Child Psychiatry Consult

After 2 decades of steady decline in adolescent and young adult use of tobacco products, e-cigarettes have dramatically altered the landscape of substance use in youth. E-cigarette use among teens has been on the rise for years but the recent exponential increase is unprecedented. From 2017 to 2018, adolescent e-cigarette use had the largest year-to-year increase (78%, from 12% to 21%) of any individual substance or class of substances at any time during the past 2 decades of nationwide monitoring.¹ This has appropriately caught the nation’s attention. In 2016, Surgeon General Vivek H. Murthy, MD, commissioned an extensive report about electronic cigarettes, and in 2018 Surgeon General Jerome Adams, MD, MPH, issued an advisory declaring e-cigarettes a public health crisis for adolescents.²

licsiren/iStock/Getty Images

E-cigarettes have received attention as a possible boon to adult cigarette smokers seeking a less hazardous product. We can consider the use of tobacco products along a continuum from smoked tobacco, dual use (both smoked tobacco and electronic nicotine delivery), electronic nicotine delivery only, and finally, nonuse. For some adults, transitioning from smoked tobacco products to electronic delivery systems has been a step toward less overall harm from substance use, with a small minority of that population going on to achieve abstinence from all nicotine products.³ For youth and teens, the story has been the opposite. With the rapid rise of e-cigarettes, adolescents overwhelmingly have been moving in the wrong direction at each potential step along this continuum.⁴ Less than 8% of teens who use e-cigarettes indicated that smoking cessation is a factor in their use.⁵ An estimated 1.3 million U.S. teens now are dependent or at high risk for dependence upon nicotine because of e-cigarette use. Furthermore, these teens are at a fourfold higher risk of progression to cigarette use, compared with their peers.⁶

One product in particular gives us information as to why this trend has accelerated so rapidly. Juul, now the sales leader among electronic nicotine delivery systems, rose from approximately 25% to a dominant 75% of market share in just over 1 fiscal year after a social media campaign targeted toward youth and young adults. The device is shaped like an elongated flash drive, is marketed as “sleek,” “looking cool,” and being “super easy” to use. This product touts its use of nicotine salts that can deliver higher concentrations of nicotine more rapidly to mimic the experience of smoking a cigarette as closely as possible. The fruity flavors in Juul “pods” and many other devices also appeal to teens. Many youth are left misinformed, thinking they are using a relatively harmless alternative to cigarettes.

E-cigarette use in youth carries many risks. Among the physical risks is exposure to harmful chemicals (even if less numerous than smoked tobacco products) such as diacetyl (a known cause of bronchiolitis obliterans, or “popcorn lung”), formaldehyde, acrolein, benzene, and metals such as nickel, tin and lead.⁷ “Safer than cigarettes” is a low bar indeed. Cognitive and emotional risks of early nicotine exposure include poor focus and attention, permanent lowering of impulse control, and a higher risk of mood and anxiety disorders.

Furthermore, nicotine is a gateway drug, with a clearly understood molecular basis for how it can potentiate the effects of later used substances, especially stimulants such as cocaine.⁸ The gateway and priming effect is compounded for youth because of ongoing brain development and plasticity during teen years. E-cigarette use also is associated with other risk behaviors including a manyfold higher likelihood of binge drinking, having multiple sexual partners in a short period of time, and using other substances such as cannabis, cocaine, methamphetamine, and heroin or nonprescribed opioids.⁹ An electronic system for vaporization also presents a risk for use of other substances. In just 1 year from 2017 to 2018, marijuana “vaping” increased by more than 50% among all ages surveyed.¹⁰

Pediatric health care providers are essential educators for both teens and parents regarding the risks of e-cigarette use. Many youth don’t know what they’re using; 66% of youth reported that the vapors they were inhaling contained only flavoring. Only 13% reported they were inhaling nicotine.¹⁰ In stark contrast to these self-reports, all Juul “pods” contain nicotine. As has been a pattern with nationwide surveys of substance use for decades, adolescent use is inversely correlated with perception of risk; 70% of 8th-12th graders do not foresee great harm in regular e-cigarette use. In addition, adolescents use substances less often when they know their parents disapprove. Parents also must be taught about the risks of e-cigarette use and can be provided with resources and taught effective strategies if they have difficulty communicating their disapproval to their children.

Age-appropriate screening in primary care settings must include specific language regarding the use of electronic cigarettes, with questions about “vaping” and “juuling.” After screening, a brief intervention includes a clear recommendation against e-cigarette use and education about the risks. Discussions with teens may be more effective with emphasis on issues that resonate with youth such as the financial cost, loss of freedom when dependence develops, and the fact that their generation is once again being targeted by the tobacco industry. Referral for further treatment, including individual and group therapy as well as family-focused interventions, should be considered for teens who use daily, use other substances regularly, or could benefit from treatment for co-occurring mental health disorders.

Electronic cigarette use should not be recommended as a smoking cessation strategy for teens.¹¹ Pediatric health care providers must advocate for regulation of these products, including increasing the legal age of purchase and banning flavoring in e-cigarettes products, Internet sales, and advertisements targeted to youth.

The rapid rise in e-cigarette use among teens is of great concern. As with all classes of substances, early initiation of nicotine drastically increases the risk of developing a substance use disorder and portends a prolonged course and greater accumulation of adverse consequences. There is an urgent need for education, prevention, and early identification of e-cigarette use to protect the current and future well-being of children and adolescents.
 

Dr. Jackson is assistant professor of psychiatry at the University of Vermont, Burlington. He said he had no relevant financial disclosures. Email Dr. Jackson at [email protected].

References

1. MMWR Morb Mortal Wkly Rep. 2018;67:1276-7.

2. e-cigarettes.surgeongeneral.gov

3. N Engl J Med 2019;380:629-37.

4. Pediatrics. 2018 Dec; 142(6):e20180486.

5. MMWR Morb Mortal Wkly Rep 2018;67:196-200.

6. JAMA Pediatr. 2017 Aug 1;171(8):788-97.

7. “Public health consequences of e-cigarettes” (Washington, DC: National Academies Press, January 2018).

8. N Engl J Med 2014;371:932-43.

9. N Engl J Med 2019;380:689-90.

10. MMWR Morb Mortal Wkly Rep. 2016 Jan 8;64(52):1403-8.

11. Pediatrics. 2019 Feb;143(2). pii: e20183652.

After 2 decades of steady decline in adolescent and young adult use of tobacco products, e-cigarettes have dramatically altered the landscape of substance use in youth. E-cigarette use among teens has been on the rise for years but the recent exponential increase is unprecedented. From 2017 to 2018, adolescent e-cigarette use had the largest year-to-year increase (78%, from 12% to 21%) of any individual substance or class of substances at any time during the past 2 decades of nationwide monitoring.¹ This has appropriately caught the nation’s attention. In 2016, Surgeon General Vivek H. Murthy, MD, commissioned an extensive report about electronic cigarettes, and in 2018 Surgeon General Jerome Adams, MD, MPH, issued an advisory declaring e-cigarettes a public health crisis for adolescents.²

licsiren/iStock/Getty Images

E-cigarettes have received attention as a possible boon to adult cigarette smokers seeking a less hazardous product. We can consider the use of tobacco products along a continuum from smoked tobacco, dual use (both smoked tobacco and electronic nicotine delivery), electronic nicotine delivery only, and finally, nonuse. For some adults, transitioning from smoked tobacco products to electronic delivery systems has been a step toward less overall harm from substance use, with a small minority of that population going on to achieve abstinence from all nicotine products.³ For youth and teens, the story has been the opposite. With the rapid rise of e-cigarettes, adolescents overwhelmingly have been moving in the wrong direction at each potential step along this continuum.⁴ Less than 8% of teens who use e-cigarettes indicated that smoking cessation is a factor in their use.⁵ An estimated 1.3 million U.S. teens now are dependent or at high risk for dependence upon nicotine because of e-cigarette use. Furthermore, these teens are at a fourfold higher risk of progression to cigarette use, compared with their peers.⁶

One product in particular gives us information as to why this trend has accelerated so rapidly. Juul, now the sales leader among electronic nicotine delivery systems, rose from approximately 25% to a dominant 75% of market share in just over 1 fiscal year after a social media campaign targeted toward youth and young adults. The device is shaped like an elongated flash drive, is marketed as “sleek,” “looking cool,” and being “super easy” to use. This product touts its use of nicotine salts that can deliver higher concentrations of nicotine more rapidly to mimic the experience of smoking a cigarette as closely as possible. The fruity flavors in Juul “pods” and many other devices also appeal to teens. Many youth are left misinformed, thinking they are using a relatively harmless alternative to cigarettes.

E-cigarette use in youth carries many risks. Among the physical risks is exposure to harmful chemicals (even if less numerous than smoked tobacco products) such as diacetyl (a known cause of bronchiolitis obliterans, or “popcorn lung”), formaldehyde, acrolein, benzene, and metals such as nickel, tin and lead.⁷ “Safer than cigarettes” is a low bar indeed. Cognitive and emotional risks of early nicotine exposure include poor focus and attention, permanent lowering of impulse control, and a higher risk of mood and anxiety disorders.

Furthermore, nicotine is a gateway drug, with a clearly understood molecular basis for how it can potentiate the effects of later used substances, especially stimulants such as cocaine.⁸ The gateway and priming effect is compounded for youth because of ongoing brain development and plasticity during teen years. E-cigarette use also is associated with other risk behaviors including a manyfold higher likelihood of binge drinking, having multiple sexual partners in a short period of time, and using other substances such as cannabis, cocaine, methamphetamine, and heroin or nonprescribed opioids.⁹ An electronic system for vaporization also presents a risk for use of other substances. In just 1 year from 2017 to 2018, marijuana “vaping” increased by more than 50% among all ages surveyed.¹⁰

Pediatric health care providers are essential educators for both teens and parents regarding the risks of e-cigarette use. Many youth don’t know what they’re using; 66% of youth reported that the vapors they were inhaling contained only flavoring. Only 13% reported they were inhaling nicotine.¹⁰ In stark contrast to these self-reports, all Juul “pods” contain nicotine. As has been a pattern with nationwide surveys of substance use for decades, adolescent use is inversely correlated with perception of risk; 70% of 8th-12th graders do not foresee great harm in regular e-cigarette use. In addition, adolescents use substances less often when they know their parents disapprove. Parents also must be taught about the risks of e-cigarette use and can be provided with resources and taught effective strategies if they have difficulty communicating their disapproval to their children.

Age-appropriate screening in primary care settings must include specific language regarding the use of electronic cigarettes, with questions about “vaping” and “juuling.” After screening, a brief intervention includes a clear recommendation against e-cigarette use and education about the risks. Discussions with teens may be more effective with emphasis on issues that resonate with youth such as the financial cost, loss of freedom when dependence develops, and the fact that their generation is once again being targeted by the tobacco industry. Referral for further treatment, including individual and group therapy as well as family-focused interventions, should be considered for teens who use daily, use other substances regularly, or could benefit from treatment for co-occurring mental health disorders.

Electronic cigarette use should not be recommended as a smoking cessation strategy for teens.¹¹ Pediatric health care providers must advocate for regulation of these products, including increasing the legal age of purchase and banning flavoring in e-cigarettes products, Internet sales, and advertisements targeted to youth.

The rapid rise in e-cigarette use among teens is of great concern. As with all classes of substances, early initiation of nicotine drastically increases the risk of developing a substance use disorder and portends a prolonged course and greater accumulation of adverse consequences. There is an urgent need for education, prevention, and early identification of e-cigarette use to protect the current and future well-being of children and adolescents.
 

Dr. Jackson is assistant professor of psychiatry at the University of Vermont, Burlington. He said he had no relevant financial disclosures. Email Dr. Jackson at [email protected].

References

1. MMWR Morb Mortal Wkly Rep. 2018;67:1276-7.

2. e-cigarettes.surgeongeneral.gov

3. N Engl J Med 2019;380:629-37.

4. Pediatrics. 2018 Dec; 142(6):e20180486.

5. MMWR Morb Mortal Wkly Rep 2018;67:196-200.

6. JAMA Pediatr. 2017 Aug 1;171(8):788-97.

7. “Public health consequences of e-cigarettes” (Washington, DC: National Academies Press, January 2018).

8. N Engl J Med 2014;371:932-43.

9. N Engl J Med 2019;380:689-90.

10. MMWR Morb Mortal Wkly Rep. 2016 Jan 8;64(52):1403-8.

11. Pediatrics. 2019 Feb;143(2). pii: e20183652.

After 2 decades of steady decline in adolescent and young adult use of tobacco products, e-cigarettes have dramatically altered the landscape of substance use in youth. E-cigarette use among teens has been on the rise for years but the recent exponential increase is unprecedented. From 2017 to 2018, adolescent e-cigarette use had the largest year-to-year increase (78%, from 12% to 21%) of any individual substance or class of substances at any time during the past 2 decades of nationwide monitoring.¹ This has appropriately caught the nation’s attention. In 2016, Surgeon General Vivek H. Murthy, MD, commissioned an extensive report about electronic cigarettes, and in 2018 Surgeon General Jerome Adams, MD, MPH, issued an advisory declaring e-cigarettes a public health crisis for adolescents.²

licsiren/iStock/Getty Images

E-cigarettes have received attention as a possible boon to adult cigarette smokers seeking a less hazardous product. We can consider the use of tobacco products along a continuum from smoked tobacco, dual use (both smoked tobacco and electronic nicotine delivery), electronic nicotine delivery only, and finally, nonuse. For some adults, transitioning from smoked tobacco products to electronic delivery systems has been a step toward less overall harm from substance use, with a small minority of that population going on to achieve abstinence from all nicotine products.³ For youth and teens, the story has been the opposite. With the rapid rise of e-cigarettes, adolescents overwhelmingly have been moving in the wrong direction at each potential step along this continuum.⁴ Less than 8% of teens who use e-cigarettes indicated that smoking cessation is a factor in their use.⁵ An estimated 1.3 million U.S. teens now are dependent or at high risk for dependence upon nicotine because of e-cigarette use. Furthermore, these teens are at a fourfold higher risk of progression to cigarette use, compared with their peers.⁶

One product in particular gives us information as to why this trend has accelerated so rapidly. Juul, now the sales leader among electronic nicotine delivery systems, rose from approximately 25% to a dominant 75% of market share in just over 1 fiscal year after a social media campaign targeted toward youth and young adults. The device is shaped like an elongated flash drive, is marketed as “sleek,” “looking cool,” and being “super easy” to use. This product touts its use of nicotine salts that can deliver higher concentrations of nicotine more rapidly to mimic the experience of smoking a cigarette as closely as possible. The fruity flavors in Juul “pods” and many other devices also appeal to teens. Many youth are left misinformed, thinking they are using a relatively harmless alternative to cigarettes.

E-cigarette use in youth carries many risks. Among the physical risks is exposure to harmful chemicals (even if less numerous than smoked tobacco products) such as diacetyl (a known cause of bronchiolitis obliterans, or “popcorn lung”), formaldehyde, acrolein, benzene, and metals such as nickel, tin and lead.⁷ “Safer than cigarettes” is a low bar indeed. Cognitive and emotional risks of early nicotine exposure include poor focus and attention, permanent lowering of impulse control, and a higher risk of mood and anxiety disorders.

Furthermore, nicotine is a gateway drug, with a clearly understood molecular basis for how it can potentiate the effects of later used substances, especially stimulants such as cocaine.⁸ The gateway and priming effect is compounded for youth because of ongoing brain development and plasticity during teen years. E-cigarette use also is associated with other risk behaviors including a manyfold higher likelihood of binge drinking, having multiple sexual partners in a short period of time, and using other substances such as cannabis, cocaine, methamphetamine, and heroin or nonprescribed opioids.⁹ An electronic system for vaporization also presents a risk for use of other substances. In just 1 year from 2017 to 2018, marijuana “vaping” increased by more than 50% among all ages surveyed.¹⁰

Pediatric health care providers are essential educators for both teens and parents regarding the risks of e-cigarette use. Many youth don’t know what they’re using; 66% of youth reported that the vapors they were inhaling contained only flavoring. Only 13% reported they were inhaling nicotine.¹⁰ In stark contrast to these self-reports, all Juul “pods” contain nicotine. As has been a pattern with nationwide surveys of substance use for decades, adolescent use is inversely correlated with perception of risk; 70% of 8th-12th graders do not foresee great harm in regular e-cigarette use. In addition, adolescents use substances less often when they know their parents disapprove. Parents also must be taught about the risks of e-cigarette use and can be provided with resources and taught effective strategies if they have difficulty communicating their disapproval to their children.

Age-appropriate screening in primary care settings must include specific language regarding the use of electronic cigarettes, with questions about “vaping” and “juuling.” After screening, a brief intervention includes a clear recommendation against e-cigarette use and education about the risks. Discussions with teens may be more effective with emphasis on issues that resonate with youth such as the financial cost, loss of freedom when dependence develops, and the fact that their generation is once again being targeted by the tobacco industry. Referral for further treatment, including individual and group therapy as well as family-focused interventions, should be considered for teens who use daily, use other substances regularly, or could benefit from treatment for co-occurring mental health disorders.

Electronic cigarette use should not be recommended as a smoking cessation strategy for teens.¹¹ Pediatric health care providers must advocate for regulation of these products, including increasing the legal age of purchase and banning flavoring in e-cigarettes products, Internet sales, and advertisements targeted to youth.

The rapid rise in e-cigarette use among teens is of great concern. As with all classes of substances, early initiation of nicotine drastically increases the risk of developing a substance use disorder and portends a prolonged course and greater accumulation of adverse consequences. There is an urgent need for education, prevention, and early identification of e-cigarette use to protect the current and future well-being of children and adolescents.
 

Dr. Jackson is assistant professor of psychiatry at the University of Vermont, Burlington. He said he had no relevant financial disclosures. Email Dr. Jackson at [email protected].

