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To refer—or not?
When I was training to become a family physician, my mentor often told me that a competent family physician should be able to manage about 80% of patients’ office visits without consultation. I am not sure where that figure came from, but my 40 years of experience in family medicine supports that prediction. Of course, the flip-side of that coin is having the wisdom to make those referrals for patients who really need a specialist’s diagnostic or treatment skills. The “rub,” of course, is that when I do need a specialist’s help, the wait for an appointment is often unacceptably long—both for me and my patients.
One way to help alleviate the logjam of referrals is to manage more medical problems ourselves. Now I don’t mean holding on to patients who definitely need a referral. But I do think we should avoid being too quick to hand off a patient. Let me explain.
When I was Chair of Family Medicine at Cleveland Clinic, I asked my specialty colleagues what percentage of the referred patients they saw in their offices could be managed competently by a well-trained family physician. The usual answer—from a variety of specialists—was “about 30%.” If we took care of that 30% of patients ourselves, it would go a long way toward freeing up specialists’ schedules to see the patients who truly require their expertise.
Some public health systems, such as the University of California San Francisco Medical Center,1 have implemented successful triage systems to alleviate the referral backlog. Patients are triaged by a specialist and assigned to 1 of 3 categories: 1) urgent—the patient will be seen right away, 2) non-urgent—the patient will be seen as soon as possible (usually within 2 weeks), or 3) phone/email consultation—the specialist provides diagnostic and management advice electronically, or by phone, but does not see the patient.
Continue to: The issue of referral comes to mind...
The issue of referral comes to mind this month in light of our cover story on migraine headache management. Migraine is one of those conditions that is often referred for specialist care, but can, in many cases, be competently managed by family physicians. The diagnosis of migraine is made almost entirely by history and physical exam, and there are many treatments for acute attacks and prevention that are effective and can be prescribed by family physicians and other primary health care professionals.
Yes, patients with more severe migraine may need a specialist consultation. But let’s remain cognizant of the fact that a good percentage of our patients will be best served staying right where they are—in the office of their family physician.
1. Chen AH, Murphy EJ, Yee HF. eReferral—a new model for integrated care. N Engl J Med. 2013;368:2450-2453.
Editor-in-Chief
Editor-in-Chief
Editor-in-Chief
When I was training to become a family physician, my mentor often told me that a competent family physician should be able to manage about 80% of patients’ office visits without consultation. I am not sure where that figure came from, but my 40 years of experience in family medicine supports that prediction. Of course, the flip-side of that coin is having the wisdom to make those referrals for patients who really need a specialist’s diagnostic or treatment skills. The “rub,” of course, is that when I do need a specialist’s help, the wait for an appointment is often unacceptably long—both for me and my patients.
One way to help alleviate the logjam of referrals is to manage more medical problems ourselves. Now I don’t mean holding on to patients who definitely need a referral. But I do think we should avoid being too quick to hand off a patient. Let me explain.
When I was Chair of Family Medicine at Cleveland Clinic, I asked my specialty colleagues what percentage of the referred patients they saw in their offices could be managed competently by a well-trained family physician. The usual answer—from a variety of specialists—was “about 30%.” If we took care of that 30% of patients ourselves, it would go a long way toward freeing up specialists’ schedules to see the patients who truly require their expertise.
Some public health systems, such as the University of California San Francisco Medical Center,1 have implemented successful triage systems to alleviate the referral backlog. Patients are triaged by a specialist and assigned to 1 of 3 categories: 1) urgent—the patient will be seen right away, 2) non-urgent—the patient will be seen as soon as possible (usually within 2 weeks), or 3) phone/email consultation—the specialist provides diagnostic and management advice electronically, or by phone, but does not see the patient.
Continue to: The issue of referral comes to mind...
The issue of referral comes to mind this month in light of our cover story on migraine headache management. Migraine is one of those conditions that is often referred for specialist care, but can, in many cases, be competently managed by family physicians. The diagnosis of migraine is made almost entirely by history and physical exam, and there are many treatments for acute attacks and prevention that are effective and can be prescribed by family physicians and other primary health care professionals.
Yes, patients with more severe migraine may need a specialist consultation. But let’s remain cognizant of the fact that a good percentage of our patients will be best served staying right where they are—in the office of their family physician.
When I was training to become a family physician, my mentor often told me that a competent family physician should be able to manage about 80% of patients’ office visits without consultation. I am not sure where that figure came from, but my 40 years of experience in family medicine supports that prediction. Of course, the flip-side of that coin is having the wisdom to make those referrals for patients who really need a specialist’s diagnostic or treatment skills. The “rub,” of course, is that when I do need a specialist’s help, the wait for an appointment is often unacceptably long—both for me and my patients.
One way to help alleviate the logjam of referrals is to manage more medical problems ourselves. Now I don’t mean holding on to patients who definitely need a referral. But I do think we should avoid being too quick to hand off a patient. Let me explain.
When I was Chair of Family Medicine at Cleveland Clinic, I asked my specialty colleagues what percentage of the referred patients they saw in their offices could be managed competently by a well-trained family physician. The usual answer—from a variety of specialists—was “about 30%.” If we took care of that 30% of patients ourselves, it would go a long way toward freeing up specialists’ schedules to see the patients who truly require their expertise.
Some public health systems, such as the University of California San Francisco Medical Center,1 have implemented successful triage systems to alleviate the referral backlog. Patients are triaged by a specialist and assigned to 1 of 3 categories: 1) urgent—the patient will be seen right away, 2) non-urgent—the patient will be seen as soon as possible (usually within 2 weeks), or 3) phone/email consultation—the specialist provides diagnostic and management advice electronically, or by phone, but does not see the patient.
Continue to: The issue of referral comes to mind...
The issue of referral comes to mind this month in light of our cover story on migraine headache management. Migraine is one of those conditions that is often referred for specialist care, but can, in many cases, be competently managed by family physicians. The diagnosis of migraine is made almost entirely by history and physical exam, and there are many treatments for acute attacks and prevention that are effective and can be prescribed by family physicians and other primary health care professionals.
Yes, patients with more severe migraine may need a specialist consultation. But let’s remain cognizant of the fact that a good percentage of our patients will be best served staying right where they are—in the office of their family physician.
1. Chen AH, Murphy EJ, Yee HF. eReferral—a new model for integrated care. N Engl J Med. 2013;368:2450-2453.
1. Chen AH, Murphy EJ, Yee HF. eReferral—a new model for integrated care. N Engl J Med. 2013;368:2450-2453.
Useful financial and efficiency advice to practices is hard to come by
This time of year the nonclinical medical journals are full of articles with titles like “Make This Your Best Financial Year!”
I read them January after January, but each year they remind me less of January 1st and more of February 2nd – Groundhog Day.
It seems you could republish the same article every year and change the title. All of them mention “collect patient copays” and “submit insurance billings promptly.” I had no idea some offices don’t. To me, this is like suggesting I pay my mortgage each month as a financial tip.
They inevitably also talk about improving my “web presence.” Most small practices don’t have an IT department. I’m it here. My modest (and that’s an exaggeration) web page has a 2003 picture of me that I desperately need to update but don’t have the time or expertise to do these days. People seem to think that small practices are wallowing in time and money, but realistically we have neither.
They also highlight all the free things we can do on the web, like a blog or Twitter account, to promote a practice. They fail to realize how much time it takes to regularly write a blog post. Twitter posts from most practices are either tripe such as “Remember – our office will be closed on Christmas!” or links to some recently published study about the importance of diet and exercise.
Besides, in this day and age pretty much anything can be taken as a claim of a doctor-patient relationship. There’s always someone looking to claim your seemingly innocuous blog post constituted harmful medical advice and try to sue you.
Turn my scheduling over to an online program for greater efficiency? No thanks, I’ll leave that to my awesome secretary. After 15 years here, she knows my personality and can quickly screen out people who will be a bad match for me. She also knows our patients and has a good gestalt for figuring how much time certain people will need. This prevents me from getting too far off schedule. She may not be as efficient as an online booking program, but she’s far more valuable. I’ll take quality over quantity any day.
Year in and year out, I see these same suggestions, which apply only to larger practices, or those run by incompetents, or both. I keep reading them, hoping I’ll glean something of value that might apply to me, but to date I haven’t found that.
Time is one of any practices’ most valuable assets. Instead of posting meaningless stuff online, or working on a better website, I’d rather invest my work time where it really belongs: on my patients.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
This time of year the nonclinical medical journals are full of articles with titles like “Make This Your Best Financial Year!”
