostic criteria for ASD. Also noted were protective factors that promoted his well-being (he’s verbal, has the capacity to play imaginatively, presents with a supportive family, and demonstrates no significant cognitive deficiencies), which were incorporated into our treatment recommendations. Recommendations included enrollment in structured educational and behavioral interventions, and corresponding parent training treatments to help his caregivers manage his disruptive behaviors while reducing the risk for the development of further emotional/behavioral problems in the future.

Everett’s ASD diagnosis also warranted a referral for genetic testing and/or counseling to help the family to obtain information about the etiology of the disorder, screen for other conditions, and help guide appropriate medical management. There were no other indications to pursue additional medical, imaging, or neurological consultations.

Clinical pearl

For some children, the diagnosis of ASD is unclear. Problems arise in making an accurate diagnosis for a variety of reasons, and fully appreciating a child’s (or adolescent’s) developmental challenges can be difficult, especially given the considerable symptom overlap ASD has with other learning, medical, cognitive, or mental health diagnoses. These children require a diagnostic evaluation using a family-focused and culturally sensitive multidisciplinary approach that incorporates standardized tools. As a primary care provider, it can often be difficult to tease out symptoms and have the time to do a thorough assessment; primary providers should be aware of their local assessment expert resources and referral options.

Jeremiah Dickerson, M.D., a child and adolescent psychiatrist, is an assistant professor of psychiatry at the University of Vermont. Dr. Dickerson is the director of the university’s autism diagnostic clinic. Contact Dr. Dickerson at [email protected].