References

1. MMWR Morb Mortal Wkly Rep. 2018;67:1276-7.

2. e-cigarettes.surgeongeneral.gov

3. N Engl J Med 2019;380:629-37.

4. Pediatrics. 2018 Dec; 142(6):e20180486.

5. MMWR Morb Mortal Wkly Rep 2018;67:196-200.

6. JAMA Pediatr. 2017 Aug 1;171(8):788-97.

7. “Public health consequences of e-cigarettes” (Washington, DC: National Academies Press, January 2018).

8. N Engl J Med 2014;371:932-43.

9. N Engl J Med 2019;380:689-90.

10. MMWR Morb Mortal Wkly Rep. 2016 Jan 8;64(52):1403-8.

11. Pediatrics. 2019 Feb;143(2). pii: e20183652.

Paul is 13-year-old male in seventh grade with a history of inattentive ADHD and a positive family history of depression and anxiety in his mother. He always has had a few friends, but recently they have not wanted to hang out with him; he feels like people are ignoring him. For the past 2 months, Paul’s mood has gotten very low. He feels sad and also bored because he is not enjoying anything anymore. He feels as though he is “a loser,” and as though nothing will ever get better. His grades have dropped. He has thoughts of wishing he were dead, although he has no specific plan and says he wouldn’t do it because he doesn’t want to hurt his parents. He is looking at his phone at night and gets to bed late, then doesn’t want to get up in the morning. He sleeps until noon on weekends. Appetite is increased. He doesn’t have energy to do things on the weekends.

Discussion

Paul clearly meets diagnostic criteria for depression. He feels sad and has lost pleasure in activities he used to enjoy. He has negative, hopeless thoughts, and vague thoughts of death although no specific plans. He has vegetative signs of depression with increased appetite and sleep; he likely has worse concentration than usual, given that his grades have dropped. Energy is low.

Both medications and specific types of psychotherapy are effective for treating depression in adolescents.

Meta-analyses have demonstrated the efficacy of SSRIs (fluoxetine, sertraline, citalopram, escitalopram) as well as venlafaxine, mirtazapine, and nefazodone with small to very small effect sizes.¹ A large placebo effect is seen in many of these studies, correlating with the number of study sites – a feature of many industry-sponsored studies.

John Walkup, MD, a leading researcher on both medication and psychotherapeutic interventions in children’s mood disorders, has pointed out that the quality of industry-sponsored studies (vs. National Institute of Mental Health–sponsored studies) is likely lower, with more pressure to get in large numbers of patients in a short period of time, less trained investigators leading to less clear-cut diagnoses, and other sources of bias.² This raises the question of whether we should weight NIMH-sponsored studies more heavily in meta-analyses.

A second factor to consider is the risk of harm, and a significant issue here is the question of whether suicidal ideation is increased among those patients taking SSRIs. Meta-analyses from the late 2000s, which balanced the number needed to treat vs. the number needed to harm, judged that for children under age 13 years, fluoxetine was the only antidepressant that was worth the cost-benefit ratio. However, in the past several years there has been a major improvement in the assessment of suicidal ideation in the form of the Columbia Suicide Severity Rating Scale, a standardized method of assessing the presence and significance of suicidal thoughts and behaviors. Studies that have used this assessment have found no significant increase in suicidal ideation with SSRIs vs. placebo.

The takeaway here is that the SSRIs can work, with fluoxetine, sertraline, and escitalopram leading the evidence, and that with refinements of the assessment they do not appear to increase the risk of suicidal ideation.³ Of course, it remains important to discuss this issue with families.

Flamingo_Photography/Getty Images

Psychotherapy is the other major treatment for depression. Cognitive behavioral therapy (CBT) and Interpersonal therapy (IPT) for adolescents show effectiveness in teens.⁴ Recent meta-analyses have gotten stronger through the use of stringent quality criteria and the inclusion of negative studies; these therapies continue to be considered well established. It is worthwhile to talk to therapists in your community to understand what type of treatment they offer. If you are hiring therapists to be embedded in your practice, look for people who have been trained in CBT or IPT. It is particularly helpful to know whether therapists have seen patients using CBT or IPT while getting supervision in these modalities.

CBT and IPT are different. CBT puts an emphasis on the thought-feeling-behavior triangle while IPT focuses more on relationships. Someone who has tried one and has not benefited nevertheless may benefit from the other.

Working with your patients to choose what type of psychotherapy modality for depression they would like is particularly effective.

Finally, be aware of how the environment may be affecting your patient. School issues related to peers, learning style or disabilities, and organization have a major effect on teens. In this case, Paul is looking at his phone nightly, which may be affecting both his sleep and self-esteem. Family issues continue to play a key role.

Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures. Email her at [email protected].

References

1. JAMA. 2007 Apr 18;297(15):1683-96.

2. Am J Psychiatry. 2017 May 1;174(5):430-7.

3. J Child Adolesc Psychopharmacol. 2018. doi: 10.1089/cap.2017.0174.

4. J Clin Child Adolesc Psychol. 2017 Jan-Feb;46(1):11-43.

Paul is 13-year-old male in seventh grade with a history of inattentive ADHD and a positive family history of depression and anxiety in his mother. He always has had a few friends, but recently they have not wanted to hang out with him; he feels like people are ignoring him. For the past 2 months, Paul’s mood has gotten very low. He feels sad and also bored because he is not enjoying anything anymore. He feels as though he is “a loser,” and as though nothing will ever get better. His grades have dropped. He has thoughts of wishing he were dead, although he has no specific plan and says he wouldn’t do it because he doesn’t want to hurt his parents. He is looking at his phone at night and gets to bed late, then doesn’t want to get up in the morning. He sleeps until noon on weekends. Appetite is increased. He doesn’t have energy to do things on the weekends.

Discussion

Paul clearly meets diagnostic criteria for depression. He feels sad and has lost pleasure in activities he used to enjoy. He has negative, hopeless thoughts, and vague thoughts of death although no specific plans. He has vegetative signs of depression with increased appetite and sleep; he likely has worse concentration than usual, given that his grades have dropped. Energy is low.

Both medications and specific types of psychotherapy are effective for treating depression in adolescents.

Meta-analyses have demonstrated the efficacy of SSRIs (fluoxetine, sertraline, citalopram, escitalopram) as well as venlafaxine, mirtazapine, and nefazodone with small to very small effect sizes.¹ A large placebo effect is seen in many of these studies, correlating with the number of study sites – a feature of many industry-sponsored studies.

John Walkup, MD, a leading researcher on both medication and psychotherapeutic interventions in children’s mood disorders, has pointed out that the quality of industry-sponsored studies (vs. National Institute of Mental Health–sponsored studies) is likely lower, with more pressure to get in large numbers of patients in a short period of time, less trained investigators leading to less clear-cut diagnoses, and other sources of bias.² This raises the question of whether we should weight NIMH-sponsored studies more heavily in meta-analyses.

A second factor to consider is the risk of harm, and a significant issue here is the question of whether suicidal ideation is increased among those patients taking SSRIs. Meta-analyses from the late 2000s, which balanced the number needed to treat vs. the number needed to harm, judged that for children under age 13 years, fluoxetine was the only antidepressant that was worth the cost-benefit ratio. However, in the past several years there has been a major improvement in the assessment of suicidal ideation in the form of the Columbia Suicide Severity Rating Scale, a standardized method of assessing the presence and significance of suicidal thoughts and behaviors. Studies that have used this assessment have found no significant increase in suicidal ideation with SSRIs vs. placebo.

The takeaway here is that the SSRIs can work, with fluoxetine, sertraline, and escitalopram leading the evidence, and that with refinements of the assessment they do not appear to increase the risk of suicidal ideation.³ Of course, it remains important to discuss this issue with families.

Flamingo_Photography/Getty Images

Psychotherapy is the other major treatment for depression. Cognitive behavioral therapy (CBT) and Interpersonal therapy (IPT) for adolescents show effectiveness in teens.⁴ Recent meta-analyses have gotten stronger through the use of stringent quality criteria and the inclusion of negative studies; these therapies continue to be considered well established. It is worthwhile to talk to therapists in your community to understand what type of treatment they offer. If you are hiring therapists to be embedded in your practice, look for people who have been trained in CBT or IPT. It is particularly helpful to know whether therapists have seen patients using CBT or IPT while getting supervision in these modalities.

CBT and IPT are different. CBT puts an emphasis on the thought-feeling-behavior triangle while IPT focuses more on relationships. Someone who has tried one and has not benefited nevertheless may benefit from the other.

Working with your patients to choose what type of psychotherapy modality for depression they would like is particularly effective.

Finally, be aware of how the environment may be affecting your patient. School issues related to peers, learning style or disabilities, and organization have a major effect on teens. In this case, Paul is looking at his phone nightly, which may be affecting both his sleep and self-esteem. Family issues continue to play a key role.

Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures. Email her at [email protected].

References

1. JAMA. 2007 Apr 18;297(15):1683-96.

2. Am J Psychiatry. 2017 May 1;174(5):430-7.

3. J Child Adolesc Psychopharmacol. 2018. doi: 10.1089/cap.2017.0174.

4. J Clin Child Adolesc Psychol. 2017 Jan-Feb;46(1):11-43.

Paul is 13-year-old male in seventh grade with a history of inattentive ADHD and a positive family history of depression and anxiety in his mother. He always has had a few friends, but recently they have not wanted to hang out with him; he feels like people are ignoring him. For the past 2 months, Paul’s mood has gotten very low. He feels sad and also bored because he is not enjoying anything anymore. He feels as though he is “a loser,” and as though nothing will ever get better. His grades have dropped. He has thoughts of wishing he were dead, although he has no specific plan and says he wouldn’t do it because he doesn’t want to hurt his parents. He is looking at his phone at night and gets to bed late, then doesn’t want to get up in the morning. He sleeps until noon on weekends. Appetite is increased. He doesn’t have energy to do things on the weekends.

Discussion

Paul clearly meets diagnostic criteria for depression. He feels sad and has lost pleasure in activities he used to enjoy. He has negative, hopeless thoughts, and vague thoughts of death although no specific plans. He has vegetative signs of depression with increased appetite and sleep; he likely has worse concentration than usual, given that his grades have dropped. Energy is low.

Both medications and specific types of psychotherapy are effective for treating depression in adolescents.

Meta-analyses have demonstrated the efficacy of SSRIs (fluoxetine, sertraline, citalopram, escitalopram) as well as venlafaxine, mirtazapine, and nefazodone with small to very small effect sizes.¹ A large placebo effect is seen in many of these studies, correlating with the number of study sites – a feature of many industry-sponsored studies.

John Walkup, MD, a leading researcher on both medication and psychotherapeutic interventions in children’s mood disorders, has pointed out that the quality of industry-sponsored studies (vs. National Institute of Mental Health–sponsored studies) is likely lower, with more pressure to get in large numbers of patients in a short period of time, less trained investigators leading to less clear-cut diagnoses, and other sources of bias.² This raises the question of whether we should weight NIMH-sponsored studies more heavily in meta-analyses.

A second factor to consider is the risk of harm, and a significant issue here is the question of whether suicidal ideation is increased among those patients taking SSRIs. Meta-analyses from the late 2000s, which balanced the number needed to treat vs. the number needed to harm, judged that for children under age 13 years, fluoxetine was the only antidepressant that was worth the cost-benefit ratio. However, in the past several years there has been a major improvement in the assessment of suicidal ideation in the form of the Columbia Suicide Severity Rating Scale, a standardized method of assessing the presence and significance of suicidal thoughts and behaviors. Studies that have used this assessment have found no significant increase in suicidal ideation with SSRIs vs. placebo.

The takeaway here is that the SSRIs can work, with fluoxetine, sertraline, and escitalopram leading the evidence, and that with refinements of the assessment they do not appear to increase the risk of suicidal ideation.³ Of course, it remains important to discuss this issue with families.

Flamingo_Photography/Getty Images

Psychotherapy is the other major treatment for depression. Cognitive behavioral therapy (CBT) and Interpersonal therapy (IPT) for adolescents show effectiveness in teens.⁴ Recent meta-analyses have gotten stronger through the use of stringent quality criteria and the inclusion of negative studies; these therapies continue to be considered well established. It is worthwhile to talk to therapists in your community to understand what type of treatment they offer. If you are hiring therapists to be embedded in your practice, look for people who have been trained in CBT or IPT. It is particularly helpful to know whether therapists have seen patients using CBT or IPT while getting supervision in these modalities.

CBT and IPT are different. CBT puts an emphasis on the thought-feeling-behavior triangle while IPT focuses more on relationships. Someone who has tried one and has not benefited nevertheless may benefit from the other.

Working with your patients to choose what type of psychotherapy modality for depression they would like is particularly effective.

Finally, be aware of how the environment may be affecting your patient. School issues related to peers, learning style or disabilities, and organization have a major effect on teens. In this case, Paul is looking at his phone nightly, which may be affecting both his sleep and self-esteem. Family issues continue to play a key role.

Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures. Email her at [email protected].

References

1. JAMA. 2007 Apr 18;297(15):1683-96.

2. Am J Psychiatry. 2017 May 1;174(5):430-7.

3. J Child Adolesc Psychopharmacol. 2018. doi: 10.1089/cap.2017.0174.

4. J Clin Child Adolesc Psychol. 2017 Jan-Feb;46(1):11-43.

• A 9-year-old boy has poor impulse control, throws things in class, and cannot sit still. Teachers ask: Is this ADHD and should we start a medication?
• A 9-year-old girl is an inattentive daydreamer with poor class performance and trouble turning in homework. Her parents and teachers ask: Is this ADHD and should we start a medication?
• A 17-year-old boy who is a high achiever is taking the upcoming SATs and does poorly on timed tests because of poor focus and is now wondering: Do I have ADHD and would a medication help me perform better?
• A 17-year-old boy had poor grades for much of his early school years, but his parents always thought he was just a “lazy kid” although he insists he is trying his best. His parents now ask: Is this ADHD and has it been all along?

The above cases may sound familiar to you. They are an oversimplification of the patients who may come to you with two questions: Do I or someone I care about have ADHD and should they have medication for it? What may matter even more is how they are doing with that inattentiveness and how much it impacts their lives.

Sigmund Freud was known to think about goals for treatment as “liebe und arbeit” translated into “to love and to work.” As in, can someone live, love, and work or are their psychiatric symptoms impairing those functionalities? For a child, to live, work, and play (well with others) is most apt here. It is often more helpful to think in terms of childhood daily life when choosing to begin a medication or not. With inattention, a child can range from having a parent hoping for performance enhancement to having a severe impairment in their day-to-day functioning in a classroom. In the above case examples, each child or adolescent has varying impairments in performance – one is a high academic performer with very few issues outside of testing and another is a young child who can’t even sit still in a classroom to learn. Who should be prescribed a stimulant? Any or all of the above? It’s not as easy an answer as you may suspect, and there may not be one “right” answer either.

We know that stimulants can help a great deal of patients. They have the highest effect size for ADHD in that about 80% of children can benefit from stimulant treatment for ADHD. Specifically, “a high response rate of 70%-85% has been noted with methylphenidate and amphetamine formulations. The response rate is lower for atomoxetine [60%-65%] and guanfacine [30%-40%]” (Venkat B, Hechtman L. Considerations in selecting pharmacological treatments for attention deficit hyperactivity disorder. Clinical Pharmacist. 2016 Feb 11). In thinking about when to prescribe, we want to balance offering nonpharmacologic means to address symptoms of inattention (like mindfulness, exercise, and school supports such as individualized learning plans where applicable). We also do not want to withhold helpful treatments such as stimulants or other nonstimulant medications or trend toward overprescribing potentially habit-forming and imperfect medications.

It is important to make that distinction between impairment and the desire for medications to “enhance” life and optimize performance rather than treating symptoms of a disorder. Most ADHD patients struggle to organize their lives, and the inattentiveness can create conflicts and challenges that won’t be managed with medication alone. It is most helpful to gain skills to navigate those challenges simultaneously to ultimately help our patients live, learn, love, and play to the best of their abilities.
 

Where to begin

When I was in training, I had difficulty teasing out the various ADHD stimulant formations. There were and are so many Ritalin preparations! Mostly there is a variation in shorter-acting to longer-acting effects. If the diagnosis is highly suspected and uncomplicated ADHD, I usually choose to start with Concerta 18 mg daily (a long-acting methylphenidate) for children aged over 6 years. Many times I don’t see the need to titrate that upwards much further toward the maximum clinically used dose of 54 mg daily (despite guidelines saying otherwise up to 72 mg daily, which I have found unnecessary usually and poorly tolerated). Concerta has an immediate effect (20%) and then slowly peaks until 12 p.m. (80%) and then is out of system by about 3 p.m. (for a total of 7 hours duration of action). There also are shorter-acting preparations (Ritalin, Methylin) which are “on/off” in 4 hours and use of these is more consistent with an antiquated way of prescribing, often up to twice daily and three times daily dosing schedules with the risk of the harder to tolerate “drop-off” effects with stimulants. And, if there is not an effect, I often reconsider the diagnosis and any co-occurring anxiety disorder, stressful life events, or depression or other illness with the knowledge that these medications so often are effective.

Anxiety + ADHD

If there is prominent anxiety, anxiety disorder, or tics, I often consider Strattera 10-20 mg daily up to around 40 mg. I tend to dose this lower than as written for tolerability and in a “dose low and go slow” approach with kids, which often results in better experiences with the medication. This medication also is recommended to be dosed by weight; this should be taken into account as well. Atomoxetine is a selective serotonin and norepinephrine reuptake inhibitor which is likely similar to Cymbalta (duloxetine). It may have a lower effect size of around less than 60% but this also is around the reported effect sizes for selective serotonin reuptake inhibitors (SSRIs) for depression. If a patient has both ADHD and an anxiety disorder, I often consider an SSRI alternatively first to manage attention issues associated with anxiety and then would add on a stimulant if attention issues persist once anxiety is better treated.

Second/third line ADHD treatments

As a second-line approach to long-acting Ritalin and if there is not a response to it, I would consider extended-release Adderall preparations such as Vyvanse, which is an amphetamine preparation supposedly less abusable than Adderall (one can’t snort it), but I also caution that it releases dopamine, peaks faster, and does not reduce to zero stimulant in 24 hours because of a variable half-life.