I read them January after January, but each year they remind me less of January 1st and more of February 2nd – Groundhog Day.
It seems you could republish the same article every year and change the title. All of them mention “collect patient copays” and “submit insurance billings promptly.” I had no idea some offices don’t. To me, this is like suggesting I pay my mortgage each month as a financial tip.
They inevitably also talk about improving my “web presence.” Most small practices don’t have an IT department. I’m it here. My modest (and that’s an exaggeration) web page has a 2003 picture of me that I desperately need to update but don’t have the time or expertise to do these days. People seem to think that small practices are wallowing in time and money, but realistically we have neither.
They also highlight all the free things we can do on the web, like a blog or Twitter account, to promote a practice. They fail to realize how much time it takes to regularly write a blog post. Twitter posts from most practices are either tripe such as “Remember – our office will be closed on Christmas!” or links to some recently published study about the importance of diet and exercise.
Besides, in this day and age pretty much anything can be taken as a claim of a doctor-patient relationship. There’s always someone looking to claim your seemingly innocuous blog post constituted harmful medical advice and try to sue you.
Turn my scheduling over to an online program for greater efficiency? No thanks, I’ll leave that to my awesome secretary. After 15 years here, she knows my personality and can quickly screen out people who will be a bad match for me. She also knows our patients and has a good gestalt for figuring how much time certain people will need. This prevents me from getting too far off schedule. She may not be as efficient as an online booking program, but she’s far more valuable. I’ll take quality over quantity any day.
Year in and year out, I see these same suggestions, which apply only to larger practices, or those run by incompetents, or both. I keep reading them, hoping I’ll glean something of value that might apply to me, but to date I haven’t found that.
Time is one of any practices’ most valuable assets. Instead of posting meaningless stuff online, or working on a better website, I’d rather invest my work time where it really belongs: on my patients.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
This time of year the nonclinical medical journals are full of articles with titles like “Make This Your Best Financial Year!”
I read them January after January, but each year they remind me less of January 1st and more of February 2nd – Groundhog Day.
It seems you could republish the same article every year and change the title. All of them mention “collect patient copays” and “submit insurance billings promptly.” I had no idea some offices don’t. To me, this is like suggesting I pay my mortgage each month as a financial tip.
They inevitably also talk about improving my “web presence.” Most small practices don’t have an IT department. I’m it here. My modest (and that’s an exaggeration) web page has a 2003 picture of me that I desperately need to update but don’t have the time or expertise to do these days. People seem to think that small practices are wallowing in time and money, but realistically we have neither.
They also highlight all the free things we can do on the web, like a blog or Twitter account, to promote a practice. They fail to realize how much time it takes to regularly write a blog post. Twitter posts from most practices are either tripe such as “Remember – our office will be closed on Christmas!” or links to some recently published study about the importance of diet and exercise.
Besides, in this day and age pretty much anything can be taken as a claim of a doctor-patient relationship. There’s always someone looking to claim your seemingly innocuous blog post constituted harmful medical advice and try to sue you.
Turn my scheduling over to an online program for greater efficiency? No thanks, I’ll leave that to my awesome secretary. After 15 years here, she knows my personality and can quickly screen out people who will be a bad match for me. She also knows our patients and has a good gestalt for figuring how much time certain people will need. This prevents me from getting too far off schedule. She may not be as efficient as an online booking program, but she’s far more valuable. I’ll take quality over quantity any day.
Year in and year out, I see these same suggestions, which apply only to larger practices, or those run by incompetents, or both. I keep reading them, hoping I’ll glean something of value that might apply to me, but to date I haven’t found that.
Time is one of any practices’ most valuable assets. Instead of posting meaningless stuff online, or working on a better website, I’d rather invest my work time where it really belongs: on my patients.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Gametes for back pain, Alice in Wonderland syndrome, and liver-saving beer
A case of emission and injection
In what might win “Most Bizarre Attempt at Home Medicine” of 2019, a 33-year-old Irish man was hospitalized after injecting himself with his own semen … in his arm … multiple times … to reduce back pain. Whew. Does this count as holistic medicine?
This at-home remedy did not cure his back pain, shockingly enough. The patient instead developed a subcutaneous abscess after a year and a half of monthly intramuscular and intravenous injections, during which the semen has leaked into the soft tissues. He reported to a Dublin hospital after suffering severe back pain and a swollen arm, and eventually revealed to doctors his miracle cure.
The doctors did some Googling and found studies where rats and rabbits were injected with semen – possibly the research that inspired this trailblazer. Or, possibly, this was just an extreme case of reduce, reuse, and recycle.
In case you’re concerned, the man was given a course of more traditional medicine, and his back pain improved greatly. The patient chose to discharge himself before doctors could drain the “local collection” – perhaps he was proud of his work.
Down the rabbit hole
Imagine sitting at your computer when suddenly the icons begin to move off the screen and hover directly in front of your eyes. Your first thought might be that someone spiked your morning coffee with acid – and you’re not far off.
This curious occurrence happened to a 54-year-old man who was diagnosed with the rare perceptual disorder Alice in Wonderland syndrome (AIWS). AIWS causes people to develop a misperception of their body or surrounding space, and can be caused by a number of things, including migraine.
In this case, the man’s LSD-like visions were caused by a glioblastoma in the left temporal-occipital region of the brain. Tumors there can interfere with spatial perception, hence the temporary trip down the rabbit hole for this patient. After chemotherapy and radiation, the tumor was defeated, and the patient is back to feeling happier than the Mad Hatter at a tea party.
Must have been some party
On Dec. 25 in the Vietnamese province of Quang Tri, a 48-year-old man was taken to a hospital with a case of alcohol poisoning. Specifically, his body contained more than 1,000 times the recommended limit of methanol.
While the two types of alcohol, ethanol and methanol, are both toxic to the human body to some degree, the liver processes methanol differently and more slowly, making it far more dangerous than ethanol, the key ingredient in commercially available alcoholic beverages. Methanol is found in bootleg liquor and in such products as gasoline, paint, ink, and cleaning products. It can cause blindness, nervous system depression, and death.
However, there is a happy ending to this story. To save their patient’s life, his doctors hit upon an ingenious solution – one that would make Homer Simpson proud.
They administered cans of beer.
When the man was admitted, the doctors immediately gave him 3 cans’ worth, and then transfused an additional 12 at the rate of 1 can per hour. The liver will always prioritize processing ethanol over methanol. By feeding the patient a steady stream of relatively friendly and ethanol-rich beer, the doctors had enough time to perform dialysis and remove the methanol from the man’s system.
So, as Homer himself might declare, here’s to alcohol – truly the cause of, and solution to, all of life’s problems.
A mistake of the bloody type
Nurse: Mr. Smeggins, I need to clear up some of the answers on your new-patient information form.
Patient: I filled the whole thing out, didn’t I?
Nurse: You did, but a couple of your responses are less than helpful. You do realize that “Helvetica” is not a blood type, right?
Patient: I took a stab at it.
Nurse: You’re not the only one. It turns out that 43% of adults don’t know their blood type, and 62% don’t know their cholesterol level, according to a recent survey by Quest Diagnostics. The 1,004 respondents were more likely to know their bank account balances (75%) or their wifi passwords (74%).
Patient: Hey, that’s right! Mine is Earwiglover122.
Nurse: Great. And can I assume that you’re one of the 30% or so supposedly Web-savvy millennials (ages 20-37 years) who keep lab results in a filing cabinet at home?
Patient: Actually, I have a pile for stuff like that.
Nurse: Fine. Now about your other answers. When we asked about sex, we were not looking for “just last night.”
A case of emission and injection
In what might win “Most Bizarre Attempt at Home Medicine” of 2019, a 33-year-old Irish man was hospitalized after injecting himself with his own semen … in his arm … multiple times … to reduce back pain. Whew. Does this count as holistic medicine?
This at-home remedy did not cure his back pain, shockingly enough. The patient instead developed a subcutaneous abscess after a year and a half of monthly intramuscular and intravenous injections, during which the semen has leaked into the soft tissues. He reported to a Dublin hospital after suffering severe back pain and a swollen arm, and eventually revealed to doctors his miracle cure.
The doctors did some Googling and found studies where rats and rabbits were injected with semen – possibly the research that inspired this trailblazer. Or, possibly, this was just an extreme case of reduce, reuse, and recycle.
In case you’re concerned, the man was given a course of more traditional medicine, and his back pain improved greatly. The patient chose to discharge himself before doctors could drain the “local collection” – perhaps he was proud of his work.
Down the rabbit hole
Imagine sitting at your computer when suddenly the icons begin to move off the screen and hover directly in front of your eyes. Your first thought might be that someone spiked your morning coffee with acid – and you’re not far off.
This curious occurrence happened to a 54-year-old man who was diagnosed with the rare perceptual disorder Alice in Wonderland syndrome (AIWS). AIWS causes people to develop a misperception of their body or surrounding space, and can be caused by a number of things, including migraine.
In this case, the man’s LSD-like visions were caused by a glioblastoma in the left temporal-occipital region of the brain. Tumors there can interfere with spatial perception, hence the temporary trip down the rabbit hole for this patient. After chemotherapy and radiation, the tumor was defeated, and the patient is back to feeling happier than the Mad Hatter at a tea party.
Must have been some party
On Dec. 25 in the Vietnamese province of Quang Tri, a 48-year-old man was taken to a hospital with a case of alcohol poisoning. Specifically, his body contained more than 1,000 times the recommended limit of methanol.
While the two types of alcohol, ethanol and methanol, are both toxic to the human body to some degree, the liver processes methanol differently and more slowly, making it far more dangerous than ethanol, the key ingredient in commercially available alcoholic beverages. Methanol is found in bootleg liquor and in such products as gasoline, paint, ink, and cleaning products. It can cause blindness, nervous system depression, and death.
However, there is a happy ending to this story. To save their patient’s life, his doctors hit upon an ingenious solution – one that would make Homer Simpson proud.
They administered cans of beer.
When the man was admitted, the doctors immediately gave him 3 cans’ worth, and then transfused an additional 12 at the rate of 1 can per hour. The liver will always prioritize processing ethanol over methanol. By feeding the patient a steady stream of relatively friendly and ethanol-rich beer, the doctors had enough time to perform dialysis and remove the methanol from the man’s system.
So, as Homer himself might declare, here’s to alcohol – truly the cause of, and solution to, all of life’s problems.
A mistake of the bloody type
Nurse: Mr. Smeggins, I need to clear up some of the answers on your new-patient information form.
Patient: I filled the whole thing out, didn’t I?
Nurse: You did, but a couple of your responses are less than helpful. You do realize that “Helvetica” is not a blood type, right?
Patient: I took a stab at it.
Nurse: You’re not the only one. It turns out that 43% of adults don’t know their blood type, and 62% don’t know their cholesterol level, according to a recent survey by Quest Diagnostics. The 1,004 respondents were more likely to know their bank account balances (75%) or their wifi passwords (74%).
Patient: Hey, that’s right! Mine is Earwiglover122.
Nurse: Great. And can I assume that you’re one of the 30% or so supposedly Web-savvy millennials (ages 20-37 years) who keep lab results in a filing cabinet at home?
Patient: Actually, I have a pile for stuff like that.
Nurse: Fine. Now about your other answers. When we asked about sex, we were not looking for “just last night.”
A case of emission and injection
In what might win “Most Bizarre Attempt at Home Medicine” of 2019, a 33-year-old Irish man was hospitalized after injecting himself with his own semen … in his arm … multiple times … to reduce back pain. Whew. Does this count as holistic medicine?
This at-home remedy did not cure his back pain, shockingly enough. The patient instead developed a subcutaneous abscess after a year and a half of monthly intramuscular and intravenous injections, during which the semen has leaked into the soft tissues. He reported to a Dublin hospital after suffering severe back pain and a swollen arm, and eventually revealed to doctors his miracle cure.
The doctors did some Googling and found studies where rats and rabbits were injected with semen – possibly the research that inspired this trailblazer. Or, possibly, this was just an extreme case of reduce, reuse, and recycle.
In case you’re concerned, the man was given a course of more traditional medicine, and his back pain improved greatly. The patient chose to discharge himself before doctors could drain the “local collection” – perhaps he was proud of his work.
Down the rabbit hole
Imagine sitting at your computer when suddenly the icons begin to move off the screen and hover directly in front of your eyes. Your first thought might be that someone spiked your morning coffee with acid – and you’re not far off.
This curious occurrence happened to a 54-year-old man who was diagnosed with the rare perceptual disorder Alice in Wonderland syndrome (AIWS). AIWS causes people to develop a misperception of their body or surrounding space, and can be caused by a number of things, including migraine.
In this case, the man’s LSD-like visions were caused by a glioblastoma in the left temporal-occipital region of the brain. Tumors there can interfere with spatial perception, hence the temporary trip down the rabbit hole for this patient. After chemotherapy and radiation, the tumor was defeated, and the patient is back to feeling happier than the Mad Hatter at a tea party.
Must have been some party
On Dec. 25 in the Vietnamese province of Quang Tri, a 48-year-old man was taken to a hospital with a case of alcohol poisoning. Specifically, his body contained more than 1,000 times the recommended limit of methanol.
While the two types of alcohol, ethanol and methanol, are both toxic to the human body to some degree, the liver processes methanol differently and more slowly, making it far more dangerous than ethanol, the key ingredient in commercially available alcoholic beverages. Methanol is found in bootleg liquor and in such products as gasoline, paint, ink, and cleaning products. It can cause blindness, nervous system depression, and death.
However, there is a happy ending to this story. To save their patient’s life, his doctors hit upon an ingenious solution – one that would make Homer Simpson proud.
They administered cans of beer.
When the man was admitted, the doctors immediately gave him 3 cans’ worth, and then transfused an additional 12 at the rate of 1 can per hour. The liver will always prioritize processing ethanol over methanol. By feeding the patient a steady stream of relatively friendly and ethanol-rich beer, the doctors had enough time to perform dialysis and remove the methanol from the man’s system.
So, as Homer himself might declare, here’s to alcohol – truly the cause of, and solution to, all of life’s problems.
A mistake of the bloody type
Nurse: Mr. Smeggins, I need to clear up some of the answers on your new-patient information form.
Patient: I filled the whole thing out, didn’t I?
Nurse: You did, but a couple of your responses are less than helpful. You do realize that “Helvetica” is not a blood type, right?
Patient: I took a stab at it.
Nurse: You’re not the only one. It turns out that 43% of adults don’t know their blood type, and 62% don’t know their cholesterol level, according to a recent survey by Quest Diagnostics. The 1,004 respondents were more likely to know their bank account balances (75%) or their wifi passwords (74%).
Patient: Hey, that’s right! Mine is Earwiglover122.
Nurse: Great. And can I assume that you’re one of the 30% or so supposedly Web-savvy millennials (ages 20-37 years) who keep lab results in a filing cabinet at home?
Patient: Actually, I have a pile for stuff like that.
Nurse: Fine. Now about your other answers. When we asked about sex, we were not looking for “just last night.”
Homelessness among LGBT youth in the United States
As winter settles in for most of the United States, there are some people who do not have access to adequate shelter from the cold. Currently, there are an estimated 700,000 homeless youth in the United States, which is roughly 1 out of 30 youth.1 The reasons for these disparities are complex, although stigma and discrimination are major factors. Despite the major challenges faced by this population, medical providers can play a role in addressing homelessness among LGBT youth.
According to the Department of Education, homeless youth are defined as youth “who lack a fixed, regular, and adequate nighttime residence.”2 Although the image of a person sleeping on a bench at a park covered with newspapers comes to mind, it may not be obvious that a youth may be homeless. Sometimes, youth may be sleeping in their cars at night and others may be staying the night at one house and then staying the next night at another house (known as “couch surfing”). Many will be utilizing homeless shelters to sleep in.
Homelessness among LGBT youth is a major problem in the United States. Although LGB (sexual minority) people comprise 2%-7% of the population,3 about one-third of homeless youth identify as LGB or questioning. Additionally, about 4% of homeless youth identify as transgender, compared with 1% of the general youth population in the United States. LGBT youth are at a higher risk for homelessness than are cisgender (gender identity matches with the assigned sex at birth), heterosexual youth. There are even disparities within LGBT youth.