In this way, I always have imagined that these amphetamines may be more theoretically concerning than Ritalin/methylphenidate because they increase dopamine dumping into the synapse (which is a different and extra mechanism than just reuptake). For a third line, I may consider guanfacine depending on weight daily, which is an Food and Drug Administration–approved, nonstimulant alpha-2 agonist, which also acts longer than clonidine and may be better for hyperactivity symptoms. I may begin with doses as low as 0.25-0.5 mg in the evening for concerns with sedation or groggy aftereffects in the morning.

Throughout all treatment with medication, I emphasize the importance of assertively managing ADHD symptoms which may be in the form of “behavioral treatment,” like cognitive behavioral therapy, organizational coaching available at some educational centers, or even finding ways to train one’s focus with athletics or practices such as yoga and mindfulness. In addition to this combined approach to treatment, stimulants are not perfect medications. All stimulants have a “drop-off effect” and were made to work during a school day lasting from 8 a.m. to 3 p.m. Some patients and families complain about the drop-off effect and may want to “dose” around a medication more frequently, in the late afternoon and in the evening, which can lead to poor appetite at dinner and insomnia.

My answers to the cases above would be that all the patients could have ADHD, but they also may have anxiety or stress-related disorders, depression, worries about performance, or poor skills to manage inattention. They may not yet have received school supports, coaching, or found ways to manage these symptoms either. Because stimulants can improve and enhance performance but also have their own drawbacks and risks not covered here, it’s important to consider each case as a whole with thoughtfulness about a child’s unique ability to “live and work” in this world.

Dr. Pawlowski is an adult, adolescent, and child psychiatrist at the University of Vermont Medical Center and an assistant professor of psychiatry at UVM, both in Burlington. She reported no relevant financial disclosures. Email her at [email protected].

• A 9-year-old boy has poor impulse control, throws things in class, and cannot sit still. Teachers ask: Is this ADHD and should we start a medication?
• A 9-year-old girl is an inattentive daydreamer with poor class performance and trouble turning in homework. Her parents and teachers ask: Is this ADHD and should we start a medication?
• A 17-year-old boy who is a high achiever is taking the upcoming SATs and does poorly on timed tests because of poor focus and is now wondering: Do I have ADHD and would a medication help me perform better?
• A 17-year-old boy had poor grades for much of his early school years, but his parents always thought he was just a “lazy kid” although he insists he is trying his best. His parents now ask: Is this ADHD and has it been all along?

The above cases may sound familiar to you. They are an oversimplification of the patients who may come to you with two questions: Do I or someone I care about have ADHD and should they have medication for it? What may matter even more is how they are doing with that inattentiveness and how much it impacts their lives.

Sigmund Freud was known to think about goals for treatment as “liebe und arbeit” translated into “to love and to work.” As in, can someone live, love, and work or are their psychiatric symptoms impairing those functionalities? For a child, to live, work, and play (well with others) is most apt here. It is often more helpful to think in terms of childhood daily life when choosing to begin a medication or not. With inattention, a child can range from having a parent hoping for performance enhancement to having a severe impairment in their day-to-day functioning in a classroom. In the above case examples, each child or adolescent has varying impairments in performance – one is a high academic performer with very few issues outside of testing and another is a young child who can’t even sit still in a classroom to learn. Who should be prescribed a stimulant? Any or all of the above? It’s not as easy an answer as you may suspect, and there may not be one “right” answer either.

We know that stimulants can help a great deal of patients. They have the highest effect size for ADHD in that about 80% of children can benefit from stimulant treatment for ADHD. Specifically, “a high response rate of 70%-85% has been noted with methylphenidate and amphetamine formulations. The response rate is lower for atomoxetine [60%-65%] and guanfacine [30%-40%]” (Venkat B, Hechtman L. Considerations in selecting pharmacological treatments for attention deficit hyperactivity disorder. Clinical Pharmacist. 2016 Feb 11). In thinking about when to prescribe, we want to balance offering nonpharmacologic means to address symptoms of inattention (like mindfulness, exercise, and school supports such as individualized learning plans where applicable). We also do not want to withhold helpful treatments such as stimulants or other nonstimulant medications or trend toward overprescribing potentially habit-forming and imperfect medications.

It is important to make that distinction between impairment and the desire for medications to “enhance” life and optimize performance rather than treating symptoms of a disorder. Most ADHD patients struggle to organize their lives, and the inattentiveness can create conflicts and challenges that won’t be managed with medication alone. It is most helpful to gain skills to navigate those challenges simultaneously to ultimately help our patients live, learn, love, and play to the best of their abilities.
 

Where to begin

When I was in training, I had difficulty teasing out the various ADHD stimulant formations. There were and are so many Ritalin preparations! Mostly there is a variation in shorter-acting to longer-acting effects. If the diagnosis is highly suspected and uncomplicated ADHD, I usually choose to start with Concerta 18 mg daily (a long-acting methylphenidate) for children aged over 6 years. Many times I don’t see the need to titrate that upwards much further toward the maximum clinically used dose of 54 mg daily (despite guidelines saying otherwise up to 72 mg daily, which I have found unnecessary usually and poorly tolerated). Concerta has an immediate effect (20%) and then slowly peaks until 12 p.m. (80%) and then is out of system by about 3 p.m. (for a total of 7 hours duration of action). There also are shorter-acting preparations (Ritalin, Methylin) which are “on/off” in 4 hours and use of these is more consistent with an antiquated way of prescribing, often up to twice daily and three times daily dosing schedules with the risk of the harder to tolerate “drop-off” effects with stimulants. And, if there is not an effect, I often reconsider the diagnosis and any co-occurring anxiety disorder, stressful life events, or depression or other illness with the knowledge that these medications so often are effective.

Anxiety + ADHD

If there is prominent anxiety, anxiety disorder, or tics, I often consider Strattera 10-20 mg daily up to around 40 mg. I tend to dose this lower than as written for tolerability and in a “dose low and go slow” approach with kids, which often results in better experiences with the medication. This medication also is recommended to be dosed by weight; this should be taken into account as well. Atomoxetine is a selective serotonin and norepinephrine reuptake inhibitor which is likely similar to Cymbalta (duloxetine). It may have a lower effect size of around less than 60% but this also is around the reported effect sizes for selective serotonin reuptake inhibitors (SSRIs) for depression. If a patient has both ADHD and an anxiety disorder, I often consider an SSRI alternatively first to manage attention issues associated with anxiety and then would add on a stimulant if attention issues persist once anxiety is better treated.

Second/third line ADHD treatments

As a second-line approach to long-acting Ritalin and if there is not a response to it, I would consider extended-release Adderall preparations such as Vyvanse, which is an amphetamine preparation supposedly less abusable than Adderall (one can’t snort it), but I also caution that it releases dopamine, peaks faster, and does not reduce to zero stimulant in 24 hours because of a variable half-life.

In this way, I always have imagined that these amphetamines may be more theoretically concerning than Ritalin/methylphenidate because they increase dopamine dumping into the synapse (which is a different and extra mechanism than just reuptake). For a third line, I may consider guanfacine depending on weight daily, which is an Food and Drug Administration–approved, nonstimulant alpha-2 agonist, which also acts longer than clonidine and may be better for hyperactivity symptoms. I may begin with doses as low as 0.25-0.5 mg in the evening for concerns with sedation or groggy aftereffects in the morning.

Throughout all treatment with medication, I emphasize the importance of assertively managing ADHD symptoms which may be in the form of “behavioral treatment,” like cognitive behavioral therapy, organizational coaching available at some educational centers, or even finding ways to train one’s focus with athletics or practices such as yoga and mindfulness. In addition to this combined approach to treatment, stimulants are not perfect medications. All stimulants have a “drop-off effect” and were made to work during a school day lasting from 8 a.m. to 3 p.m. Some patients and families complain about the drop-off effect and may want to “dose” around a medication more frequently, in the late afternoon and in the evening, which can lead to poor appetite at dinner and insomnia.

My answers to the cases above would be that all the patients could have ADHD, but they also may have anxiety or stress-related disorders, depression, worries about performance, or poor skills to manage inattention. They may not yet have received school supports, coaching, or found ways to manage these symptoms either. Because stimulants can improve and enhance performance but also have their own drawbacks and risks not covered here, it’s important to consider each case as a whole with thoughtfulness about a child’s unique ability to “live and work” in this world.

Dr. Pawlowski is an adult, adolescent, and child psychiatrist at the University of Vermont Medical Center and an assistant professor of psychiatry at UVM, both in Burlington. She reported no relevant financial disclosures. Email her at [email protected].

• A 9-year-old boy has poor impulse control, throws things in class, and cannot sit still. Teachers ask: Is this ADHD and should we start a medication?
• A 9-year-old girl is an inattentive daydreamer with poor class performance and trouble turning in homework. Her parents and teachers ask: Is this ADHD and should we start a medication?
• A 17-year-old boy who is a high achiever is taking the upcoming SATs and does poorly on timed tests because of poor focus and is now wondering: Do I have ADHD and would a medication help me perform better?
• A 17-year-old boy had poor grades for much of his early school years, but his parents always thought he was just a “lazy kid” although he insists he is trying his best. His parents now ask: Is this ADHD and has it been all along?

The above cases may sound familiar to you. They are an oversimplification of the patients who may come to you with two questions: Do I or someone I care about have ADHD and should they have medication for it? What may matter even more is how they are doing with that inattentiveness and how much it impacts their lives.

Sigmund Freud was known to think about goals for treatment as “liebe und arbeit” translated into “to love and to work.” As in, can someone live, love, and work or are their psychiatric symptoms impairing those functionalities? For a child, to live, work, and play (well with others) is most apt here. It is often more helpful to think in terms of childhood daily life when choosing to begin a medication or not. With inattention, a child can range from having a parent hoping for performance enhancement to having a severe impairment in their day-to-day functioning in a classroom. In the above case examples, each child or adolescent has varying impairments in performance – one is a high academic performer with very few issues outside of testing and another is a young child who can’t even sit still in a classroom to learn. Who should be prescribed a stimulant? Any or all of the above? It’s not as easy an answer as you may suspect, and there may not be one “right” answer either.

We know that stimulants can help a great deal of patients. They have the highest effect size for ADHD in that about 80% of children can benefit from stimulant treatment for ADHD. Specifically, “a high response rate of 70%-85% has been noted with methylphenidate and amphetamine formulations. The response rate is lower for atomoxetine [60%-65%] and guanfacine [30%-40%]” (Venkat B, Hechtman L. Considerations in selecting pharmacological treatments for attention deficit hyperactivity disorder. Clinical Pharmacist. 2016 Feb 11). In thinking about when to prescribe, we want to balance offering nonpharmacologic means to address symptoms of inattention (like mindfulness, exercise, and school supports such as individualized learning plans where applicable). We also do not want to withhold helpful treatments such as stimulants or other nonstimulant medications or trend toward overprescribing potentially habit-forming and imperfect medications.

It is important to make that distinction between impairment and the desire for medications to “enhance” life and optimize performance rather than treating symptoms of a disorder. Most ADHD patients struggle to organize their lives, and the inattentiveness can create conflicts and challenges that won’t be managed with medication alone. It is most helpful to gain skills to navigate those challenges simultaneously to ultimately help our patients live, learn, love, and play to the best of their abilities.
 

Where to begin

When I was in training, I had difficulty teasing out the various ADHD stimulant formations. There were and are so many Ritalin preparations! Mostly there is a variation in shorter-acting to longer-acting effects. If the diagnosis is highly suspected and uncomplicated ADHD, I usually choose to start with Concerta 18 mg daily (a long-acting methylphenidate) for children aged over 6 years. Many times I don’t see the need to titrate that upwards much further toward the maximum clinically used dose of 54 mg daily (despite guidelines saying otherwise up to 72 mg daily, which I have found unnecessary usually and poorly tolerated). Concerta has an immediate effect (20%) and then slowly peaks until 12 p.m. (80%) and then is out of system by about 3 p.m. (for a total of 7 hours duration of action). There also are shorter-acting preparations (Ritalin, Methylin) which are “on/off” in 4 hours and use of these is more consistent with an antiquated way of prescribing, often up to twice daily and three times daily dosing schedules with the risk of the harder to tolerate “drop-off” effects with stimulants. And, if there is not an effect, I often reconsider the diagnosis and any co-occurring anxiety disorder, stressful life events, or depression or other illness with the knowledge that these medications so often are effective.

Anxiety + ADHD

If there is prominent anxiety, anxiety disorder, or tics, I often consider Strattera 10-20 mg daily up to around 40 mg. I tend to dose this lower than as written for tolerability and in a “dose low and go slow” approach with kids, which often results in better experiences with the medication. This medication also is recommended to be dosed by weight; this should be taken into account as well. Atomoxetine is a selective serotonin and norepinephrine reuptake inhibitor which is likely similar to Cymbalta (duloxetine). It may have a lower effect size of around less than 60% but this also is around the reported effect sizes for selective serotonin reuptake inhibitors (SSRIs) for depression. If a patient has both ADHD and an anxiety disorder, I often consider an SSRI alternatively first to manage attention issues associated with anxiety and then would add on a stimulant if attention issues persist once anxiety is better treated.

Second/third line ADHD treatments

As a second-line approach to long-acting Ritalin and if there is not a response to it, I would consider extended-release Adderall preparations such as Vyvanse, which is an amphetamine preparation supposedly less abusable than Adderall (one can’t snort it), but I also caution that it releases dopamine, peaks faster, and does not reduce to zero stimulant in 24 hours because of a variable half-life.

In this way, I always have imagined that these amphetamines may be more theoretically concerning than Ritalin/methylphenidate because they increase dopamine dumping into the synapse (which is a different and extra mechanism than just reuptake). For a third line, I may consider guanfacine depending on weight daily, which is an Food and Drug Administration–approved, nonstimulant alpha-2 agonist, which also acts longer than clonidine and may be better for hyperactivity symptoms. I may begin with doses as low as 0.25-0.5 mg in the evening for concerns with sedation or groggy aftereffects in the morning.

Throughout all treatment with medication, I emphasize the importance of assertively managing ADHD symptoms which may be in the form of “behavioral treatment,” like cognitive behavioral therapy, organizational coaching available at some educational centers, or even finding ways to train one’s focus with athletics or practices such as yoga and mindfulness. In addition to this combined approach to treatment, stimulants are not perfect medications. All stimulants have a “drop-off effect” and were made to work during a school day lasting from 8 a.m. to 3 p.m. Some patients and families complain about the drop-off effect and may want to “dose” around a medication more frequently, in the late afternoon and in the evening, which can lead to poor appetite at dinner and insomnia.

My answers to the cases above would be that all the patients could have ADHD, but they also may have anxiety or stress-related disorders, depression, worries about performance, or poor skills to manage inattention. They may not yet have received school supports, coaching, or found ways to manage these symptoms either. Because stimulants can improve and enhance performance but also have their own drawbacks and risks not covered here, it’s important to consider each case as a whole with thoughtfulness about a child’s unique ability to “live and work” in this world.

Dr. Pawlowski is an adult, adolescent, and child psychiatrist at the University of Vermont Medical Center and an assistant professor of psychiatry at UVM, both in Burlington. She reported no relevant financial disclosures. Email her at [email protected].

Less clinical attention has been paid to caffeine lately as the medical community works to overcome the negative effects of substances such as opiates and cannabis. Quietly, however, caffeine continues to be widely consumed among children and adolescents, and its use often flies under the radar for pediatricians who have so many other topics to address. To help clinicians decide whether more focus on caffeine use is needed, a review was published in the Journal of the American Academy of Child & Adolescent Psychiatry (2019;58[1]:36-45). A synopsis of this paper which summarizes 90 individual studies on caffeine use in children and adolescents is provided here.

MonthiraYodtiwong/Thinkstock

Caffeine usage in children and adolescents

Caffeine continues to be one of the most commonly used substances in youth, with about 75% of older children and adolescents consuming it regularly, often at an average dose of about 25 mg/day for children aged 6-11 years and 50 mg/day for adolescents. Because most people have trouble quickly converting commonly used products into milligrams of caffeine, the following guide can be useful:

• Soda (12 oz). About 40 mg caffeine.
• Coffee (8 oz). About 100 mg caffeine.
• Tea (8 oz). About 48 mg caffeine.
• Energy drinks (12 oz). About 150 mg caffeine plus, with 5-Hour Energy being around 215 mg caffeine, according to a Consumer Reports study.

It is important to pay attention to the serving size, as the actual volume consumed of products like coffee or soft drinks often are much higher.

With regards to caffeine trends over time, a surprising observation is that total caffeine consumption among youth over the past decade or so looks relatively flat and may even be decreasing. This trend has occurred despite the aggressive marketing to youth of many energy drinks that contain high amounts of caffeine. In many ways, the pattern of caffeine use fits with what we know about substance use in general in adolescents, with rates dropping for many commonly used substances – with the exception of cannabis.
 

Effects of caffeine

As many know, caffeine is a stimulant and is known to increase arousal, alertness, and amount of motor behavior. While many youth drink caffeine in an effort to improve cognitive performance, the evidence that it does so directly is modest. There are some studies that show improvements on some cognitive tests when children take moderate doses of caffeine, but these effects tend to be most pronounced for kids who are more naive to caffeine at baseline. Of course, caffeine also can temporarily reduce feelings of fatigue and sleepiness.

Anecdotally, many youth and parents will report that caffeine is a way to “self-medicate” various symptoms of ADHD. While many will report some benefit, there is a surprising lack of rigorous data about the effects of caffeine for youth who meet criteria for ADHD, according to this review.

There also are some well-known negative effects of caffeine use. One of the most important ones is that caffeine can interfere with sleep onset, thereby inducing a cycle that reinforces more caffeine use in the day in an effort to compensate for poor sleep at night. A less obvious negative effect that has been documented is that caffeine added to sweetened beverages can increase consumption of similar sugary foods, even if they don’t have caffeine.

A number of adverse effects have been observed when youth consume caffeine at excessive doses, which tend to be around a threshold of 400 mg/day for teens and about 100 mg/day for younger children. These can include both behavioral and nonbehavioral changes such as agitation or irritability, anxiety, heart arrhythmias, and hypertension. Concern over high caffeine intake also was raised in relation to a number of cases of sudden death, although these events fortunately are rare. The review mentions that one factor that could increase the risk of a serious medical event related to caffeine use is the presence of an underlying cardiac problem which may go undetected until a negative outcome occurs. In thinking about these risks associated with “excessive” caffeine consumption, it can be important to go back to the guides and see just how easily an adolescent can get to a level of 400 mg or more. A couple large cups of coffee per day or two to three specific “energy-boosting” products can be all that it takes.

There also are a few large longitudinal studies that have shown a significant association between increased caffeine consumption and future problems with anger, aggression, risky sexual behavior, and substance use. Energy drinks, which can deliver a lot of caffeine quickly, were singled out as particularly problematic in some of these studies, although these naturalistic studies are unable to determine causation, and it also is possible that teens who are already prone towards behavioral problems tend to consume more caffeine. However, the review also mentions animal studies that have demonstrated that caffeine may prime the brain to use other substances like amphetamines or cocaine. Finally, another concern raised about energy drinks in particular is that they also often contain other substances which may have similar physiological effects but are relatively untested when it comes to safety.
 

Conclusions

This review, like the current position of the Food and Drug Administration, considers caffeine as generally safe at low doses because there does not appear to be much evidence that low or moderate use in youth leads to significant problems. The conclusion changes, however, with higher levels of consumption, as more frequent and more serious risks are encountered. The article recommends that both parents and doctors be more vigilant in monitoring the amount of caffeine that a child consumes as well as the timing of that use during the day. Some quick calculations can be done to give adolescents and their parents an estimate of their caffeine use in milligrams. And while caffeine may not rise to the level of public health concern as substances like opiates or alcohol, there is evidence that it can cause some real problems in children and teens, especially in higher amounts, and thus shouldn’t be given a total pass by parents and doctors alike.

Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Email him at [email protected]. Follow him on Twitter @PediPsych. Looking for more mental health training? Attend the 13th annual Child Psychiatry in Primary Care conference in Burlington, Vt., May 3, 2019 (http://www.med.uvm.edu/cme/conferences).

Less clinical attention has been paid to caffeine lately as the medical community works to overcome the negative effects of substances such as opiates and cannabis. Quietly, however, caffeine continues to be widely consumed among children and adolescents, and its use often flies under the radar for pediatricians who have so many other topics to address. To help clinicians decide whether more focus on caffeine use is needed, a review was published in the Journal of the American Academy of Child & Adolescent Psychiatry (2019;58[1]:36-45). A synopsis of this paper which summarizes 90 individual studies on caffeine use in children and adolescents is provided here.

MonthiraYodtiwong/Thinkstock

Caffeine usage in children and adolescents

Caffeine continues to be one of the most commonly used substances in youth, with about 75% of older children and adolescents consuming it regularly, often at an average dose of about 25 mg/day for children aged 6-11 years and 50 mg/day for adolescents. Because most people have trouble quickly converting commonly used products into milligrams of caffeine, the following guide can be useful:

• Soda (12 oz). About 40 mg caffeine.
• Coffee (8 oz). About 100 mg caffeine.
• Tea (8 oz). About 48 mg caffeine.
• Energy drinks (12 oz). About 150 mg caffeine plus, with 5-Hour Energy being around 215 mg caffeine, according to a Consumer Reports study.

It is important to pay attention to the serving size, as the actual volume consumed of products like coffee or soft drinks often are much higher.

With regards to caffeine trends over time, a surprising observation is that total caffeine consumption among youth over the past decade or so looks relatively flat and may even be decreasing. This trend has occurred despite the aggressive marketing to youth of many energy drinks that contain high amounts of caffeine. In many ways, the pattern of caffeine use fits with what we know about substance use in general in adolescents, with rates dropping for many commonly used substances – with the exception of cannabis.
 

Effects of caffeine

As many know, caffeine is a stimulant and is known to increase arousal, alertness, and amount of motor behavior. While many youth drink caffeine in an effort to improve cognitive performance, the evidence that it does so directly is modest. There are some studies that show improvements on some cognitive tests when children take moderate doses of caffeine, but these effects tend to be most pronounced for kids who are more naive to caffeine at baseline. Of course, caffeine also can temporarily reduce feelings of fatigue and sleepiness.

Anecdotally, many youth and parents will report that caffeine is a way to “self-medicate” various symptoms of ADHD. While many will report some benefit, there is a surprising lack of rigorous data about the effects of caffeine for youth who meet criteria for ADHD, according to this review.

There also are some well-known negative effects of caffeine use. One of the most important ones is that caffeine can interfere with sleep onset, thereby inducing a cycle that reinforces more caffeine use in the day in an effort to compensate for poor sleep at night. A less obvious negative effect that has been documented is that caffeine added to sweetened beverages can increase consumption of similar sugary foods, even if they don’t have caffeine.

A number of adverse effects have been observed when youth consume caffeine at excessive doses, which tend to be around a threshold of 400 mg/day for teens and about 100 mg/day for younger children. These can include both behavioral and nonbehavioral changes such as agitation or irritability, anxiety, heart arrhythmias, and hypertension. Concern over high caffeine intake also was raised in relation to a number of cases of sudden death, although these events fortunately are rare. The review mentions that one factor that could increase the risk of a serious medical event related to caffeine use is the presence of an underlying cardiac problem which may go undetected until a negative outcome occurs. In thinking about these risks associated with “excessive” caffeine consumption, it can be important to go back to the guides and see just how easily an adolescent can get to a level of 400 mg or more. A couple large cups of coffee per day or two to three specific “energy-boosting” products can be all that it takes.

There also are a few large longitudinal studies that have shown a significant association between increased caffeine consumption and future problems with anger, aggression, risky sexual behavior, and substance use. Energy drinks, which can deliver a lot of caffeine quickly, were singled out as particularly problematic in some of these studies, although these naturalistic studies are unable to determine causation, and it also is possible that teens who are already prone towards behavioral problems tend to consume more caffeine. However, the review also mentions animal studies that have demonstrated that caffeine may prime the brain to use other substances like amphetamines or cocaine. Finally, another concern raised about energy drinks in particular is that they also often contain other substances which may have similar physiological effects but are relatively untested when it comes to safety.
 

Conclusions

This review, like the current position of the Food and Drug Administration, considers caffeine as generally safe at low doses because there does not appear to be much evidence that low or moderate use in youth leads to significant problems. The conclusion changes, however, with higher levels of consumption, as more frequent and more serious risks are encountered. The article recommends that both parents and doctors be more vigilant in monitoring the amount of caffeine that a child consumes as well as the timing of that use during the day. Some quick calculations can be done to give adolescents and their parents an estimate of their caffeine use in milligrams. And while caffeine may not rise to the level of public health concern as substances like opiates or alcohol, there is evidence that it can cause some real problems in children and teens, especially in higher amounts, and thus shouldn’t be given a total pass by parents and doctors alike.

Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Email him at [email protected]. Follow him on Twitter @PediPsych. Looking for more mental health training? Attend the 13th annual Child Psychiatry in Primary Care conference in Burlington, Vt., May 3, 2019 (http://www.med.uvm.edu/cme/conferences).

Less clinical attention has been paid to caffeine lately as the medical community works to overcome the negative effects of substances such as opiates and cannabis. Quietly, however, caffeine continues to be widely consumed among children and adolescents, and its use often flies under the radar for pediatricians who have so many other topics to address. To help clinicians decide whether more focus on caffeine use is needed, a review was published in the Journal of the American Academy of Child & Adolescent Psychiatry (2019;58[1]:36-45). A synopsis of this paper which summarizes 90 individual studies on caffeine use in children and adolescents is provided here.

MonthiraYodtiwong/Thinkstock

Caffeine usage in children and adolescents

Caffeine continues to be one of the most commonly used substances in youth, with about 75% of older children and adolescents consuming it regularly, often at an average dose of about 25 mg/day for children aged 6-11 years and 50 mg/day for adolescents. Because most people have trouble quickly converting commonly used products into milligrams of caffeine, the following guide can be useful:

• Soda (12 oz). About 40 mg caffeine.
• Coffee (8 oz). About 100 mg caffeine.
• Tea (8 oz). About 48 mg caffeine.
• Energy drinks (12 oz). About 150 mg caffeine plus, with 5-Hour Energy being around 215 mg caffeine, according to a Consumer Reports study.

It is important to pay attention to the serving size, as the actual volume consumed of products like coffee or soft drinks often are much higher.

With regards to caffeine trends over time, a surprising observation is that total caffeine consumption among youth over the past decade or so looks relatively flat and may even be decreasing. This trend has occurred despite the aggressive marketing to youth of many energy drinks that contain high amounts of caffeine. In many ways, the pattern of caffeine use fits with what we know about substance use in general in adolescents, with rates dropping for many commonly used substances – with the exception of cannabis.
 

Effects of caffeine

As many know, caffeine is a stimulant and is known to increase arousal, alertness, and amount of motor behavior. While many youth drink caffeine in an effort to improve cognitive performance, the evidence that it does so directly is modest. There are some studies that show improvements on some cognitive tests when children take moderate doses of caffeine, but these effects tend to be most pronounced for kids who are more naive to caffeine at baseline. Of course, caffeine also can temporarily reduce feelings of fatigue and sleepiness.

Anecdotally, many youth and parents will report that caffeine is a way to “self-medicate” various symptoms of ADHD. While many will report some benefit, there is a surprising lack of rigorous data about the effects of caffeine for youth who meet criteria for ADHD, according to this review.

There also are some well-known negative effects of caffeine use. One of the most important ones is that caffeine can interfere with sleep onset, thereby inducing a cycle that reinforces more caffeine use in the day in an effort to compensate for poor sleep at night. A less obvious negative effect that has been documented is that caffeine added to sweetened beverages can increase consumption of similar sugary foods, even if they don’t have caffeine.

A number of adverse effects have been observed when youth consume caffeine at excessive doses, which tend to be around a threshold of 400 mg/day for teens and about 100 mg/day for younger children. These can include both behavioral and nonbehavioral changes such as agitation or irritability, anxiety, heart arrhythmias, and hypertension. Concern over high caffeine intake also was raised in relation to a number of cases of sudden death, although these events fortunately are rare. The review mentions that one factor that could increase the risk of a serious medical event related to caffeine use is the presence of an underlying cardiac problem which may go undetected until a negative outcome occurs. In thinking about these risks associated with “excessive” caffeine consumption, it can be important to go back to the guides and see just how easily an adolescent can get to a level of 400 mg or more. A couple large cups of coffee per day or two to three specific “energy-boosting” products can be all that it takes.

There also are a few large longitudinal studies that have shown a significant association between increased caffeine consumption and future problems with anger, aggression, risky sexual behavior, and substance use. Energy drinks, which can deliver a lot of caffeine quickly, were singled out as particularly problematic in some of these studies, although these naturalistic studies are unable to determine causation, and it also is possible that teens who are already prone towards behavioral problems tend to consume more caffeine. However, the review also mentions animal studies that have demonstrated that caffeine may prime the brain to use other substances like amphetamines or cocaine. Finally, another concern raised about energy drinks in particular is that they also often contain other substances which may have similar physiological effects but are relatively untested when it comes to safety.
 

Conclusions

This review, like the current position of the Food and Drug Administration, considers caffeine as generally safe at low doses because there does not appear to be much evidence that low or moderate use in youth leads to significant problems. The conclusion changes, however, with higher levels of consumption, as more frequent and more serious risks are encountered. The article recommends that both parents and doctors be more vigilant in monitoring the amount of caffeine that a child consumes as well as the timing of that use during the day. Some quick calculations can be done to give adolescents and their parents an estimate of their caffeine use in milligrams. And while caffeine may not rise to the level of public health concern as substances like opiates or alcohol, there is evidence that it can cause some real problems in children and teens, especially in higher amounts, and thus shouldn’t be given a total pass by parents and doctors alike.

Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Email him at [email protected]. Follow him on Twitter @PediPsych. Looking for more mental health training? Attend the 13th annual Child Psychiatry in Primary Care conference in Burlington, Vt., May 3, 2019 (http://www.med.uvm.edu/cme/conferences).

A relatively high proportion of pediatric visits to the emergency department are related to psychiatric symptoms, oftentimes with suicidal or violent ideation.¹ Given that pediatric emergencies related to psychiatric symptoms are on the increase, clinicians frequently are called to assess children and adolescents with symptoms of aggression and violence. Management of these cases can be tricky.

Case presentation

Henry is a 6-year-old boy with mild developmental delays and possible anxiety who was brought to the emergency department because of concerns on the bus. For about a month, Henry, who is repeating his kindergarten year, had been struggling with getting on and off the bus and with other transitions at school. These struggles had been attributed to anxiety. He was started on sertraline and the dose was increased about 2 weeks later. Soon thereafter he complained of stomach upset with the sertraline, refused to take the medicine, and had a very hard day at school. He required one-on-one attention for unsafe behavior most of that day, and he missed most of his lunch and recess. His school support team was able to get him onto the bus at the end of the day, but he refused to get off of the bus at home. He became violent with the bus driver, kicking and biting him until the police were called. The police called EMS and he was brought into the emergency department after fighting to get on the transport stretcher. He was eventually brought into a secure exam room in the emergency department, but was unable to be fully assessed because he would only make animal noises when approached. His father already had been called, but was unable to calm him down. The emergency department physician was unable to approach Henry because he began swinging at him as soon as the physician entered the room. An emergent psychiatric consultation was called to determine what medication to give to Henry to calm him down and to assess him for possible psychosis.

Case discussion

It sounds like Henry was having a severe tantrum exacerbated by a number of factors. First of all, this is a child who struggles with transitions. That day had been loaded with transitions, eventually leading him to be in an unfamiliar environment with many unfamiliar faces. Even the familiar face of his father wasn’t enough to help because he was overly stimulated and scared. Next, he was probably hungry. We know for certain that he missed lunch, and several hours into his presentation there were no breaks to deal with his basic needs. The first approach to assessment of aggressive behavior in the emergency setting is to try to care for the basic needs of the individual to deescalate the situation. Finally, he had recently been started on sertraline, a selective serotonin reuptake inhibitor. He had been having some dyspepsia and/or nausea with the sertraline, leading to his having missed some doses. Some children and adolescents have a discontinuation syndrome, which can be more severe in younger children and with medications that have shorter half-lives.² In Henry’s case, a missed dose or two can be enough to trigger this discontinuation response leading to more aggressive behavior.

Case follow-up

The child and adolescent psychiatrist called to the case received a history from the primary team. When he started to try to talk with the parent outside of the room, the child became upset. He was able to gather the information that Henry also had skipped breakfast. In an attempt to calm the patient down, the psychiatrist addressed Henry using a nonjudgmental, nonconfrontational, collaborative approach, incorporating play. Henry responded to this approach and allowed the psychiatrist to ask a few questions about basic needs, and admitted that he was hungry. He was offered a turkey sandwich, which was rapidly ingested. The tantrum slowly subsided. Within about 30 minutes (and with some more food), the child was able to sit on his parent’s lap and finish the interview. The decision was made to have him follow up with his primary care provider to change to an SSRI with a longer half-life, such as fluoxetine, as he did seem to be experiencing some discontinuation even after missing just a dose or two of sertraline.

RatRanch/Flickr/CC by 2.0 RatRanch/Flickr/CC by 2.0

When dealing with emergent, aggressive behavior, food isn’t always the best medicine, but sometimes it is. In the context of aggression with children, it is critical to evaluate for triggers that can worsen a fight or flight response. Environmental barriers to the child’s regaining control include hunger, thirst, a full bladder, constipation, or other pain. Attending to these issues first sometimes can help avoid sedating medications, which can prolong emergency visits and lead to unwelcome side effects.
 

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

References

1. Pediatrics. 2011 May;127(5):e1356-66.

2. J Can Acad Child Adolesc Psychiatry. 2011 Feb;20(1):60-7.

A relatively high proportion of pediatric visits to the emergency department are related to psychiatric symptoms, oftentimes with suicidal or violent ideation.¹ Given that pediatric emergencies related to psychiatric symptoms are on the increase, clinicians frequently are called to assess children and adolescents with symptoms of aggression and violence. Management of these cases can be tricky.

Case presentation

Henry is a 6-year-old boy with mild developmental delays and possible anxiety who was brought to the emergency department because of concerns on the bus. For about a month, Henry, who is repeating his kindergarten year, had been struggling with getting on and off the bus and with other transitions at school. These struggles had been attributed to anxiety. He was started on sertraline and the dose was increased about 2 weeks later. Soon thereafter he complained of stomach upset with the sertraline, refused to take the medicine, and had a very hard day at school. He required one-on-one attention for unsafe behavior most of that day, and he missed most of his lunch and recess. His school support team was able to get him onto the bus at the end of the day, but he refused to get off of the bus at home. He became violent with the bus driver, kicking and biting him until the police were called. The police called EMS and he was brought into the emergency department after fighting to get on the transport stretcher. He was eventually brought into a secure exam room in the emergency department, but was unable to be fully assessed because he would only make animal noises when approached. His father already had been called, but was unable to calm him down. The emergency department physician was unable to approach Henry because he began swinging at him as soon as the physician entered the room. An emergent psychiatric consultation was called to determine what medication to give to Henry to calm him down and to assess him for possible psychosis.