Why are LGBT youth at high risk for homelessness? The most common reason is family rejection of their sexual orientation and/or gender identity.4 Some are directly kicked out by their families. Whereas others leave because relationships with their families have become so strained after the child has come out that the environment is no longer tolerable to live in. However, poverty and race may play a significant role in this phenomenon. There is a misperception that families of color are more homophobic or transphobic (disliking or having a prejudice against transsexual or transgender people) than white families because there is a higher proportion of LGBT homeless youth of color. However, what most likely increases the likelihood of family rejection is the strain of poverty, which people of color are more likely to experience. Chronic unemployment or unstable housing makes it very difficult for families to utilize the important skills to accept and support their LGBT child. Whenever a child comes out to their parents, it is a stressful event for the family. Family with stable physical resources (decent income, stable housing) also are more likely to have psychological resources (family cohesiveness, open communication, good parent-child relationships) to manage these types of stress. However, for those with unstable resources, they are unable to tap into their psychological resources to handle the stress of a child coming out to them.5 As a result, they resort to rejection. Many parents believe that rejecting their child’s sexual orientation or gender identity will protect them from stigma and discrimination, and they do not realize that rejection can harm their child.6,7
There are other reasons LGBT youth become homeless. One is untreated mental illness and substance use, mostly likely a result from experiencing stigma and discrimination. Another is that some age out of the foster care system.4 Finally, some LGBT youth run away from home because of abuse from their parents, and unfortunately, LGBT youth are more likely to experience abuse from a parent than are heterosexual, cisgender youth.8
Furthermore, although there are homeless shelters for youth, many LGBT youth avoid going to homeless shelters out of fear for their own safety. Many homeless shelters are ill equipped to work with LGBT youth, especially in managing other homeless youth who may harass or assault another youth on the basis of their sexual orientation or gender identity.4 Additionally, many homeless shelters arrangements are gendered, making it difficult for transgender youth to find a shelter as they may be forced to live with people of their assigned sex of birth, putting them at an increased risk for harassment and violence.9
Despite the many challenges faced by homeless LGBT youth, medical providers can play a role in promoting their health and well-being. Screening for homelessness can create opportunities for medical providers to offer resources for immediate needs. Three good questions are: “During the last 12 months, was there a time when you were not able to pay the mortgage or rent on time?” “In the past 12 months, how many places [have you] lived?” and “What type of housing do you currently live in?”10 Resources for such youth would include the National Coalition for the Homeless, which contains a list of homeless shelters that are equipped to address the needs of LGBT homeless youth.
Medical providers must address some of the root causes of homelessness among LGBT youth. One of them is family rejection. Medical providers can counsel parents of LGBT youth in the importance of family support in protecting their LGBT child from adverse health outcomes. One good resource is the Family Acceptance Project, which teaches parents skills to support their LGBT child. Additionally, medical providers can work with homeless shelters and help them develop best practices for working with LGBT youth. A good place to start is Lambda Legal’s National Recommended Best Practices for Serving LGBT Homeless Youth.
Educating both families and homeless shelters are key in both preventing homelessness and mitigating the effects of homelessness on the health of LGBT youth.
Dr. Montano is assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].
References
1. “Missed opportunities: Youth homelessness in America,” Chapin Hall at the University of Chicago, 2017. voicesofyouthcount.org.
2. Homelessness & Runaway Youth. Federal Definitions. youth.gov.
3. MMWR Surveill Summ. 2016. doi: 10.15585/mmwr.ss6509a1.
4. “Serving Our Youth 2015: The Needs and Experiences of Lesbian, Gay, Bisexual, Transgender and Questioning Youth Experiencing Homelesness,” The Williams Institute with True Colors Fund, June 2015.
5. Sex Roles. 2013 Jun;68(11-12):690-702.
6. “Supportive families, healthy children: Helping families with lesbian, gay, bisexual & transgender children,” Family Acceptance Project, San Francisco State University, 2009.
7. Pediatrics. 2009 Jan. doi: 10.1542/peds.2007-3524.
8. Am J Public Health. 2011. doi: 10.2105/AJPH.2009.190009.
9. Am J Orthopsychiatry. 2014. doi: 10.1037/h0098852.
10. Pediatrics. 2018. doi: 10.1542/peds.2017-2199.
As winter settles in for most of the United States, there are some people who do not have access to adequate shelter from the cold. Currently, there are an estimated 700,000 homeless youth in the United States, which is roughly 1 out of 30 youth.1 The reasons for these disparities are complex, although stigma and discrimination are major factors. Despite the major challenges faced by this population, medical providers can play a role in addressing homelessness among LGBT youth.
According to the Department of Education, homeless youth are defined as youth “who lack a fixed, regular, and adequate nighttime residence.”2 Although the image of a person sleeping on a bench at a park covered with newspapers comes to mind, it may not be obvious that a youth may be homeless. Sometimes, youth may be sleeping in their cars at night and others may be staying the night at one house and then staying the next night at another house (known as “couch surfing”). Many will be utilizing homeless shelters to sleep in.
Homelessness among LGBT youth is a major problem in the United States. Although LGB (sexual minority) people comprise 2%-7% of the population,3 about one-third of homeless youth identify as LGB or questioning. Additionally, about 4% of homeless youth identify as transgender, compared with 1% of the general youth population in the United States. LGBT youth are at a higher risk for homelessness than are cisgender (gender identity matches with the assigned sex at birth), heterosexual youth. There are even disparities within LGBT youth.
Why are LGBT youth at high risk for homelessness? The most common reason is family rejection of their sexual orientation and/or gender identity.4 Some are directly kicked out by their families. Whereas others leave because relationships with their families have become so strained after the child has come out that the environment is no longer tolerable to live in. However, poverty and race may play a significant role in this phenomenon. There is a misperception that families of color are more homophobic or transphobic (disliking or having a prejudice against transsexual or transgender people) than white families because there is a higher proportion of LGBT homeless youth of color. However, what most likely increases the likelihood of family rejection is the strain of poverty, which people of color are more likely to experience. Chronic unemployment or unstable housing makes it very difficult for families to utilize the important skills to accept and support their LGBT child. Whenever a child comes out to their parents, it is a stressful event for the family. Family with stable physical resources (decent income, stable housing) also are more likely to have psychological resources (family cohesiveness, open communication, good parent-child relationships) to manage these types of stress. However, for those with unstable resources, they are unable to tap into their psychological resources to handle the stress of a child coming out to them.5 As a result, they resort to rejection. Many parents believe that rejecting their child’s sexual orientation or gender identity will protect them from stigma and discrimination, and they do not realize that rejection can harm their child.6,7
There are other reasons LGBT youth become homeless. One is untreated mental illness and substance use, mostly likely a result from experiencing stigma and discrimination. Another is that some age out of the foster care system.4 Finally, some LGBT youth run away from home because of abuse from their parents, and unfortunately, LGBT youth are more likely to experience abuse from a parent than are heterosexual, cisgender youth.8
Furthermore, although there are homeless shelters for youth, many LGBT youth avoid going to homeless shelters out of fear for their own safety. Many homeless shelters are ill equipped to work with LGBT youth, especially in managing other homeless youth who may harass or assault another youth on the basis of their sexual orientation or gender identity.4 Additionally, many homeless shelters arrangements are gendered, making it difficult for transgender youth to find a shelter as they may be forced to live with people of their assigned sex of birth, putting them at an increased risk for harassment and violence.9
Despite the many challenges faced by homeless LGBT youth, medical providers can play a role in promoting their health and well-being. Screening for homelessness can create opportunities for medical providers to offer resources for immediate needs. Three good questions are: “During the last 12 months, was there a time when you were not able to pay the mortgage or rent on time?” “In the past 12 months, how many places [have you] lived?” and “What type of housing do you currently live in?”10 Resources for such youth would include the National Coalition for the Homeless, which contains a list of homeless shelters that are equipped to address the needs of LGBT homeless youth.
Medical providers must address some of the root causes of homelessness among LGBT youth. One of them is family rejection. Medical providers can counsel parents of LGBT youth in the importance of family support in protecting their LGBT child from adverse health outcomes. One good resource is the Family Acceptance Project, which teaches parents skills to support their LGBT child. Additionally, medical providers can work with homeless shelters and help them develop best practices for working with LGBT youth. A good place to start is Lambda Legal’s National Recommended Best Practices for Serving LGBT Homeless Youth.
Educating both families and homeless shelters are key in both preventing homelessness and mitigating the effects of homelessness on the health of LGBT youth.
Dr. Montano is assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].
References
1. “Missed opportunities: Youth homelessness in America,” Chapin Hall at the University of Chicago, 2017. voicesofyouthcount.org.
2. Homelessness & Runaway Youth. Federal Definitions. youth.gov.
3. MMWR Surveill Summ. 2016. doi: 10.15585/mmwr.ss6509a1.
4. “Serving Our Youth 2015: The Needs and Experiences of Lesbian, Gay, Bisexual, Transgender and Questioning Youth Experiencing Homelesness,” The Williams Institute with True Colors Fund, June 2015.
5. Sex Roles. 2013 Jun;68(11-12):690-702.
6. “Supportive families, healthy children: Helping families with lesbian, gay, bisexual & transgender children,” Family Acceptance Project, San Francisco State University, 2009.