Case discussion

It sounds like Henry was having a severe tantrum exacerbated by a number of factors. First of all, this is a child who struggles with transitions. That day had been loaded with transitions, eventually leading him to be in an unfamiliar environment with many unfamiliar faces. Even the familiar face of his father wasn’t enough to help because he was overly stimulated and scared. Next, he was probably hungry. We know for certain that he missed lunch, and several hours into his presentation there were no breaks to deal with his basic needs. The first approach to assessment of aggressive behavior in the emergency setting is to try to care for the basic needs of the individual to deescalate the situation. Finally, he had recently been started on sertraline, a selective serotonin reuptake inhibitor. He had been having some dyspepsia and/or nausea with the sertraline, leading to his having missed some doses. Some children and adolescents have a discontinuation syndrome, which can be more severe in younger children and with medications that have shorter half-lives.² In Henry’s case, a missed dose or two can be enough to trigger this discontinuation response leading to more aggressive behavior.

Case follow-up

The child and adolescent psychiatrist called to the case received a history from the primary team. When he started to try to talk with the parent outside of the room, the child became upset. He was able to gather the information that Henry also had skipped breakfast. In an attempt to calm the patient down, the psychiatrist addressed Henry using a nonjudgmental, nonconfrontational, collaborative approach, incorporating play. Henry responded to this approach and allowed the psychiatrist to ask a few questions about basic needs, and admitted that he was hungry. He was offered a turkey sandwich, which was rapidly ingested. The tantrum slowly subsided. Within about 30 minutes (and with some more food), the child was able to sit on his parent’s lap and finish the interview. The decision was made to have him follow up with his primary care provider to change to an SSRI with a longer half-life, such as fluoxetine, as he did seem to be experiencing some discontinuation even after missing just a dose or two of sertraline.

RatRanch/Flickr/CC by 2.0 RatRanch/Flickr/CC by 2.0

When dealing with emergent, aggressive behavior, food isn’t always the best medicine, but sometimes it is. In the context of aggression with children, it is critical to evaluate for triggers that can worsen a fight or flight response. Environmental barriers to the child’s regaining control include hunger, thirst, a full bladder, constipation, or other pain. Attending to these issues first sometimes can help avoid sedating medications, which can prolong emergency visits and lead to unwelcome side effects.
 

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

References

1. Pediatrics. 2011 May;127(5):e1356-66.

2. J Can Acad Child Adolesc Psychiatry. 2011 Feb;20(1):60-7.

A relatively high proportion of pediatric visits to the emergency department are related to psychiatric symptoms, oftentimes with suicidal or violent ideation.¹ Given that pediatric emergencies related to psychiatric symptoms are on the increase, clinicians frequently are called to assess children and adolescents with symptoms of aggression and violence. Management of these cases can be tricky.

Case presentation

Henry is a 6-year-old boy with mild developmental delays and possible anxiety who was brought to the emergency department because of concerns on the bus. For about a month, Henry, who is repeating his kindergarten year, had been struggling with getting on and off the bus and with other transitions at school. These struggles had been attributed to anxiety. He was started on sertraline and the dose was increased about 2 weeks later. Soon thereafter he complained of stomach upset with the sertraline, refused to take the medicine, and had a very hard day at school. He required one-on-one attention for unsafe behavior most of that day, and he missed most of his lunch and recess. His school support team was able to get him onto the bus at the end of the day, but he refused to get off of the bus at home. He became violent with the bus driver, kicking and biting him until the police were called. The police called EMS and he was brought into the emergency department after fighting to get on the transport stretcher. He was eventually brought into a secure exam room in the emergency department, but was unable to be fully assessed because he would only make animal noises when approached. His father already had been called, but was unable to calm him down. The emergency department physician was unable to approach Henry because he began swinging at him as soon as the physician entered the room. An emergent psychiatric consultation was called to determine what medication to give to Henry to calm him down and to assess him for possible psychosis.

Case discussion

It sounds like Henry was having a severe tantrum exacerbated by a number of factors. First of all, this is a child who struggles with transitions. That day had been loaded with transitions, eventually leading him to be in an unfamiliar environment with many unfamiliar faces. Even the familiar face of his father wasn’t enough to help because he was overly stimulated and scared. Next, he was probably hungry. We know for certain that he missed lunch, and several hours into his presentation there were no breaks to deal with his basic needs. The first approach to assessment of aggressive behavior in the emergency setting is to try to care for the basic needs of the individual to deescalate the situation. Finally, he had recently been started on sertraline, a selective serotonin reuptake inhibitor. He had been having some dyspepsia and/or nausea with the sertraline, leading to his having missed some doses. Some children and adolescents have a discontinuation syndrome, which can be more severe in younger children and with medications that have shorter half-lives.² In Henry’s case, a missed dose or two can be enough to trigger this discontinuation response leading to more aggressive behavior.

Case follow-up

The child and adolescent psychiatrist called to the case received a history from the primary team. When he started to try to talk with the parent outside of the room, the child became upset. He was able to gather the information that Henry also had skipped breakfast. In an attempt to calm the patient down, the psychiatrist addressed Henry using a nonjudgmental, nonconfrontational, collaborative approach, incorporating play. Henry responded to this approach and allowed the psychiatrist to ask a few questions about basic needs, and admitted that he was hungry. He was offered a turkey sandwich, which was rapidly ingested. The tantrum slowly subsided. Within about 30 minutes (and with some more food), the child was able to sit on his parent’s lap and finish the interview. The decision was made to have him follow up with his primary care provider to change to an SSRI with a longer half-life, such as fluoxetine, as he did seem to be experiencing some discontinuation even after missing just a dose or two of sertraline.

RatRanch/Flickr/CC by 2.0 RatRanch/Flickr/CC by 2.0

When dealing with emergent, aggressive behavior, food isn’t always the best medicine, but sometimes it is. In the context of aggression with children, it is critical to evaluate for triggers that can worsen a fight or flight response. Environmental barriers to the child’s regaining control include hunger, thirst, a full bladder, constipation, or other pain. Attending to these issues first sometimes can help avoid sedating medications, which can prolong emergency visits and lead to unwelcome side effects.
 

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

References

1. Pediatrics. 2011 May;127(5):e1356-66.

2. J Can Acad Child Adolesc Psychiatry. 2011 Feb;20(1):60-7.

Parents whose kids are diagnosed with ADHD face important questions about what to expect in the long term and how that might inform treatment. Studies find that ADHD diagnosed in childhood tends to persist in up to 65% of adolescents (some estimates are lower depending on criteria used),¹ and about 50% of people are estimated to continue to meet criteria for ADHD as adults.² Many studies have attempted to understand what long-term risks are associated with ADHD, as well as the factors that help better predict which characteristics in childhood might predict those risks. A recent article was published on a cohort of boys followed over 33 years.³ This, as well as other large prospective studies, such as the Multimodal Treatment of ADHD (MTA) provide us with helpful long-range data that inform this article.^4-6 This article reviews risks in adolescence and adulthood and the factors thought to be associated with them.

javi_indy/ Thinkstock

What predicts persistence of ADHD symptoms in adolescence?

Several factors emerge consistently, including higher symptom severity, comorbid conduct disorder, and lower childhood IQ; other findings include family-related factors, such as lower parental mental health, less-positive parenting, and lower rates of parental education. In general, hyperactivity and impulsivity wanes, while inattention symptoms remain more stable.

What does ADHD predict for adolescents?

Adolescents with ADHD are more than twice as likely to be involved in pregnancies under the age of 18 years, true for both male and female genders.⁷ This finding also is associated with increased substance use and low academic achievement but not completely explained by it. Adolescents with persistent ADHD symptoms experience poorer educational success than do kids without ADHD symptoms, according to teacher reports of performance and measurements of grade point average. They are more likely to repeat a grade.⁸ Related but independent is the relationship of substance use disorders in kids with ADHD. Adolescents with ADHD are more likely to use nicotine or marijuana or meet criteria for any substance use disorder than adolescents without ADHD. Finally, adolescents aged 12-18 years with ADHD are at higher risk for motor vehicle accidents and all types of accidental injuries.⁹

What predicts persistence of ADHD symptoms in adulthood?

A follow-up study of the MTA trial 16 years later looked at ADHD diagnosed before age 12 years and the association with symptom persistence in adulthood, defined by the DSM-5 cutoff criteria of five symptoms. The following factors related to symptom persistence: childhood psychiatric comorbidity, higher ADHD symptom severity, and parental mental health problems. Notably, family socioeconomic status, child IQ, and parental education were not associated. In addition to looking at symptom persistence, other studies have looked at predictors of functional impairment in adulthood following a childhood ADHD diagnosis (independent of whether people continue to meet criteria for the disorder). The main findings that seem consistently related to all functional outcomes, including social, occupational, and educational, are lower childhood IQ and history of conduct problems (in the absence of meeting criteria for full childhood conduct disorder). Educational family-related factors, such as socioeconomic status and lower parental education, were related to lower educational functioning only.

What does ADHD predict for adults?

It appears that overall, adults who were diagnosed with ADHD as children show poorer functional outcomes than did those who weren’t, and there is a step-wise relationship when considering adults whose symptoms persist, with more severe outcomes compared with adults whose symptoms have desisted, who in turn have worse outcomes than adults who were never diagnosed with ADHD. Educational attainments follow this pattern with the highest average levels of education in the non-ADHD group and the lowest average years in the group with persistent symptoms. Occupational success and percent receiving public assistance again separated between each group, with the symptom persisters faring the worst, the symptom desisters better, and those never affected by ADHD, the best. In terms of emotional disorders, it was only the symptom persisters who suffered from higher rates of mood and anxiety disorders. Similarly, only the symptom persisters had significantly more marijuana use disorders. No other substance use disorders or legal outcomes were significant.

How does this affect how we approach treatment?

Clinicians and researchers who specialize in ADHD have been arguing for ADHD to be treated as more of a chronic disease and for impairment to be the focus of treatment, rather than simply symptom control.¹⁰ With what we know about long-term functional impairment, there is reason to consider a more holistic picture of a child or an adolescent and how they are functioning in their academic, emotional, and social domains. A meta-analysis of treatment and long-term outcomes suggests that psychostimulant treatment, psychotherapy treatment, and combined treatment all improve long-term functioning, especially self-esteem, social functioning, and academic functioning, with combined psychotherapeutic and pharmacologic treatments associated with the highest effect sizes.¹¹

For those who treat ADHD, it is our job to provide education to families about the chronic risks associated with the diagnosis, and the importance of offering multimodal therapy that can address family factors that might be contributing to risks, as well as the child’s overall well-being. If we are to make sense of how adults may experience impairment even in the absence of ongoing symptoms, we might look at how their overall wellness was interrupted during development. Maybe they fell into a different crowd of kids? Maybe they stopped achieving at school in a way that changed the achievement trajectory they were on? Maybe they impulsively picked up substances or got in trouble with the law? These events can have lasting impacts on well-being. We must use medicine and psychotherapy to help with symptoms, but we must look beyond treating illness and use evidence-based strategies to promote wellness at the level of the entire family.
 

Dr. Guth is an assistant professor in the department of psychiatry at the University of Vermont Medical Center and the University of Vermont, both in Burlington. She works with children and adolescents as well as women in the perinatal period. She has no relevant financial disclosures.

References

1. Psychol Med. 2006 Feb;36(2):159-65.

2. J Am Acad Child Adolesc Psychiatry. 2016 Nov;55(11):937-44.e4.

3. J Am Acad Child Adolesc Psychiatry. 2018 Aug;57(8):571-82.e1.

4. J Am Acad Child Adolesc Psychiatry. 2017 Aug;56(8):687-95.e7.

5. J Am Acad Child Adolesc Psychiatry. 2016 Nov;55(11):945-52.e2.

6. J Am Acad Child Adolesc Psychiatry. 2009 May;48(5):484-500.

7. J Atten Disord. 2017 Sep 1:1087054717730610. doi: 10.1177/1087054717730610.

8. J Atten Disord. 2016 May;20(5):383-9.

9. Eur Child Adolesc Psychiatry. 2014 Feb;23(2):95-102.

10. JAMA Pediatr. 2018 Aug 13. doi: 10.1001/jamapediatrics.2018.1642.

11. PLoS One. 2015 Feb 25;10(2):e0116407.


 

Parents whose kids are diagnosed with ADHD face important questions about what to expect in the long term and how that might inform treatment. Studies find that ADHD diagnosed in childhood tends to persist in up to 65% of adolescents (some estimates are lower depending on criteria used),¹ and about 50% of people are estimated to continue to meet criteria for ADHD as adults.² Many studies have attempted to understand what long-term risks are associated with ADHD, as well as the factors that help better predict which characteristics in childhood might predict those risks. A recent article was published on a cohort of boys followed over 33 years.³ This, as well as other large prospective studies, such as the Multimodal Treatment of ADHD (MTA) provide us with helpful long-range data that inform this article.^4-6 This article reviews risks in adolescence and adulthood and the factors thought to be associated with them.

javi_indy/ Thinkstock

What predicts persistence of ADHD symptoms in adolescence?

Several factors emerge consistently, including higher symptom severity, comorbid conduct disorder, and lower childhood IQ; other findings include family-related factors, such as lower parental mental health, less-positive parenting, and lower rates of parental education. In general, hyperactivity and impulsivity wanes, while inattention symptoms remain more stable.

What does ADHD predict for adolescents?

Adolescents with ADHD are more than twice as likely to be involved in pregnancies under the age of 18 years, true for both male and female genders.⁷ This finding also is associated with increased substance use and low academic achievement but not completely explained by it. Adolescents with persistent ADHD symptoms experience poorer educational success than do kids without ADHD symptoms, according to teacher reports of performance and measurements of grade point average. They are more likely to repeat a grade.⁸ Related but independent is the relationship of substance use disorders in kids with ADHD. Adolescents with ADHD are more likely to use nicotine or marijuana or meet criteria for any substance use disorder than adolescents without ADHD. Finally, adolescents aged 12-18 years with ADHD are at higher risk for motor vehicle accidents and all types of accidental injuries.⁹

What predicts persistence of ADHD symptoms in adulthood?

A follow-up study of the MTA trial 16 years later looked at ADHD diagnosed before age 12 years and the association with symptom persistence in adulthood, defined by the DSM-5 cutoff criteria of five symptoms. The following factors related to symptom persistence: childhood psychiatric comorbidity, higher ADHD symptom severity, and parental mental health problems. Notably, family socioeconomic status, child IQ, and parental education were not associated. In addition to looking at symptom persistence, other studies have looked at predictors of functional impairment in adulthood following a childhood ADHD diagnosis (independent of whether people continue to meet criteria for the disorder). The main findings that seem consistently related to all functional outcomes, including social, occupational, and educational, are lower childhood IQ and history of conduct problems (in the absence of meeting criteria for full childhood conduct disorder). Educational family-related factors, such as socioeconomic status and lower parental education, were related to lower educational functioning only.

What does ADHD predict for adults?

It appears that overall, adults who were diagnosed with ADHD as children show poorer functional outcomes than did those who weren’t, and there is a step-wise relationship when considering adults whose symptoms persist, with more severe outcomes compared with adults whose symptoms have desisted, who in turn have worse outcomes than adults who were never diagnosed with ADHD. Educational attainments follow this pattern with the highest average levels of education in the non-ADHD group and the lowest average years in the group with persistent symptoms. Occupational success and percent receiving public assistance again separated between each group, with the symptom persisters faring the worst, the symptom desisters better, and those never affected by ADHD, the best. In terms of emotional disorders, it was only the symptom persisters who suffered from higher rates of mood and anxiety disorders. Similarly, only the symptom persisters had significantly more marijuana use disorders. No other substance use disorders or legal outcomes were significant.

How does this affect how we approach treatment?

Clinicians and researchers who specialize in ADHD have been arguing for ADHD to be treated as more of a chronic disease and for impairment to be the focus of treatment, rather than simply symptom control.¹⁰ With what we know about long-term functional impairment, there is reason to consider a more holistic picture of a child or an adolescent and how they are functioning in their academic, emotional, and social domains. A meta-analysis of treatment and long-term outcomes suggests that psychostimulant treatment, psychotherapy treatment, and combined treatment all improve long-term functioning, especially self-esteem, social functioning, and academic functioning, with combined psychotherapeutic and pharmacologic treatments associated with the highest effect sizes.¹¹

For those who treat ADHD, it is our job to provide education to families about the chronic risks associated with the diagnosis, and the importance of offering multimodal therapy that can address family factors that might be contributing to risks, as well as the child’s overall well-being. If we are to make sense of how adults may experience impairment even in the absence of ongoing symptoms, we might look at how their overall wellness was interrupted during development. Maybe they fell into a different crowd of kids? Maybe they stopped achieving at school in a way that changed the achievement trajectory they were on? Maybe they impulsively picked up substances or got in trouble with the law? These events can have lasting impacts on well-being. We must use medicine and psychotherapy to help with symptoms, but we must look beyond treating illness and use evidence-based strategies to promote wellness at the level of the entire family.
 

Dr. Guth is an assistant professor in the department of psychiatry at the University of Vermont Medical Center and the University of Vermont, both in Burlington. She works with children and adolescents as well as women in the perinatal period. She has no relevant financial disclosures.

References

1. Psychol Med. 2006 Feb;36(2):159-65.

2. J Am Acad Child Adolesc Psychiatry. 2016 Nov;55(11):937-44.e4.

3. J Am Acad Child Adolesc Psychiatry. 2018 Aug;57(8):571-82.e1.

4. J Am Acad Child Adolesc Psychiatry. 2017 Aug;56(8):687-95.e7.

5. J Am Acad Child Adolesc Psychiatry. 2016 Nov;55(11):945-52.e2.

6. J Am Acad Child Adolesc Psychiatry. 2009 May;48(5):484-500.

7. J Atten Disord. 2017 Sep 1:1087054717730610. doi: 10.1177/1087054717730610.

8. J Atten Disord. 2016 May;20(5):383-9.

9. Eur Child Adolesc Psychiatry. 2014 Feb;23(2):95-102.

10. JAMA Pediatr. 2018 Aug 13. doi: 10.1001/jamapediatrics.2018.1642.

11. PLoS One. 2015 Feb 25;10(2):e0116407.


 

Parents whose kids are diagnosed with ADHD face important questions about what to expect in the long term and how that might inform treatment. Studies find that ADHD diagnosed in childhood tends to persist in up to 65% of adolescents (some estimates are lower depending on criteria used),¹ and about 50% of people are estimated to continue to meet criteria for ADHD as adults.² Many studies have attempted to understand what long-term risks are associated with ADHD, as well as the factors that help better predict which characteristics in childhood might predict those risks. A recent article was published on a cohort of boys followed over 33 years.³ This, as well as other large prospective studies, such as the Multimodal Treatment of ADHD (MTA) provide us with helpful long-range data that inform this article.^4-6 This article reviews risks in adolescence and adulthood and the factors thought to be associated with them.

javi_indy/ Thinkstock

What predicts persistence of ADHD symptoms in adolescence?

Several factors emerge consistently, including higher symptom severity, comorbid conduct disorder, and lower childhood IQ; other findings include family-related factors, such as lower parental mental health, less-positive parenting, and lower rates of parental education. In general, hyperactivity and impulsivity wanes, while inattention symptoms remain more stable.

What does ADHD predict for adolescents?

Adolescents with ADHD are more than twice as likely to be involved in pregnancies under the age of 18 years, true for both male and female genders.⁷ This finding also is associated with increased substance use and low academic achievement but not completely explained by it. Adolescents with persistent ADHD symptoms experience poorer educational success than do kids without ADHD symptoms, according to teacher reports of performance and measurements of grade point average. They are more likely to repeat a grade.⁸ Related but independent is the relationship of substance use disorders in kids with ADHD. Adolescents with ADHD are more likely to use nicotine or marijuana or meet criteria for any substance use disorder than adolescents without ADHD. Finally, adolescents aged 12-18 years with ADHD are at higher risk for motor vehicle accidents and all types of accidental injuries.⁹

What predicts persistence of ADHD symptoms in adulthood?

A follow-up study of the MTA trial 16 years later looked at ADHD diagnosed before age 12 years and the association with symptom persistence in adulthood, defined by the DSM-5 cutoff criteria of five symptoms. The following factors related to symptom persistence: childhood psychiatric comorbidity, higher ADHD symptom severity, and parental mental health problems. Notably, family socioeconomic status, child IQ, and parental education were not associated. In addition to looking at symptom persistence, other studies have looked at predictors of functional impairment in adulthood following a childhood ADHD diagnosis (independent of whether people continue to meet criteria for the disorder). The main findings that seem consistently related to all functional outcomes, including social, occupational, and educational, are lower childhood IQ and history of conduct problems (in the absence of meeting criteria for full childhood conduct disorder). Educational family-related factors, such as socioeconomic status and lower parental education, were related to lower educational functioning only.

What does ADHD predict for adults?

It appears that overall, adults who were diagnosed with ADHD as children show poorer functional outcomes than did those who weren’t, and there is a step-wise relationship when considering adults whose symptoms persist, with more severe outcomes compared with adults whose symptoms have desisted, who in turn have worse outcomes than adults who were never diagnosed with ADHD. Educational attainments follow this pattern with the highest average levels of education in the non-ADHD group and the lowest average years in the group with persistent symptoms. Occupational success and percent receiving public assistance again separated between each group, with the symptom persisters faring the worst, the symptom desisters better, and those never affected by ADHD, the best. In terms of emotional disorders, it was only the symptom persisters who suffered from higher rates of mood and anxiety disorders. Similarly, only the symptom persisters had significantly more marijuana use disorders. No other substance use disorders or legal outcomes were significant.

How does this affect how we approach treatment?

Clinicians and researchers who specialize in ADHD have been arguing for ADHD to be treated as more of a chronic disease and for impairment to be the focus of treatment, rather than simply symptom control.¹⁰ With what we know about long-term functional impairment, there is reason to consider a more holistic picture of a child or an adolescent and how they are functioning in their academic, emotional, and social domains. A meta-analysis of treatment and long-term outcomes suggests that psychostimulant treatment, psychotherapy treatment, and combined treatment all improve long-term functioning, especially self-esteem, social functioning, and academic functioning, with combined psychotherapeutic and pharmacologic treatments associated with the highest effect sizes.¹¹

For those who treat ADHD, it is our job to provide education to families about the chronic risks associated with the diagnosis, and the importance of offering multimodal therapy that can address family factors that might be contributing to risks, as well as the child’s overall well-being. If we are to make sense of how adults may experience impairment even in the absence of ongoing symptoms, we might look at how their overall wellness was interrupted during development. Maybe they fell into a different crowd of kids? Maybe they stopped achieving at school in a way that changed the achievement trajectory they were on? Maybe they impulsively picked up substances or got in trouble with the law? These events can have lasting impacts on well-being. We must use medicine and psychotherapy to help with symptoms, but we must look beyond treating illness and use evidence-based strategies to promote wellness at the level of the entire family.
 

Dr. Guth is an assistant professor in the department of psychiatry at the University of Vermont Medical Center and the University of Vermont, both in Burlington. She works with children and adolescents as well as women in the perinatal period. She has no relevant financial disclosures.

References

1. Psychol Med. 2006 Feb;36(2):159-65.

2. J Am Acad Child Adolesc Psychiatry. 2016 Nov;55(11):937-44.e4.

3. J Am Acad Child Adolesc Psychiatry. 2018 Aug;57(8):571-82.e1.

4. J Am Acad Child Adolesc Psychiatry. 2017 Aug;56(8):687-95.e7.

5. J Am Acad Child Adolesc Psychiatry. 2016 Nov;55(11):945-52.e2.

6. J Am Acad Child Adolesc Psychiatry. 2009 May;48(5):484-500.

7. J Atten Disord. 2017 Sep 1:1087054717730610. doi: 10.1177/1087054717730610.

8. J Atten Disord. 2016 May;20(5):383-9.

9. Eur Child Adolesc Psychiatry. 2014 Feb;23(2):95-102.

10. JAMA Pediatr. 2018 Aug 13. doi: 10.1001/jamapediatrics.2018.1642.

11. PLoS One. 2015 Feb 25;10(2):e0116407.


 

Over the past several months, I’ve found myself increasingly reflective on the intersection of culture, relationships, and my professional work with those who have an autism spectrum disorder. Last winter, an adolescent boy treated by myself and other providers died by suicide. Adam (name changed) had been diagnosed with autism as a toddler and had struggled with anxiety and depression for several years; in the office, as he grew into an athletic teenager, Adam spoke more frequently about “not fitting in” with his peers and therapeutic focus was placed on building Adam’s sense of himself and fostering his self-confidence and perceived self-competence. His unexpected death was a tremendous shock, and his loved ones – including the clinical team – desperately searched for answers that could help add some understanding to the heartbreaking event.

Rawpixel/Thinkstock

As I attempted to search for answers and reconcile national news with my clinical and teaching experiences, I was struck by something that Andrew Solomon eloquently captured in his June 2018 New Yorker article that again touches upon the theme of connection.⁶ Mr. Solomon writes “modernity is alienating” and about how he receives correspondence from those who struggle with depression. “What is most striking to me is how alone many of them are ... these people are so alone that they are effectively invisible to the rest of us ... many of them describe suicidal feelings,” he noted.

The power of connection in our day-to-day work is undeniable. The influence of human interaction and appreciating one’s unique narrative is a bedrock of clinical care and can unquestionably allow us to better understand individual suffering, deliver optimal care, and combat shame as Hannah Gadsby boldly shared in her recent Netflix comedy special “Nanette.” This shame can drive one to experience earth-shattering depressive episodes and influence thoughts of suicide. “We simply cannot make it on our own,” Ms. Gadsby explains, “we’re humans. We’re to be connected.” Humans are indeed hardwired for connection; isolation and disconnection can lead to significant health problems and are linked with mental health concerns. The former U.S. Surgeon General Vivek H. Murthy, MD, has referred to loneliness as an epidemic, and those with autism may be at increased risk for feeling lonely and isolated.^7,8

Synthesizing thoughts about relationships, suicide, loneliness, love, well-being, and autism produces a complicated web of, well, connections. Suicide in the autism population hasn’t been well researched, but one 2016 study revealed sobering numbers about suicide being a leading cause of premature death in people with autism.⁹ How do these numbers associate with feelings of isolation, wanting to fit in, and troubles talking about emotions – all of which can characterize those with ASD? Data, not surprisingly, support the role of loneliness as a risk factor for the development of depression and suicidal ideation in those with ASD.¹⁰ In addition, social-communication challenges, even in the absence of an autism diagnosis, are related to depression and suicidality.¹¹ Another recent study showed a relationship between autistic traits and depression symptoms, an association seemingly linked to being bullied.¹² We cannot continue to hold onto the myth that individuals with autism don’t desire relationships and love because it’s these desires and not being able to fulfill them, limited opportunities to engage in meaningful experiences, and feeling different that can lead to negative outcomes.

Dr. Dickerson, a child and adolescent psychiatrist, is assistant professor of psychiatry at the University of Vermont, Burlington, where he is director of the autism diagnostic clinic. Email him at [email protected].

References

1. Harv Rev Psychiatry. 2018 Jul/Aug;26(4):201-15.

2. MMWR Morb Mortal Wkly Rep. 2018 Jun 8;67(22):617-24.

3. www.healthvermont.gov/YRBS

4. MMWR Surveill Summ. 2017 Oct;66(18):1-16.

5. JAMA Pediatr. 2015 May;169(5):466-73.

6. “Anthony Bourdain, Kate Spade, and the Preventable Tragedies of Suicide,” By Anthony Solomon, The New Yorker. Jun 8, 2018.

7. “Work and the Loneliness Epidemic,” By Vivek H. Murthy, Harvard Business Review. Sep 28, 2017.

8. Child Dev. 2000 Mar-Apr;71(2):447-56.

9. Br J Psychiatry. 2016 Mar;208(3):232-8.

10. Depress Anxiety. 2018 Jul;35(7):648-57.

11. J Am Acad Child Adolesc Psychiatry. 2018 May;57(5):313-20.

12. JAMA Psychiatry. 2018 Aug 1;75(8):835-43.

13. The Lancet Psychiatry. 2017 Jun;4(6):e11.

14. “Promoting Individual, Family, and Community Connectedness to Prevent Suicidal Behavior,” Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, www.cdc.gov/injury.

15. JAMA Psychiatry. 2018 Jul 11. doi: 10.1001/jamapsychiatry.2018.1776.

Over the past several months, I’ve found myself increasingly reflective on the intersection of culture, relationships, and my professional work with those who have an autism spectrum disorder. Last winter, an adolescent boy treated by myself and other providers died by suicide. Adam (name changed) had been diagnosed with autism as a toddler and had struggled with anxiety and depression for several years; in the office, as he grew into an athletic teenager, Adam spoke more frequently about “not fitting in” with his peers and therapeutic focus was placed on building Adam’s sense of himself and fostering his self-confidence and perceived self-competence. His unexpected death was a tremendous shock, and his loved ones – including the clinical team – desperately searched for answers that could help add some understanding to the heartbreaking event.

Rawpixel/Thinkstock

As I attempted to search for answers and reconcile national news with my clinical and teaching experiences, I was struck by something that Andrew Solomon eloquently captured in his June 2018 New Yorker article that again touches upon the theme of connection.⁶ Mr. Solomon writes “modernity is alienating” and about how he receives correspondence from those who struggle with depression. “What is most striking to me is how alone many of them are ... these people are so alone that they are effectively invisible to the rest of us ... many of them describe suicidal feelings,” he noted.

The power of connection in our day-to-day work is undeniable. The influence of human interaction and appreciating one’s unique narrative is a bedrock of clinical care and can unquestionably allow us to better understand individual suffering, deliver optimal care, and combat shame as Hannah Gadsby boldly shared in her recent Netflix comedy special “Nanette.” This shame can drive one to experience earth-shattering depressive episodes and influence thoughts of suicide. “We simply cannot make it on our own,” Ms. Gadsby explains, “we’re humans. We’re to be connected.” Humans are indeed hardwired for connection; isolation and disconnection can lead to significant health problems and are linked with mental health concerns. The former U.S. Surgeon General Vivek H. Murthy, MD, has referred to loneliness as an epidemic, and those with autism may be at increased risk for feeling lonely and isolated.^7,8

Synthesizing thoughts about relationships, suicide, loneliness, love, well-being, and autism produces a complicated web of, well, connections. Suicide in the autism population hasn’t been well researched, but one 2016 study revealed sobering numbers about suicide being a leading cause of premature death in people with autism.⁹ How do these numbers associate with feelings of isolation, wanting to fit in, and troubles talking about emotions – all of which can characterize those with ASD? Data, not surprisingly, support the role of loneliness as a risk factor for the development of depression and suicidal ideation in those with ASD.¹⁰ In addition, social-communication challenges, even in the absence of an autism diagnosis, are related to depression and suicidality.¹¹ Another recent study showed a relationship between autistic traits and depression symptoms, an association seemingly linked to being bullied.¹² We cannot continue to hold onto the myth that individuals with autism don’t desire relationships and love because it’s these desires and not being able to fulfill them, limited opportunities to engage in meaningful experiences, and feeling different that can lead to negative outcomes.

Dr. Dickerson, a child and adolescent psychiatrist, is assistant professor of psychiatry at the University of Vermont, Burlington, where he is director of the autism diagnostic clinic. Email him at [email protected].

References

1. Harv Rev Psychiatry. 2018 Jul/Aug;26(4):201-15.

2. MMWR Morb Mortal Wkly Rep. 2018 Jun 8;67(22):617-24.

3. www.healthvermont.gov/YRBS

4. MMWR Surveill Summ. 2017 Oct;66(18):1-16.

5. JAMA Pediatr. 2015 May;169(5):466-73.

6. “Anthony Bourdain, Kate Spade, and the Preventable Tragedies of Suicide,” By Anthony Solomon, The New Yorker. Jun 8, 2018.

7. “Work and the Loneliness Epidemic,” By Vivek H. Murthy, Harvard Business Review. Sep 28, 2017.

8. Child Dev. 2000 Mar-Apr;71(2):447-56.

9. Br J Psychiatry. 2016 Mar;208(3):232-8.

10. Depress Anxiety. 2018 Jul;35(7):648-57.

11. J Am Acad Child Adolesc Psychiatry. 2018 May;57(5):313-20.

12. JAMA Psychiatry. 2018 Aug 1;75(8):835-43.

13. The Lancet Psychiatry. 2017 Jun;4(6):e11.

14. “Promoting Individual, Family, and Community Connectedness to Prevent Suicidal Behavior,” Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, www.cdc.gov/injury.

15. JAMA Psychiatry. 2018 Jul 11. doi: 10.1001/jamapsychiatry.2018.1776.

Over the past several months, I’ve found myself increasingly reflective on the intersection of culture, relationships, and my professional work with those who have an autism spectrum disorder. Last winter, an adolescent boy treated by myself and other providers died by suicide. Adam (name changed) had been diagnosed with autism as a toddler and had struggled with anxiety and depression for several years; in the office, as he grew into an athletic teenager, Adam spoke more frequently about “not fitting in” with his peers and therapeutic focus was placed on building Adam’s sense of himself and fostering his self-confidence and perceived self-competence. His unexpected death was a tremendous shock, and his loved ones – including the clinical team – desperately searched for answers that could help add some understanding to the heartbreaking event.

Rawpixel/Thinkstock

As I attempted to search for answers and reconcile national news with my clinical and teaching experiences, I was struck by something that Andrew Solomon eloquently captured in his June 2018 New Yorker article that again touches upon the theme of connection.⁶ Mr. Solomon writes “modernity is alienating” and about how he receives correspondence from those who struggle with depression. “What is most striking to me is how alone many of them are ... these people are so alone that they are effectively invisible to the rest of us ... many of them describe suicidal feelings,” he noted.

The power of connection in our day-to-day work is undeniable. The influence of human interaction and appreciating one’s unique narrative is a bedrock of clinical care and can unquestionably allow us to better understand individual suffering, deliver optimal care, and combat shame as Hannah Gadsby boldly shared in her recent Netflix comedy special “Nanette.” This shame can drive one to experience earth-shattering depressive episodes and influence thoughts of suicide. “We simply cannot make it on our own,” Ms. Gadsby explains, “we’re humans. We’re to be connected.” Humans are indeed hardwired for connection; isolation and disconnection can lead to significant health problems and are linked with mental health concerns. The former U.S. Surgeon General Vivek H. Murthy, MD, has referred to loneliness as an epidemic, and those with autism may be at increased risk for feeling lonely and isolated.^7,8

Synthesizing thoughts about relationships, suicide, loneliness, love, well-being, and autism produces a complicated web of, well, connections. Suicide in the autism population hasn’t been well researched, but one 2016 study revealed sobering numbers about suicide being a leading cause of premature death in people with autism.⁹ How do these numbers associate with feelings of isolation, wanting to fit in, and troubles talking about emotions – all of which can characterize those with ASD? Data, not surprisingly, support the role of loneliness as a risk factor for the development of depression and suicidal ideation in those with ASD.¹⁰ In addition, social-communication challenges, even in the absence of an autism diagnosis, are related to depression and suicidality.¹¹ Another recent study showed a relationship between autistic traits and depression symptoms, an association seemingly linked to being bullied.¹² We cannot continue to hold onto the myth that individuals with autism don’t desire relationships and love because it’s these desires and not being able to fulfill them, limited opportunities to engage in meaningful experiences, and feeling different that can lead to negative outcomes.

Dr. Dickerson, a child and adolescent psychiatrist, is assistant professor of psychiatry at the University of Vermont, Burlington, where he is director of the autism diagnostic clinic. Email him at [email protected].

References

1. Harv Rev Psychiatry. 2018 Jul/Aug;26(4):201-15.

2. MMWR Morb Mortal Wkly Rep. 2018 Jun 8;67(22):617-24.

3. www.healthvermont.gov/YRBS

4. MMWR Surveill Summ. 2017 Oct;66(18):1-16.

5. JAMA Pediatr. 2015 May;169(5):466-73.

6. “Anthony Bourdain, Kate Spade, and the Preventable Tragedies of Suicide,” By Anthony Solomon, The New Yorker. Jun 8, 2018.