7. Pediatrics. 2009 Jan. doi: 10.1542/peds.2007-3524.
8. Am J Public Health. 2011. doi: 10.2105/AJPH.2009.190009.
9. Am J Orthopsychiatry. 2014. doi: 10.1037/h0098852.
10. Pediatrics. 2018. doi: 10.1542/peds.2017-2199.
As winter settles in for most of the United States, there are some people who do not have access to adequate shelter from the cold. Currently, there are an estimated 700,000 homeless youth in the United States, which is roughly 1 out of 30 youth.1 The reasons for these disparities are complex, although stigma and discrimination are major factors. Despite the major challenges faced by this population, medical providers can play a role in addressing homelessness among LGBT youth.
According to the Department of Education, homeless youth are defined as youth “who lack a fixed, regular, and adequate nighttime residence.”2 Although the image of a person sleeping on a bench at a park covered with newspapers comes to mind, it may not be obvious that a youth may be homeless. Sometimes, youth may be sleeping in their cars at night and others may be staying the night at one house and then staying the next night at another house (known as “couch surfing”). Many will be utilizing homeless shelters to sleep in.
Homelessness among LGBT youth is a major problem in the United States. Although LGB (sexual minority) people comprise 2%-7% of the population,3 about one-third of homeless youth identify as LGB or questioning. Additionally, about 4% of homeless youth identify as transgender, compared with 1% of the general youth population in the United States. LGBT youth are at a higher risk for homelessness than are cisgender (gender identity matches with the assigned sex at birth), heterosexual youth. There are even disparities within LGBT youth.
Why are LGBT youth at high risk for homelessness? The most common reason is family rejection of their sexual orientation and/or gender identity.4 Some are directly kicked out by their families. Whereas others leave because relationships with their families have become so strained after the child has come out that the environment is no longer tolerable to live in. However, poverty and race may play a significant role in this phenomenon. There is a misperception that families of color are more homophobic or transphobic (disliking or having a prejudice against transsexual or transgender people) than white families because there is a higher proportion of LGBT homeless youth of color. However, what most likely increases the likelihood of family rejection is the strain of poverty, which people of color are more likely to experience. Chronic unemployment or unstable housing makes it very difficult for families to utilize the important skills to accept and support their LGBT child. Whenever a child comes out to their parents, it is a stressful event for the family. Family with stable physical resources (decent income, stable housing) also are more likely to have psychological resources (family cohesiveness, open communication, good parent-child relationships) to manage these types of stress. However, for those with unstable resources, they are unable to tap into their psychological resources to handle the stress of a child coming out to them.5 As a result, they resort to rejection. Many parents believe that rejecting their child’s sexual orientation or gender identity will protect them from stigma and discrimination, and they do not realize that rejection can harm their child.6,7
There are other reasons LGBT youth become homeless. One is untreated mental illness and substance use, mostly likely a result from experiencing stigma and discrimination. Another is that some age out of the foster care system.4 Finally, some LGBT youth run away from home because of abuse from their parents, and unfortunately, LGBT youth are more likely to experience abuse from a parent than are heterosexual, cisgender youth.8
Furthermore, although there are homeless shelters for youth, many LGBT youth avoid going to homeless shelters out of fear for their own safety. Many homeless shelters are ill equipped to work with LGBT youth, especially in managing other homeless youth who may harass or assault another youth on the basis of their sexual orientation or gender identity.4 Additionally, many homeless shelters arrangements are gendered, making it difficult for transgender youth to find a shelter as they may be forced to live with people of their assigned sex of birth, putting them at an increased risk for harassment and violence.9
Despite the many challenges faced by homeless LGBT youth, medical providers can play a role in promoting their health and well-being. Screening for homelessness can create opportunities for medical providers to offer resources for immediate needs. Three good questions are: “During the last 12 months, was there a time when you were not able to pay the mortgage or rent on time?” “In the past 12 months, how many places [have you] lived?” and “What type of housing do you currently live in?”10 Resources for such youth would include the National Coalition for the Homeless, which contains a list of homeless shelters that are equipped to address the needs of LGBT homeless youth.
Medical providers must address some of the root causes of homelessness among LGBT youth. One of them is family rejection. Medical providers can counsel parents of LGBT youth in the importance of family support in protecting their LGBT child from adverse health outcomes. One good resource is the Family Acceptance Project, which teaches parents skills to support their LGBT child. Additionally, medical providers can work with homeless shelters and help them develop best practices for working with LGBT youth. A good place to start is Lambda Legal’s National Recommended Best Practices for Serving LGBT Homeless Youth.
Educating both families and homeless shelters are key in both preventing homelessness and mitigating the effects of homelessness on the health of LGBT youth.
Dr. Montano is assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].
References
1. “Missed opportunities: Youth homelessness in America,” Chapin Hall at the University of Chicago, 2017. voicesofyouthcount.org.
2. Homelessness & Runaway Youth. Federal Definitions. youth.gov.
3. MMWR Surveill Summ. 2016. doi: 10.15585/mmwr.ss6509a1.
4. “Serving Our Youth 2015: The Needs and Experiences of Lesbian, Gay, Bisexual, Transgender and Questioning Youth Experiencing Homelesness,” The Williams Institute with True Colors Fund, June 2015.
5. Sex Roles. 2013 Jun;68(11-12):690-702.
6. “Supportive families, healthy children: Helping families with lesbian, gay, bisexual & transgender children,” Family Acceptance Project, San Francisco State University, 2009.
7. Pediatrics. 2009 Jan. doi: 10.1542/peds.2007-3524.
8. Am J Public Health. 2011. doi: 10.2105/AJPH.2009.190009.
9. Am J Orthopsychiatry. 2014. doi: 10.1037/h0098852.
10. Pediatrics. 2018. doi: 10.1542/peds.2017-2199.
Mandatory reporting laws
Question: You are moonlighting in the emergency department and have just finished treating a 5-year-old boy with an apparent Colles’ fracture, who was accompanied by his mother with bruises on her face. Her exam revealed additional bruises over her abdominal wall. The mother said they accidentally tripped and fell down the stairs, and spontaneously denied any acts of violence in the family.
Given this scenario, which of the following is best?
A. You suspect both child and spousal abuse, but lack sufficient evidence to report the incident.
B. Failure to report based on reasonable suspicion alone may amount to a criminal offense punishable by possible imprisonment.
C. You may face a potential malpractice lawsuit if subsequent injuries caused by abuse could have been prevented had you reported.
D. Mandatory reporting laws apply not only to abuse of children and spouses, but also of the elderly and other vulnerable adults.
E. All are correct except A.
Answer: E. All doctors, especially those working in emergency departments, treat injuries on a regular basis. Accidents probably account for the majority of these injuries, but the most pernicious are those caused by willful abuse or neglect. Such conduct, believed to be widespread and underrecognized, victimizes children, women, the elderly, and other vulnerable groups.
Mandatory reporting laws arose from the need to identify and prevent these activities that cause serious harm and loss of lives. Physicians and other health care workers are in a prime position to diagnose or raise the suspicion of abuse and neglect. This article focuses on laws that mandate physician reporting of such behavior. Not addressed are other reportable situations such as certain infectious diseases, gunshot wounds, threats to third parties, and so on.
Child abuse
The best-known example of a mandatory reporting law relates to child abuse, which is broadly defined as when a parent or caretaker emotionally, physically, or sexually abuses, neglects, or abandons a child. Child abuse laws are intended to protect children from serious harm without abridging parental discipline of their children.
Cases of child abuse are pervasive; four or five children are tragically killed by abuse or neglect every day, and each year, some 6 million children are reported as victims of child abuse. Henry Kempe’s studies on the “battered child syndrome” in 1962 served to underscore the physician’s role in exposing child maltreatment, and 1973 saw the enactment of the Child Abuse Prevention and Treatment Act, which set standards for mandatory reporting as a condition for federal funding.
All U.S. states have statutes identifying persons who are required to report suspected child maltreatment to an appropriate agency, such as child protective services. Reasonable suspicion, without need for proof, is sufficient to trigger the mandatory reporting duty. A summary of the general reporting requirements, as well as each state’s key statutory features, are available at Child Welfare Information Gateway.1
Bruises, fractures, and burns are recurring examples of injuries resulting from child abuse, but there are many others, including severe emotional harm, which is an important consequence. Clues to abuse include a child’s fearful and anxious demeanor, wearing clothes to hide injuries, and inappropriate sexual conduct.2 The perpetrators and/or complicit parties typically blame an innocent home accident for the victim’s injuries to mislead the health care provider.
Elder abuse
Elder abuse is broadly construed to include physical, sexual, and psychological abuse, as well as financial exploitation and caregiver neglect.3 It is a serious problem in the United States, estimated in 2008 to affect 1 in 10 elders. The figure is likely an underestimate, because many elderly victims are afraid or unwilling to lodge a complaint against the abuser whom they love and may depend upon.4
The law, which protects the “elderly” (e.g., those aged 62 years or older in Hawaii), may also be extended to other younger vulnerable adults, who because of an impairment, are unable to 1) communicate or make responsible decisions to manage one’s own care or resources, 2) carry out or arrange for essential activities of daily living, or 3) protect one’s self from abuse.5
The law mandates reporting where there is reason to believe abuse has occurred or the vulnerable adult is in danger of abuse if immediate action is not taken. Reporting statutes for elder abuse vary somewhat on the identity of mandated reporters (health care providers are always included), the victim’s mental capacity, dwelling place (home or in an assisted-living facility), and type of purported activity that warrants reporting.
Domestic violence
As defined by the National Coalition Against Domestic Violence, “Domestic violence is the willful intimidation, physical assault, battery, sexual assault, and/or other abusive behavior as part of a systematic pattern of power and control perpetrated by one intimate partner against another. ... The frequency and severity of domestic violence can vary dramatically; however, the one constant component of domestic violence is one partner’s consistent efforts to maintain power and control over the other.”6 Domestic violence is said to have reached epidemic proportions, with one in four women experiencing it at some point in her life.
Virtually all states mandate the reporting of domestic violence by health care providers if there is a reasonable suspicion that observed patient injuries are the result of physical abuse.7 California, for example, requires the provider to call local law enforcement as soon as possible or to send in a written report within 48 hours.
There may be exceptions to required reporting, as when an adult victim withholds consent but accepts victim referral services. State laws encourage but do not always require that the health care provider inform the patient about the report, but federal law dictates otherwise unless this puts the patient at risk. Hawaii’s domestic violence laws were originally enacted to deter spousal abuse, but they now also protect other household members.8
Any individual who assumes a duty or responsibility pursuant to all of these reporting laws is immunized from criminal or civil liability. On the other hand, a mandated reporter who knowingly fails to report an incident or who willfully prevents another person from reporting such an incident commits a criminal offence.
In the case of a physician, there is the added risk of a malpractice lawsuit based on “violation of statute” (breach of a legal duty), should another injury occur down the road that was arguably preventable by his or her failure to report.
Experts generally believe that mandatory reporting laws are important in identifying child maltreatment. However, it has been asserted that despite a 5-decade history of mandatory reporting, no clear endpoints attest to the efficacy of this approach, and it is argued that no data exist to demonstrate that incremental increases in reporting have contributed to child safety.
Particularly challenging are attempts at impact comparisons between states with different policies. A number of countries, including the United Kingdom, do not have mandatory reporting laws and regulate reporting by professional societies.9
In addition, some critics of mandatory reporting raise concerns surrounding law enforcement showing up at the victim’s house to question the family about abuse, or to make an arrest or issue warnings. They posit that when the behavior of an abuser is under scrutiny, this can paradoxically create a potentially more dangerous environment for the patient-victim, whom the perpetrator now considers to have betrayed his or her trust. Others bemoan that revealing patient confidences violates the physician’s ethical code.
However, the intolerable incidence of violence against the vulnerable has properly made mandatory reporting the law of the land. Although the criminal penalty is currently light for failure to report, there is a move toward increasing its severity. Hawaii, for example, recently introduced Senate Bill 2477 that makes nonreporting by those required to do so a Class C felony punishable by up to 5 years in prison. The offense currently is a petty misdemeanor punishable by up to 30 days in jail.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at [email protected].
References
1. Child Welfare Information Gateway (2016). Mandatory reporters of child abuse and neglect. Washington, D.C.: U.S. Department of Health and Human Services, Children’s Bureau. Available at www.childwelfare.gov; email: [email protected]; phone: 800-394-3366.
2. Available at www.childwelfare.gov/topics/can.
3. Available at www.justice.gov/elderjustice/elder-justice-statutes-0.
4. Available at www.cdc.gov/violenceprevention/elderabuse/index.html.
5. Hawaii Revised Statutes, Sec. 346-222, 346-224, 346-250, 412:3-114.5.
6. Available at ncadv.org.
7. Ann Emerg Med. 2002 Jan;39(1):56-60.
8. Hawaii Revised Statutes, Sec. 709-906.
9. Pediatrics. 2017 Apr;139(4). pii: e20163511.
Question: You are moonlighting in the emergency department and have just finished treating a 5-year-old boy with an apparent Colles’ fracture, who was accompanied by his mother with bruises on her face. Her exam revealed additional bruises over her abdominal wall. The mother said they accidentally tripped and fell down the stairs, and spontaneously denied any acts of violence in the family.
Given this scenario, which of the following is best?
A. You suspect both child and spousal abuse, but lack sufficient evidence to report the incident.
B. Failure to report based on reasonable suspicion alone may amount to a criminal offense punishable by possible imprisonment.
C. You may face a potential malpractice lawsuit if subsequent injuries caused by abuse could have been prevented had you reported.
D. Mandatory reporting laws apply not only to abuse of children and spouses, but also of the elderly and other vulnerable adults.
E. All are correct except A.
Answer: E. All doctors, especially those working in emergency departments, treat injuries on a regular basis. Accidents probably account for the majority of these injuries, but the most pernicious are those caused by willful abuse or neglect. Such conduct, believed to be widespread and underrecognized, victimizes children, women, the elderly, and other vulnerable groups.
Mandatory reporting laws arose from the need to identify and prevent these activities that cause serious harm and loss of lives. Physicians and other health care workers are in a prime position to diagnose or raise the suspicion of abuse and neglect. This article focuses on laws that mandate physician reporting of such behavior. Not addressed are other reportable situations such as certain infectious diseases, gunshot wounds, threats to third parties, and so on.
Child abuse
The best-known example of a mandatory reporting law relates to child abuse, which is broadly defined as when a parent or caretaker emotionally, physically, or sexually abuses, neglects, or abandons a child. Child abuse laws are intended to protect children from serious harm without abridging parental discipline of their children.
Cases of child abuse are pervasive; four or five children are tragically killed by abuse or neglect every day, and each year, some 6 million children are reported as victims of child abuse. Henry Kempe’s studies on the “battered child syndrome” in 1962 served to underscore the physician’s role in exposing child maltreatment, and 1973 saw the enactment of the Child Abuse Prevention and Treatment Act, which set standards for mandatory reporting as a condition for federal funding.
All U.S. states have statutes identifying persons who are required to report suspected child maltreatment to an appropriate agency, such as child protective services. Reasonable suspicion, without need for proof, is sufficient to trigger the mandatory reporting duty. A summary of the general reporting requirements, as well as each state’s key statutory features, are available at Child Welfare Information Gateway.1
Bruises, fractures, and burns are recurring examples of injuries resulting from child abuse, but there are many others, including severe emotional harm, which is an important consequence. Clues to abuse include a child’s fearful and anxious demeanor, wearing clothes to hide injuries, and inappropriate sexual conduct.2 The perpetrators and/or complicit parties typically blame an innocent home accident for the victim’s injuries to mislead the health care provider.
Elder abuse
Elder abuse is broadly construed to include physical, sexual, and psychological abuse, as well as financial exploitation and caregiver neglect.3 It is a serious problem in the United States, estimated in 2008 to affect 1 in 10 elders. The figure is likely an underestimate, because many elderly victims are afraid or unwilling to lodge a complaint against the abuser whom they love and may depend upon.4
The law, which protects the “elderly” (e.g., those aged 62 years or older in Hawaii), may also be extended to other younger vulnerable adults, who because of an impairment, are unable to 1) communicate or make responsible decisions to manage one’s own care or resources, 2) carry out or arrange for essential activities of daily living, or 3) protect one’s self from abuse.5
The law mandates reporting where there is reason to believe abuse has occurred or the vulnerable adult is in danger of abuse if immediate action is not taken. Reporting statutes for elder abuse vary somewhat on the identity of mandated reporters (health care providers are always included), the victim’s mental capacity, dwelling place (home or in an assisted-living facility), and type of purported activity that warrants reporting.