7. “Work and the Loneliness Epidemic,” By Vivek H. Murthy, Harvard Business Review. Sep 28, 2017.

8. Child Dev. 2000 Mar-Apr;71(2):447-56.

9. Br J Psychiatry. 2016 Mar;208(3):232-8.

10. Depress Anxiety. 2018 Jul;35(7):648-57.

11. J Am Acad Child Adolesc Psychiatry. 2018 May;57(5):313-20.

12. JAMA Psychiatry. 2018 Aug 1;75(8):835-43.

13. The Lancet Psychiatry. 2017 Jun;4(6):e11.

14. “Promoting Individual, Family, and Community Connectedness to Prevent Suicidal Behavior,” Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, www.cdc.gov/injury.

15. JAMA Psychiatry. 2018 Jul 11. doi: 10.1001/jamapsychiatry.2018.1776.

As an inpatient child psychiatrist, I see children with some of the most difficult emotional and behavioral issues. And among them, children with adverse childhood experiences (ACE) make up a significant portion. But early childhood adversity is common not just among children who present to the hospital. In the landmark ACE study, which was an ongoing collaboration between Kaiser Permanente and the Centers for Disease Control and Prevention to assess impact of ACEs on various health outcomes, 40% percent of the participants reported experiencing two or more ACEs.¹ Subsequent studies have shown even higher numbers. The study by Copeland et al. on traumatic events based on the Great Smokey Mountains Study showed that more than two-thirds of children reported at least one traumatic event by the age of 16 years.²

diego_cervo/Thinkstock

The significance of this finding cannot be overstated. It is clear that the cumulative incidences of ACEs are associated with poorer health outcomes in a graded dose-response relationship. Those exposed are at great risk of developing PTSD, ADHD, mood disorders, anxiety disorders, and substance use disorder.³ Furthermore, they also are at risk for developing asthma, obesity, ischemic heart disease, diabetes, chronic obstructive pulmonary disease, autoimmune disease, and sexually transmitted disease.⁴ They have lower quality of life, use more health care services, and die nearly 20 years younger.⁵

Currently, the biology of adverse childhood experiences is being elucidated. The deleterious effects of chronically elevated cortisol leading to smaller hippocampal volume through atrophy, neurotoxicity, and disruption of neurogenesis has been demonstrated in adults, but children and adolescents have been found to have reduced medial and posterior corpus callosum.^6-10 Other alterations include changes in EEG activity, and dysregulation of the sympathetic nervous system.^11-13 New systems or neuropeptides that could potentially be beneficial in the treatment of trauma include tempering down of the locus coeruleus–norepinephrine system, the anxiolytic effect of neuropeptide Y, and brain-derived neurotrophic factor.^14,15

Despite all the progress, the treatment for trauma remains imperfect. Depending on the presenting symptoms, stimulants, alpha-agonists (guanfacine or clonidine), alpha-1 blocker, and/or SSRIs all could be a good first step. Medication could reduce the burden of some of the symptoms, but its effects are limited. During the 1970s, researchers started noticing that some children were able to thrive despite substantial risk factors for mental illness. This led to research identifying individual and environmental factors that could be protective against ACEs.

So, what is resilience? It is the development of positive adaptations in the context of significant adversity.¹⁶ But this ability is not purely incumbent on the child. The individual characteristics that lead to resilience such as internal locus of control, optimism, and determination also are dependent on their environment. As such, it is a complex dynamic interplay of genetics, temperament, experience, and environmental supports. As much as the environment can affect resilience, this gives us opportunities to help the child be more resilient, perhaps before an adverse event happens.

One, emphasize the family! A strong family relationship is among the most robust predictor of resilient adaptation. Early experiences and attachments will shape the lens through which people view their subsequent relationships and place them on probabilistic trajectories of “relatively good or bad adaptation.”¹⁷ And just what constitutes “good parenting”? The authoritative parenting style that balances appropriate controls and warmth with consistency and responsiveness generally lead to better outcomes.¹⁸ Other important features include reasonable limit-setting, monitoring, and containment.^{19, 20} Clinicians with expertise in one of the parent-coaching manuals (i.e., “Helping the Noncompliant Child,” by McMahon and Forehand; and “Your Defiant Child: Eight Steps to Better Behavior,” by Barkley and Benton and others) can be helpful in answering parenting questions whether individually or in the group setting.

In addition, parental mental health issues also can adversely affect family relationships. Based on previous studies, mothers who suffer from depression have more difficulty being responsive and warm to their child.²¹ They are often times more punitive and less consistent. Children of mothers with depression are at risk for internalizing, externalizing, and general psychopathology.²² Mothers with history of ACEs are less able to modulate stress and model coping skills. As such, it can be just as important to screen the parents for mental health issues and refer to the appropriate clinician.

Two, community supports also can facilitate development of resilience. Studies have shown participants in the Big Brothers and Big Sisters programs of America exhibit more positive behavior such as better academic behaviors, better relationships with family and friends, and decreased substance use.²³ Furthermore, studies on minority students (African American and Hispanic) suggest improved relationship with teachers led to less behavioral problems and improved social competence. Religious affiliations and other social supports can serve similar purposes as well.²⁴

Three, keep in mind the malleability of the child. Many child attributes are dependent on environmental influences and resilience should focus more on what adults can do to bolster the child’s own efforts.

Dr. Chung is a child and adolescent psychiatrist at the University of Vermont Medical Center, Burlington, and practices at Champlain Valley Physician’s Hospital in Plattsburgh, N.Y. Email him at [email protected].

References

1. Am J Prev Med. 1998 May;14(4):245-58.

2. Arch Gen Psychiatry. 2007 May;64(5):577-84.

3. Eur Arch Psychiatry Clin Neurosci. 2006 Apr;256(3):174-86.

4. Am J Prev Med. 1998 May;14(4):245-58.

5. Pediatr Res. 2016 Jan;79(1-2):227-33.

6. Prog Neuropsychopharmacol Biol Psychiatry. 2010 Oct 1;34(7):1181-8.

7. Brain Res. 1992 Aug 21;588(2):341-5.

8. J Neurosci. 1985 May;5(5):1222-7.

9. J Comp Neurol. 1996 May 20;369(1):56-63.

10. Biol Psychiatry. 2002 Dec 1;52(11):1066-78.

11. J Neuropsychiatry Clin Neurosci. 1998 Summer;10(3):298-307.

12. Biol Psychiatry. 2002 Apr 1;51(7):575-82.

13. Brain Res. 2009 Oct 13;1293:13-23.

14. Neuropeptides. 2016 Apr;56:19-24.

15. Cell. 2007 Oct 19;131(2):391-404.

16. Child Dev. 2000; 71(3): 543-62.

17. Lewis’s Child and Adolescent Psychiatry: A Comprehensive Textbook, 4th ed. (Baltimore: Lippincott Williams & Wilkins, 2007)

18. Early Hum Dev. 2010 Nov;86(11):689-93.

19. Clin Child Fam Psychol Rev. 1998 Mar;1(1):61-75.

20. Dev Psychopathol. 2003 Winter;15(1):95-117.

21. Clin Psychol Rev. 2000 Aug;20(5):561-92.

22. Clin Child Fam Psychol Rev. 2011 Mar;14(1):1-27.

23. “Making a Difference: An Impact Study of Big Brothers Big Sisters,” (Philadelphia: Public/Private Ventures, 1995).

24. Child Dev. 2003 Nov-Dec;74(6):1682-96.


 

As an inpatient child psychiatrist, I see children with some of the most difficult emotional and behavioral issues. And among them, children with adverse childhood experiences (ACE) make up a significant portion. But early childhood adversity is common not just among children who present to the hospital. In the landmark ACE study, which was an ongoing collaboration between Kaiser Permanente and the Centers for Disease Control and Prevention to assess impact of ACEs on various health outcomes, 40% percent of the participants reported experiencing two or more ACEs.¹ Subsequent studies have shown even higher numbers. The study by Copeland et al. on traumatic events based on the Great Smokey Mountains Study showed that more than two-thirds of children reported at least one traumatic event by the age of 16 years.²

diego_cervo/Thinkstock

The significance of this finding cannot be overstated. It is clear that the cumulative incidences of ACEs are associated with poorer health outcomes in a graded dose-response relationship. Those exposed are at great risk of developing PTSD, ADHD, mood disorders, anxiety disorders, and substance use disorder.³ Furthermore, they also are at risk for developing asthma, obesity, ischemic heart disease, diabetes, chronic obstructive pulmonary disease, autoimmune disease, and sexually transmitted disease.⁴ They have lower quality of life, use more health care services, and die nearly 20 years younger.⁵

Currently, the biology of adverse childhood experiences is being elucidated. The deleterious effects of chronically elevated cortisol leading to smaller hippocampal volume through atrophy, neurotoxicity, and disruption of neurogenesis has been demonstrated in adults, but children and adolescents have been found to have reduced medial and posterior corpus callosum.^6-10 Other alterations include changes in EEG activity, and dysregulation of the sympathetic nervous system.^11-13 New systems or neuropeptides that could potentially be beneficial in the treatment of trauma include tempering down of the locus coeruleus–norepinephrine system, the anxiolytic effect of neuropeptide Y, and brain-derived neurotrophic factor.^14,15

Despite all the progress, the treatment for trauma remains imperfect. Depending on the presenting symptoms, stimulants, alpha-agonists (guanfacine or clonidine), alpha-1 blocker, and/or SSRIs all could be a good first step. Medication could reduce the burden of some of the symptoms, but its effects are limited. During the 1970s, researchers started noticing that some children were able to thrive despite substantial risk factors for mental illness. This led to research identifying individual and environmental factors that could be protective against ACEs.

So, what is resilience? It is the development of positive adaptations in the context of significant adversity.¹⁶ But this ability is not purely incumbent on the child. The individual characteristics that lead to resilience such as internal locus of control, optimism, and determination also are dependent on their environment. As such, it is a complex dynamic interplay of genetics, temperament, experience, and environmental supports. As much as the environment can affect resilience, this gives us opportunities to help the child be more resilient, perhaps before an adverse event happens.

One, emphasize the family! A strong family relationship is among the most robust predictor of resilient adaptation. Early experiences and attachments will shape the lens through which people view their subsequent relationships and place them on probabilistic trajectories of “relatively good or bad adaptation.”¹⁷ And just what constitutes “good parenting”? The authoritative parenting style that balances appropriate controls and warmth with consistency and responsiveness generally lead to better outcomes.¹⁸ Other important features include reasonable limit-setting, monitoring, and containment.^{19, 20} Clinicians with expertise in one of the parent-coaching manuals (i.e., “Helping the Noncompliant Child,” by McMahon and Forehand; and “Your Defiant Child: Eight Steps to Better Behavior,” by Barkley and Benton and others) can be helpful in answering parenting questions whether individually or in the group setting.

In addition, parental mental health issues also can adversely affect family relationships. Based on previous studies, mothers who suffer from depression have more difficulty being responsive and warm to their child.²¹ They are often times more punitive and less consistent. Children of mothers with depression are at risk for internalizing, externalizing, and general psychopathology.²² Mothers with history of ACEs are less able to modulate stress and model coping skills. As such, it can be just as important to screen the parents for mental health issues and refer to the appropriate clinician.

Two, community supports also can facilitate development of resilience. Studies have shown participants in the Big Brothers and Big Sisters programs of America exhibit more positive behavior such as better academic behaviors, better relationships with family and friends, and decreased substance use.²³ Furthermore, studies on minority students (African American and Hispanic) suggest improved relationship with teachers led to less behavioral problems and improved social competence. Religious affiliations and other social supports can serve similar purposes as well.²⁴

Three, keep in mind the malleability of the child. Many child attributes are dependent on environmental influences and resilience should focus more on what adults can do to bolster the child’s own efforts.

Dr. Chung is a child and adolescent psychiatrist at the University of Vermont Medical Center, Burlington, and practices at Champlain Valley Physician’s Hospital in Plattsburgh, N.Y. Email him at [email protected].

References

1. Am J Prev Med. 1998 May;14(4):245-58.

2. Arch Gen Psychiatry. 2007 May;64(5):577-84.

3. Eur Arch Psychiatry Clin Neurosci. 2006 Apr;256(3):174-86.

4. Am J Prev Med. 1998 May;14(4):245-58.

5. Pediatr Res. 2016 Jan;79(1-2):227-33.

6. Prog Neuropsychopharmacol Biol Psychiatry. 2010 Oct 1;34(7):1181-8.

7. Brain Res. 1992 Aug 21;588(2):341-5.

8. J Neurosci. 1985 May;5(5):1222-7.

9. J Comp Neurol. 1996 May 20;369(1):56-63.

10. Biol Psychiatry. 2002 Dec 1;52(11):1066-78.

11. J Neuropsychiatry Clin Neurosci. 1998 Summer;10(3):298-307.

12. Biol Psychiatry. 2002 Apr 1;51(7):575-82.

13. Brain Res. 2009 Oct 13;1293:13-23.

14. Neuropeptides. 2016 Apr;56:19-24.

15. Cell. 2007 Oct 19;131(2):391-404.

16. Child Dev. 2000; 71(3): 543-62.

17. Lewis’s Child and Adolescent Psychiatry: A Comprehensive Textbook, 4th ed. (Baltimore: Lippincott Williams & Wilkins, 2007)

18. Early Hum Dev. 2010 Nov;86(11):689-93.

19. Clin Child Fam Psychol Rev. 1998 Mar;1(1):61-75.

20. Dev Psychopathol. 2003 Winter;15(1):95-117.

21. Clin Psychol Rev. 2000 Aug;20(5):561-92.

22. Clin Child Fam Psychol Rev. 2011 Mar;14(1):1-27.

23. “Making a Difference: An Impact Study of Big Brothers Big Sisters,” (Philadelphia: Public/Private Ventures, 1995).

24. Child Dev. 2003 Nov-Dec;74(6):1682-96.


 

As an inpatient child psychiatrist, I see children with some of the most difficult emotional and behavioral issues. And among them, children with adverse childhood experiences (ACE) make up a significant portion. But early childhood adversity is common not just among children who present to the hospital. In the landmark ACE study, which was an ongoing collaboration between Kaiser Permanente and the Centers for Disease Control and Prevention to assess impact of ACEs on various health outcomes, 40% percent of the participants reported experiencing two or more ACEs.¹ Subsequent studies have shown even higher numbers. The study by Copeland et al. on traumatic events based on the Great Smokey Mountains Study showed that more than two-thirds of children reported at least one traumatic event by the age of 16 years.²

diego_cervo/Thinkstock

The significance of this finding cannot be overstated. It is clear that the cumulative incidences of ACEs are associated with poorer health outcomes in a graded dose-response relationship. Those exposed are at great risk of developing PTSD, ADHD, mood disorders, anxiety disorders, and substance use disorder.³ Furthermore, they also are at risk for developing asthma, obesity, ischemic heart disease, diabetes, chronic obstructive pulmonary disease, autoimmune disease, and sexually transmitted disease.⁴ They have lower quality of life, use more health care services, and die nearly 20 years younger.⁵

Currently, the biology of adverse childhood experiences is being elucidated. The deleterious effects of chronically elevated cortisol leading to smaller hippocampal volume through atrophy, neurotoxicity, and disruption of neurogenesis has been demonstrated in adults, but children and adolescents have been found to have reduced medial and posterior corpus callosum.^6-10 Other alterations include changes in EEG activity, and dysregulation of the sympathetic nervous system.^11-13 New systems or neuropeptides that could potentially be beneficial in the treatment of trauma include tempering down of the locus coeruleus–norepinephrine system, the anxiolytic effect of neuropeptide Y, and brain-derived neurotrophic factor.^14,15

Despite all the progress, the treatment for trauma remains imperfect. Depending on the presenting symptoms, stimulants, alpha-agonists (guanfacine or clonidine), alpha-1 blocker, and/or SSRIs all could be a good first step. Medication could reduce the burden of some of the symptoms, but its effects are limited. During the 1970s, researchers started noticing that some children were able to thrive despite substantial risk factors for mental illness. This led to research identifying individual and environmental factors that could be protective against ACEs.

So, what is resilience? It is the development of positive adaptations in the context of significant adversity.¹⁶ But this ability is not purely incumbent on the child. The individual characteristics that lead to resilience such as internal locus of control, optimism, and determination also are dependent on their environment. As such, it is a complex dynamic interplay of genetics, temperament, experience, and environmental supports. As much as the environment can affect resilience, this gives us opportunities to help the child be more resilient, perhaps before an adverse event happens.

One, emphasize the family! A strong family relationship is among the most robust predictor of resilient adaptation. Early experiences and attachments will shape the lens through which people view their subsequent relationships and place them on probabilistic trajectories of “relatively good or bad adaptation.”¹⁷ And just what constitutes “good parenting”? The authoritative parenting style that balances appropriate controls and warmth with consistency and responsiveness generally lead to better outcomes.¹⁸ Other important features include reasonable limit-setting, monitoring, and containment.^{19, 20} Clinicians with expertise in one of the parent-coaching manuals (i.e., “Helping the Noncompliant Child,” by McMahon and Forehand; and “Your Defiant Child: Eight Steps to Better Behavior,” by Barkley and Benton and others) can be helpful in answering parenting questions whether individually or in the group setting.

In addition, parental mental health issues also can adversely affect family relationships. Based on previous studies, mothers who suffer from depression have more difficulty being responsive and warm to their child.²¹ They are often times more punitive and less consistent. Children of mothers with depression are at risk for internalizing, externalizing, and general psychopathology.²² Mothers with history of ACEs are less able to modulate stress and model coping skills. As such, it can be just as important to screen the parents for mental health issues and refer to the appropriate clinician.

Two, community supports also can facilitate development of resilience. Studies have shown participants in the Big Brothers and Big Sisters programs of America exhibit more positive behavior such as better academic behaviors, better relationships with family and friends, and decreased substance use.²³ Furthermore, studies on minority students (African American and Hispanic) suggest improved relationship with teachers led to less behavioral problems and improved social competence. Religious affiliations and other social supports can serve similar purposes as well.²⁴

Three, keep in mind the malleability of the child. Many child attributes are dependent on environmental influences and resilience should focus more on what adults can do to bolster the child’s own efforts.