Domestic violence
As defined by the National Coalition Against Domestic Violence, “Domestic violence is the willful intimidation, physical assault, battery, sexual assault, and/or other abusive behavior as part of a systematic pattern of power and control perpetrated by one intimate partner against another. ... The frequency and severity of domestic violence can vary dramatically; however, the one constant component of domestic violence is one partner’s consistent efforts to maintain power and control over the other.”6 Domestic violence is said to have reached epidemic proportions, with one in four women experiencing it at some point in her life.
Virtually all states mandate the reporting of domestic violence by health care providers if there is a reasonable suspicion that observed patient injuries are the result of physical abuse.7 California, for example, requires the provider to call local law enforcement as soon as possible or to send in a written report within 48 hours.
There may be exceptions to required reporting, as when an adult victim withholds consent but accepts victim referral services. State laws encourage but do not always require that the health care provider inform the patient about the report, but federal law dictates otherwise unless this puts the patient at risk. Hawaii’s domestic violence laws were originally enacted to deter spousal abuse, but they now also protect other household members.8
Any individual who assumes a duty or responsibility pursuant to all of these reporting laws is immunized from criminal or civil liability. On the other hand, a mandated reporter who knowingly fails to report an incident or who willfully prevents another person from reporting such an incident commits a criminal offence.
In the case of a physician, there is the added risk of a malpractice lawsuit based on “violation of statute” (breach of a legal duty), should another injury occur down the road that was arguably preventable by his or her failure to report.
Experts generally believe that mandatory reporting laws are important in identifying child maltreatment. However, it has been asserted that despite a 5-decade history of mandatory reporting, no clear endpoints attest to the efficacy of this approach, and it is argued that no data exist to demonstrate that incremental increases in reporting have contributed to child safety.
Particularly challenging are attempts at impact comparisons between states with different policies. A number of countries, including the United Kingdom, do not have mandatory reporting laws and regulate reporting by professional societies.9
In addition, some critics of mandatory reporting raise concerns surrounding law enforcement showing up at the victim’s house to question the family about abuse, or to make an arrest or issue warnings. They posit that when the behavior of an abuser is under scrutiny, this can paradoxically create a potentially more dangerous environment for the patient-victim, whom the perpetrator now considers to have betrayed his or her trust. Others bemoan that revealing patient confidences violates the physician’s ethical code.
However, the intolerable incidence of violence against the vulnerable has properly made mandatory reporting the law of the land. Although the criminal penalty is currently light for failure to report, there is a move toward increasing its severity. Hawaii, for example, recently introduced Senate Bill 2477 that makes nonreporting by those required to do so a Class C felony punishable by up to 5 years in prison. The offense currently is a petty misdemeanor punishable by up to 30 days in jail.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at [email protected].
References
1. Child Welfare Information Gateway (2016). Mandatory reporters of child abuse and neglect. Washington, D.C.: U.S. Department of Health and Human Services, Children’s Bureau. Available at www.childwelfare.gov; email: [email protected]; phone: 800-394-3366.
2. Available at www.childwelfare.gov/topics/can.
3. Available at www.justice.gov/elderjustice/elder-justice-statutes-0.
4. Available at www.cdc.gov/violenceprevention/elderabuse/index.html.
5. Hawaii Revised Statutes, Sec. 346-222, 346-224, 346-250, 412:3-114.5.
6. Available at ncadv.org.
7. Ann Emerg Med. 2002 Jan;39(1):56-60.
8. Hawaii Revised Statutes, Sec. 709-906.
9. Pediatrics. 2017 Apr;139(4). pii: e20163511.
Question: You are moonlighting in the emergency department and have just finished treating a 5-year-old boy with an apparent Colles’ fracture, who was accompanied by his mother with bruises on her face. Her exam revealed additional bruises over her abdominal wall. The mother said they accidentally tripped and fell down the stairs, and spontaneously denied any acts of violence in the family.
Given this scenario, which of the following is best?
A. You suspect both child and spousal abuse, but lack sufficient evidence to report the incident.
B. Failure to report based on reasonable suspicion alone may amount to a criminal offense punishable by possible imprisonment.
C. You may face a potential malpractice lawsuit if subsequent injuries caused by abuse could have been prevented had you reported.
D. Mandatory reporting laws apply not only to abuse of children and spouses, but also of the elderly and other vulnerable adults.
E. All are correct except A.
Answer: E. All doctors, especially those working in emergency departments, treat injuries on a regular basis. Accidents probably account for the majority of these injuries, but the most pernicious are those caused by willful abuse or neglect. Such conduct, believed to be widespread and underrecognized, victimizes children, women, the elderly, and other vulnerable groups.
Mandatory reporting laws arose from the need to identify and prevent these activities that cause serious harm and loss of lives. Physicians and other health care workers are in a prime position to diagnose or raise the suspicion of abuse and neglect. This article focuses on laws that mandate physician reporting of such behavior. Not addressed are other reportable situations such as certain infectious diseases, gunshot wounds, threats to third parties, and so on.
Child abuse
The best-known example of a mandatory reporting law relates to child abuse, which is broadly defined as when a parent or caretaker emotionally, physically, or sexually abuses, neglects, or abandons a child. Child abuse laws are intended to protect children from serious harm without abridging parental discipline of their children.
Cases of child abuse are pervasive; four or five children are tragically killed by abuse or neglect every day, and each year, some 6 million children are reported as victims of child abuse. Henry Kempe’s studies on the “battered child syndrome” in 1962 served to underscore the physician’s role in exposing child maltreatment, and 1973 saw the enactment of the Child Abuse Prevention and Treatment Act, which set standards for mandatory reporting as a condition for federal funding.
All U.S. states have statutes identifying persons who are required to report suspected child maltreatment to an appropriate agency, such as child protective services. Reasonable suspicion, without need for proof, is sufficient to trigger the mandatory reporting duty. A summary of the general reporting requirements, as well as each state’s key statutory features, are available at Child Welfare Information Gateway.1
Bruises, fractures, and burns are recurring examples of injuries resulting from child abuse, but there are many others, including severe emotional harm, which is an important consequence. Clues to abuse include a child’s fearful and anxious demeanor, wearing clothes to hide injuries, and inappropriate sexual conduct.2 The perpetrators and/or complicit parties typically blame an innocent home accident for the victim’s injuries to mislead the health care provider.
Elder abuse
Elder abuse is broadly construed to include physical, sexual, and psychological abuse, as well as financial exploitation and caregiver neglect.3 It is a serious problem in the United States, estimated in 2008 to affect 1 in 10 elders. The figure is likely an underestimate, because many elderly victims are afraid or unwilling to lodge a complaint against the abuser whom they love and may depend upon.4
The law, which protects the “elderly” (e.g., those aged 62 years or older in Hawaii), may also be extended to other younger vulnerable adults, who because of an impairment, are unable to 1) communicate or make responsible decisions to manage one’s own care or resources, 2) carry out or arrange for essential activities of daily living, or 3) protect one’s self from abuse.5
The law mandates reporting where there is reason to believe abuse has occurred or the vulnerable adult is in danger of abuse if immediate action is not taken. Reporting statutes for elder abuse vary somewhat on the identity of mandated reporters (health care providers are always included), the victim’s mental capacity, dwelling place (home or in an assisted-living facility), and type of purported activity that warrants reporting.
Domestic violence
As defined by the National Coalition Against Domestic Violence, “Domestic violence is the willful intimidation, physical assault, battery, sexual assault, and/or other abusive behavior as part of a systematic pattern of power and control perpetrated by one intimate partner against another. ... The frequency and severity of domestic violence can vary dramatically; however, the one constant component of domestic violence is one partner’s consistent efforts to maintain power and control over the other.”6 Domestic violence is said to have reached epidemic proportions, with one in four women experiencing it at some point in her life.
Virtually all states mandate the reporting of domestic violence by health care providers if there is a reasonable suspicion that observed patient injuries are the result of physical abuse.7 California, for example, requires the provider to call local law enforcement as soon as possible or to send in a written report within 48 hours.
There may be exceptions to required reporting, as when an adult victim withholds consent but accepts victim referral services. State laws encourage but do not always require that the health care provider inform the patient about the report, but federal law dictates otherwise unless this puts the patient at risk. Hawaii’s domestic violence laws were originally enacted to deter spousal abuse, but they now also protect other household members.8
Any individual who assumes a duty or responsibility pursuant to all of these reporting laws is immunized from criminal or civil liability. On the other hand, a mandated reporter who knowingly fails to report an incident or who willfully prevents another person from reporting such an incident commits a criminal offence.
In the case of a physician, there is the added risk of a malpractice lawsuit based on “violation of statute” (breach of a legal duty), should another injury occur down the road that was arguably preventable by his or her failure to report.