Dr. Chung is a child and adolescent psychiatrist at the University of Vermont Medical Center, Burlington, and practices at Champlain Valley Physician’s Hospital in Plattsburgh, N.Y. Email him at [email protected].

References

1. Am J Prev Med. 1998 May;14(4):245-58.

2. Arch Gen Psychiatry. 2007 May;64(5):577-84.

3. Eur Arch Psychiatry Clin Neurosci. 2006 Apr;256(3):174-86.

4. Am J Prev Med. 1998 May;14(4):245-58.

5. Pediatr Res. 2016 Jan;79(1-2):227-33.

6. Prog Neuropsychopharmacol Biol Psychiatry. 2010 Oct 1;34(7):1181-8.

7. Brain Res. 1992 Aug 21;588(2):341-5.

8. J Neurosci. 1985 May;5(5):1222-7.

9. J Comp Neurol. 1996 May 20;369(1):56-63.

10. Biol Psychiatry. 2002 Dec 1;52(11):1066-78.

11. J Neuropsychiatry Clin Neurosci. 1998 Summer;10(3):298-307.

12. Biol Psychiatry. 2002 Apr 1;51(7):575-82.

13. Brain Res. 2009 Oct 13;1293:13-23.

14. Neuropeptides. 2016 Apr;56:19-24.

15. Cell. 2007 Oct 19;131(2):391-404.

16. Child Dev. 2000; 71(3): 543-62.

17. Lewis’s Child and Adolescent Psychiatry: A Comprehensive Textbook, 4th ed. (Baltimore: Lippincott Williams & Wilkins, 2007)

18. Early Hum Dev. 2010 Nov;86(11):689-93.

19. Clin Child Fam Psychol Rev. 1998 Mar;1(1):61-75.

20. Dev Psychopathol. 2003 Winter;15(1):95-117.

21. Clin Psychol Rev. 2000 Aug;20(5):561-92.

22. Clin Child Fam Psychol Rev. 2011 Mar;14(1):1-27.

23. “Making a Difference: An Impact Study of Big Brothers Big Sisters,” (Philadelphia: Public/Private Ventures, 1995).

24. Child Dev. 2003 Nov-Dec;74(6):1682-96.


 

Behavioral parent management training (PMT), which teaches parents concrete skills to increase their attention to positive behavior and to plan for their response to undesired behavior, has abundant evidence for success for many challenging child behaviors. But sometimes parents have a hard time managing their own emotional responses in the often highly triggering situation of family conflict. Mindfulness has the potential to provide a complement to the PMT skills. Studies are beginning to explore these possibilities.

Case summary

Zoe is a bright 5-year-old who has been “strong willed” and shown intense emotional responses since early in life. The usual 2-year-old temper tantrums increased over time. She has outbursts of yelling, kicking, and hitting, especially with transitions. Her parents tried behavioral parent training, but found it frustrating. If Zoe has been yelling and hitting earlier in the day, her mother feels hurt and angry and can’t bring herself to pay warm attention when Zoe is doing better. When Zoe refuses to pick up her room, her father is flooded with thoughts about his own father hitting him for the slightest disrespect. He thinks that he is a bad, weak father, and sometimes “sees red” and ends up yelling at Zoe instead of putting into place a calm consequence.

kali9/Getty Images

Discussion

Mindfulness is defined by Jon Kabat-Zinn as “paying attention in a particular way – on purpose, in the present moment, and nonjudgmentally.” A central feature of mindfulness is strengthening the ability to focus our attention. We learn to pay attention to aspects of the present moment, be that breathing, the sensations in our body, or the experiences of our senses. Often the first skill in behavioral training methods is getting parents to pay attention to their children by participating in child-led play or spending attentive time with older children. This means attending to what the child is doing or talking about rather than jumping in and taking over with suggestions, instructions, or judgments. This meshes very well with this central aspect of mindfulness.

As we practice paying attention, we observe that the mind naturally jumps around from what we mean to be attending to, to a host of distractions, worries, plans, memories, thoughts, and emotions. Mindfulness encourages practitioners to notice these thoughts, to avoid criticizing or judging oneself for becoming involved with these, but instead gently lead the mind back to what you had intended to focus on. This observation of the mind’s activity gives the mindfulness practitioner a bit of space from the thought or emotion itself. We are encouraged to name the thought or emotional processes we notice: “I am worrying, I am planning, I am remembering.”

In the heat of a difficult moment with the child, parents often are flooded with intense emotions (such as anger, fear, anxiety, panic, despair) and thoughts (such as “If my child keeps acting this way he is going to go to jail when he grows up,” “I am a terrible parent,” “Why is my child doing this to me?” or “He is just like his father”). These emotions and thoughts can drive intense, impulsive responses from the parents. As they practice mindfulness, they can gain the ability to observe themselves having these thoughts; observe harsh judgments of themselves or their children or their partners; have some space from them; and realize they may change in a few minutes or realize they may be painful but don’t necessarily have to spur impulsive action. In that moment, parents can give themselves time and space to think through possible actions, and then choose one.

Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures. Email her at [email protected].

Resources

“Mindful Parenting” (New York: Norton & Co., 2015).

“Integrating mindfulness with parent training: Effects of the mindfulness-enhanced strengthening families program” (Dev Psychol. 2015;51[1]:26-35).

“Everyday blessings: The inner work of mindful parenting,” (New York: Hyperion, 1997).

Behavioral parent management training (PMT), which teaches parents concrete skills to increase their attention to positive behavior and to plan for their response to undesired behavior, has abundant evidence for success for many challenging child behaviors. But sometimes parents have a hard time managing their own emotional responses in the often highly triggering situation of family conflict. Mindfulness has the potential to provide a complement to the PMT skills. Studies are beginning to explore these possibilities.

Case summary

Zoe is a bright 5-year-old who has been “strong willed” and shown intense emotional responses since early in life. The usual 2-year-old temper tantrums increased over time. She has outbursts of yelling, kicking, and hitting, especially with transitions. Her parents tried behavioral parent training, but found it frustrating. If Zoe has been yelling and hitting earlier in the day, her mother feels hurt and angry and can’t bring herself to pay warm attention when Zoe is doing better. When Zoe refuses to pick up her room, her father is flooded with thoughts about his own father hitting him for the slightest disrespect. He thinks that he is a bad, weak father, and sometimes “sees red” and ends up yelling at Zoe instead of putting into place a calm consequence.

kali9/Getty Images

Discussion

Mindfulness is defined by Jon Kabat-Zinn as “paying attention in a particular way – on purpose, in the present moment, and nonjudgmentally.” A central feature of mindfulness is strengthening the ability to focus our attention. We learn to pay attention to aspects of the present moment, be that breathing, the sensations in our body, or the experiences of our senses. Often the first skill in behavioral training methods is getting parents to pay attention to their children by participating in child-led play or spending attentive time with older children. This means attending to what the child is doing or talking about rather than jumping in and taking over with suggestions, instructions, or judgments. This meshes very well with this central aspect of mindfulness.

As we practice paying attention, we observe that the mind naturally jumps around from what we mean to be attending to, to a host of distractions, worries, plans, memories, thoughts, and emotions. Mindfulness encourages practitioners to notice these thoughts, to avoid criticizing or judging oneself for becoming involved with these, but instead gently lead the mind back to what you had intended to focus on. This observation of the mind’s activity gives the mindfulness practitioner a bit of space from the thought or emotion itself. We are encouraged to name the thought or emotional processes we notice: “I am worrying, I am planning, I am remembering.”

In the heat of a difficult moment with the child, parents often are flooded with intense emotions (such as anger, fear, anxiety, panic, despair) and thoughts (such as “If my child keeps acting this way he is going to go to jail when he grows up,” “I am a terrible parent,” “Why is my child doing this to me?” or “He is just like his father”). These emotions and thoughts can drive intense, impulsive responses from the parents. As they practice mindfulness, they can gain the ability to observe themselves having these thoughts; observe harsh judgments of themselves or their children or their partners; have some space from them; and realize they may change in a few minutes or realize they may be painful but don’t necessarily have to spur impulsive action. In that moment, parents can give themselves time and space to think through possible actions, and then choose one.

Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures. Email her at [email protected].

Resources

“Mindful Parenting” (New York: Norton & Co., 2015).

“Integrating mindfulness with parent training: Effects of the mindfulness-enhanced strengthening families program” (Dev Psychol. 2015;51[1]:26-35).

“Everyday blessings: The inner work of mindful parenting,” (New York: Hyperion, 1997).

Behavioral parent management training (PMT), which teaches parents concrete skills to increase their attention to positive behavior and to plan for their response to undesired behavior, has abundant evidence for success for many challenging child behaviors. But sometimes parents have a hard time managing their own emotional responses in the often highly triggering situation of family conflict. Mindfulness has the potential to provide a complement to the PMT skills. Studies are beginning to explore these possibilities.

Case summary

Zoe is a bright 5-year-old who has been “strong willed” and shown intense emotional responses since early in life. The usual 2-year-old temper tantrums increased over time. She has outbursts of yelling, kicking, and hitting, especially with transitions. Her parents tried behavioral parent training, but found it frustrating. If Zoe has been yelling and hitting earlier in the day, her mother feels hurt and angry and can’t bring herself to pay warm attention when Zoe is doing better. When Zoe refuses to pick up her room, her father is flooded with thoughts about his own father hitting him for the slightest disrespect. He thinks that he is a bad, weak father, and sometimes “sees red” and ends up yelling at Zoe instead of putting into place a calm consequence.

kali9/Getty Images

Discussion

Mindfulness is defined by Jon Kabat-Zinn as “paying attention in a particular way – on purpose, in the present moment, and nonjudgmentally.” A central feature of mindfulness is strengthening the ability to focus our attention. We learn to pay attention to aspects of the present moment, be that breathing, the sensations in our body, or the experiences of our senses. Often the first skill in behavioral training methods is getting parents to pay attention to their children by participating in child-led play or spending attentive time with older children. This means attending to what the child is doing or talking about rather than jumping in and taking over with suggestions, instructions, or judgments. This meshes very well with this central aspect of mindfulness.

As we practice paying attention, we observe that the mind naturally jumps around from what we mean to be attending to, to a host of distractions, worries, plans, memories, thoughts, and emotions. Mindfulness encourages practitioners to notice these thoughts, to avoid criticizing or judging oneself for becoming involved with these, but instead gently lead the mind back to what you had intended to focus on. This observation of the mind’s activity gives the mindfulness practitioner a bit of space from the thought or emotion itself. We are encouraged to name the thought or emotional processes we notice: “I am worrying, I am planning, I am remembering.”

In the heat of a difficult moment with the child, parents often are flooded with intense emotions (such as anger, fear, anxiety, panic, despair) and thoughts (such as “If my child keeps acting this way he is going to go to jail when he grows up,” “I am a terrible parent,” “Why is my child doing this to me?” or “He is just like his father”). These emotions and thoughts can drive intense, impulsive responses from the parents. As they practice mindfulness, they can gain the ability to observe themselves having these thoughts; observe harsh judgments of themselves or their children or their partners; have some space from them; and realize they may change in a few minutes or realize they may be painful but don’t necessarily have to spur impulsive action. In that moment, parents can give themselves time and space to think through possible actions, and then choose one.

Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures. Email her at [email protected].

Resources

“Mindful Parenting” (New York: Norton & Co., 2015).

“Integrating mindfulness with parent training: Effects of the mindfulness-enhanced strengthening families program” (Dev Psychol. 2015;51[1]:26-35).

“Everyday blessings: The inner work of mindful parenting,” (New York: Hyperion, 1997).

You are on the front lines of the prevention, screening, and treatment decisions for adolescent substance use disorders. You often must choose whether to disclose information about substance use to parents and other concerned adults.

The risk of developing a substance use disorder increases dramatically the earlier an individual begins using a given substance.¹ The neurobiology behind this risk is becoming increasingly clear. Young brains are undergoing crucial developmental processes, including synaptic pruning and myelination. The brain increasingly becomes more efficient in a staggered pattern, with limbic regions preceding frontal and executive regions, so we see adolescents with “more gas than brakes.” This has wisely been identified as developmentally appropriate, and even beneficial, rather than evidence that adolescents are somehow broken.²

SolStock/Getty Images

Steve Debenport/Getty Images

In most cases, adolescents should be informed of a decision to disclose substance use to their parents. Inviting adolescents to discuss how this will be done, including if the adolescent will be present, and whether you or the adolescent will disclose the use can be an opportunity to discuss their concerns. You should seek to understand if an adolescent has specific fears related to such a disclosure including careful consideration of any history of domestic violence or abuse.

Although adolescents increasingly identify with the opinions and values of their peers, it is a mistake to assume that they therefore do not value the opinions of their parents and the concerned adults in their lives. Parents play an integral role in preventing and treating adolescent substance use disorders. Except in rare instances of severe parent-child relationship problems or abuse, parents can and should be engaged as invaluable participants

Dr. Jackson is a child and adolescent psychiatrist at the University of Vermont, Burlington.

References

1. “Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings.” NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. (Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013).

2. “The Amazing Teen Brain,” Jay N. Geidd, Scientific American, May 2016.

3. Pediatrics 2011 Oct. doi: 10.1542/peds.2011-1754.

4. Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide.

5. Pediatrics. 2016 Jul 1. doi: 10.1542/peds.2016-1211.

6. J Fam Commun. 2014 Jan 1:14(4):328-51.

7. J Clin Child Adolesc. Psychol. 2008;37(1):236-59.

8. J Child Adolesc Subst Abuse. 2015 May 4;24(3):155-65.

9. Arch Pediatr Adolesc Med. 2012;166(12):1132-9.

You are on the front lines of the prevention, screening, and treatment decisions for adolescent substance use disorders. You often must choose whether to disclose information about substance use to parents and other concerned adults.

The risk of developing a substance use disorder increases dramatically the earlier an individual begins using a given substance.¹ The neurobiology behind this risk is becoming increasingly clear. Young brains are undergoing crucial developmental processes, including synaptic pruning and myelination. The brain increasingly becomes more efficient in a staggered pattern, with limbic regions preceding frontal and executive regions, so we see adolescents with “more gas than brakes.” This has wisely been identified as developmentally appropriate, and even beneficial, rather than evidence that adolescents are somehow broken.²

SolStock/Getty Images

Steve Debenport/Getty Images

In most cases, adolescents should be informed of a decision to disclose substance use to their parents. Inviting adolescents to discuss how this will be done, including if the adolescent will be present, and whether you or the adolescent will disclose the use can be an opportunity to discuss their concerns. You should seek to understand if an adolescent has specific fears related to such a disclosure including careful consideration of any history of domestic violence or abuse.

Although adolescents increasingly identify with the opinions and values of their peers, it is a mistake to assume that they therefore do not value the opinions of their parents and the concerned adults in their lives. Parents play an integral role in preventing and treating adolescent substance use disorders. Except in rare instances of severe parent-child relationship problems or abuse, parents can and should be engaged as invaluable participants

Dr. Jackson is a child and adolescent psychiatrist at the University of Vermont, Burlington.

References

1. “Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings.” NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. (Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013).

2. “The Amazing Teen Brain,” Jay N. Geidd, Scientific American, May 2016.

3. Pediatrics 2011 Oct. doi: 10.1542/peds.2011-1754.

4. Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide.

5. Pediatrics. 2016 Jul 1. doi: 10.1542/peds.2016-1211.

6. J Fam Commun. 2014 Jan 1:14(4):328-51.

7. J Clin Child Adolesc. Psychol. 2008;37(1):236-59.

8. J Child Adolesc Subst Abuse. 2015 May 4;24(3):155-65.

9. Arch Pediatr Adolesc Med. 2012;166(12):1132-9.

You are on the front lines of the prevention, screening, and treatment decisions for adolescent substance use disorders. You often must choose whether to disclose information about substance use to parents and other concerned adults.

The risk of developing a substance use disorder increases dramatically the earlier an individual begins using a given substance.¹ The neurobiology behind this risk is becoming increasingly clear. Young brains are undergoing crucial developmental processes, including synaptic pruning and myelination. The brain increasingly becomes more efficient in a staggered pattern, with limbic regions preceding frontal and executive regions, so we see adolescents with “more gas than brakes.” This has wisely been identified as developmentally appropriate, and even beneficial, rather than evidence that adolescents are somehow broken.²

SolStock/Getty Images

Steve Debenport/Getty Images

In most cases, adolescents should be informed of a decision to disclose substance use to their parents. Inviting adolescents to discuss how this will be done, including if the adolescent will be present, and whether you or the adolescent will disclose the use can be an opportunity to discuss their concerns. You should seek to understand if an adolescent has specific fears related to such a disclosure including careful consideration of any history of domestic violence or abuse.

Although adolescents increasingly identify with the opinions and values of their peers, it is a mistake to assume that they therefore do not value the opinions of their parents and the concerned adults in their lives. Parents play an integral role in preventing and treating adolescent substance use disorders. Except in rare instances of severe parent-child relationship problems or abuse, parents can and should be engaged as invaluable participants

Dr. Jackson is a child and adolescent psychiatrist at the University of Vermont, Burlington.

References

1. “Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings.” NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. (Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013).

2. “The Amazing Teen Brain,” Jay N. Geidd, Scientific American, May 2016.

3. Pediatrics 2011 Oct. doi: 10.1542/peds.2011-1754.

4. Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide.

5. Pediatrics. 2016 Jul 1. doi: 10.1542/peds.2016-1211.

6. J Fam Commun. 2014 Jan 1:14(4):328-51.

7. J Clin Child Adolesc. Psychol. 2008;37(1):236-59.

8. J Child Adolesc Subst Abuse. 2015 May 4;24(3):155-65.

9. Arch Pediatr Adolesc Med. 2012;166(12):1132-9.