Experts generally believe that mandatory reporting laws are important in identifying child maltreatment. However, it has been asserted that despite a 5-decade history of mandatory reporting, no clear endpoints attest to the efficacy of this approach, and it is argued that no data exist to demonstrate that incremental increases in reporting have contributed to child safety.
Particularly challenging are attempts at impact comparisons between states with different policies. A number of countries, including the United Kingdom, do not have mandatory reporting laws and regulate reporting by professional societies.9
In addition, some critics of mandatory reporting raise concerns surrounding law enforcement showing up at the victim’s house to question the family about abuse, or to make an arrest or issue warnings. They posit that when the behavior of an abuser is under scrutiny, this can paradoxically create a potentially more dangerous environment for the patient-victim, whom the perpetrator now considers to have betrayed his or her trust. Others bemoan that revealing patient confidences violates the physician’s ethical code.
However, the intolerable incidence of violence against the vulnerable has properly made mandatory reporting the law of the land. Although the criminal penalty is currently light for failure to report, there is a move toward increasing its severity. Hawaii, for example, recently introduced Senate Bill 2477 that makes nonreporting by those required to do so a Class C felony punishable by up to 5 years in prison. The offense currently is a petty misdemeanor punishable by up to 30 days in jail.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at [email protected].
References
1. Child Welfare Information Gateway (2016). Mandatory reporters of child abuse and neglect. Washington, D.C.: U.S. Department of Health and Human Services, Children’s Bureau. Available at www.childwelfare.gov; email: [email protected]; phone: 800-394-3366.
2. Available at www.childwelfare.gov/topics/can.
3. Available at www.justice.gov/elderjustice/elder-justice-statutes-0.
4. Available at www.cdc.gov/violenceprevention/elderabuse/index.html.
5. Hawaii Revised Statutes, Sec. 346-222, 346-224, 346-250, 412:3-114.5.
6. Available at ncadv.org.
7. Ann Emerg Med. 2002 Jan;39(1):56-60.
8. Hawaii Revised Statutes, Sec. 709-906.
9. Pediatrics. 2017 Apr;139(4). pii: e20163511.
Dissuading parents from using corporal punishment
The American Academy of Pediatrics recently issued an updated policy statement on discipline,1 calling for us to teach parents not to use corporal punishment or verbally abuse their children. While a 2016 survey of 787 pediatricians found only 6% endorsed spanking as a positive, and, in a 2013 Harris Poll, fewer parents (72%) endorsed spanking, compared with 87% in 1995, we still have a lot of work to do given the even clearer adverse effects of painful discipline.
One of the difficult things about teaching parents to stop corporal punishment is that it works. A smack instantly stops many misbehaviors, but, when asked closely, parents admit that the pause is only about 10 minutes. Instant results are highly reinforcing, and smacking gives welcome emotional release for adults. Most parents who hit their children also were hit growing up. Hitting seems a natural and appropriate method of parenting because this is what their own beloved parents did. Hitting is not a logical decision but a reflex reinforced by early and current experiences.
Another barrier to stopping hitting is that, while some adverse effects appear immediately, most occur later. Immediate effects of the child screaming, telling the parent “I hate you,” throwing things, or stomping to their room may upset the parent, but also may be seen as signs that their action was effective, if retribution is their unconscious goal. Parenting comes at you like a fire hose, and our visits with families can be a special opportunity for reflection on their goals and how well their methods are working.
We can help parents see the later effects appearing hours or days after the hitting. Children feel degraded by spanking, and they may talk back; act sassy; refuse to follow directions or cooperate; and be mean to siblings, pets, or peers. Wait, you say, those were the behaviors the parent cited for hitting the child in the first place! This “hit, act up, hit” cycle perpetuating corporal punishment2 may be invisible to the parent.
Corporal punishment effects
“But he knows I love him,” parents will say, “and he respects me because of the way I have raised him.” Those things may be true, but the residual of loving combined with fearing has been shown to result in adulthood with increased aggression towards loved ones, including child abuse, partner violence, and sadistic sexual behaviors.
We can explain the much-later effects of corporal punishment: A child who experiences pain from the person they love and count on the most in life may develop very mixed feelings in future relationships. Especially if the pain was not countered by affection and admiration from the parent most of the time, the child may become aggressive; numb to others and to him/herself; and develop low self-esteem, learning difficulties, and depression or other mental health disorders. In some cases, the emotionally wounded child is driven to cause similar pain in others through mean acts, stealing things, hurting animals, and violence. “People hurt me so I am going to hurt them” is their unconscious path. As an adult, coping with old hurts may include numbing it with alcohol, drugs, overeating, smoking, or excessive sexual activities.
Do these sound like the familiar aftereffects of having adverse childhood experiences (ACE)? In fact, data from the original ACEs group who were recalling their childhoods showed that corporal punishment had a similar but independent impact as abuse, increasing suicide, and alcohol and substance use disorder.3 And the brain changes on MRIs of children with repeated corporal punishment had similar reductions of the prefrontal cortex and similar abnormalities of stress-related cortisol release.4
Parents commonly counter our advice not to hit their child by saying they were spanked and “came out okay.” But as for other medical problems, the effects of corporal punishment vary from child to child. Feelings are more easily and permanently damaged for some than for others, and we cannot predict who will have the worst outcomes. We do know that hitting is more harmful if not counteracted with affection, that more arbitrary hitting is worse than planned hitting for breaking prespecified rules, that more frequent hitting over time and to a later age has worse outcome, and that effects are smaller in studies of African Americans. Abuse, most often an acceleration of a disciplinary encounter, of course must be stopped and reported. Considered independently of parent factors, the children most likely to get hit are those with frequent impulsive misbehavior, such as ADHD, where our counseling to distinguish intentional from ADHD-related behaviors is most crucial. Anxious children likely take hitting to heart.
Specific strategies
We can’t just count on words and a handout to counter reflexes to hit, although these have some proven benefit. We have to convince parents to take action on other invisible health conditions such as high cholesterol or blood pressure, prescribing difficult changes in family diet and exercise. While these are also challenging they are not fraught with similar emotion. Parents resorting to hitting are more likely to be depressed, stressed, or have their own histories of ACEs. While we need to advise parents in practical strategies, we need to do this while attending to their strong feelings, family loyalty, frustration with the child’s misbehavior, and personal context, not just the facts about adverse outcomes.
Before it must come eliciting a specific example (What would s/he have to do to get hit? How did it work?), empathy with their pain (That sounds really [upsetting, frustrating, embarrassing]), problem solving (What have you tried so far? What has worked best?), and connecting to family opinions (What do your parents/partner say about this? How would your/his or her parents have handled this when you/he or she were growing up?).
Often advice for daily irrevocable special time and quick attention to desirable bits of behavior are first steps to breaking negative parent-child cycles. When a behavior requires intervention, eye contact at child level, acknowledgment of the child’s point of view, brief explanation of why a behavior is not okay, and an age- and offense-relevant consequence (removal of toy, time out, chore card, loss of privileges) have best evidence for reducing misbehavior over time. Letting them know that smaller consequences work better than larger ones is a relief for both child and parent!
The new AAP policy article has references for parenting programs, videos, and handouts – all good ideas. But parents are more likely to make the effort to use these resources when you develop understanding of their situation without judging them, explain reasons for choosing noncorporal discipline, provide evidence-based alternatives, and offer return visits to support them in changing their ways.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She reported no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. Email her at [email protected].
References
1. Pediatrics. 2018 Dec 1;142[6]: e20183112.
2. J Youth Adolesc. 2015 Mar;44(3):658-69.
3. Child Abuse Negl. 2017 Sep;71:24-31.
4. Neuroimage. 2009 Aug;47 Suppl 2:T66-71.
The American Academy of Pediatrics recently issued an updated policy statement on discipline,1 calling for us to teach parents not to use corporal punishment or verbally abuse their children. While a 2016 survey of 787 pediatricians found only 6% endorsed spanking as a positive, and, in a 2013 Harris Poll, fewer parents (72%) endorsed spanking, compared with 87% in 1995, we still have a lot of work to do given the even clearer adverse effects of painful discipline.
One of the difficult things about teaching parents to stop corporal punishment is that it works. A smack instantly stops many misbehaviors, but, when asked closely, parents admit that the pause is only about 10 minutes. Instant results are highly reinforcing, and smacking gives welcome emotional release for adults. Most parents who hit their children also were hit growing up. Hitting seems a natural and appropriate method of parenting because this is what their own beloved parents did. Hitting is not a logical decision but a reflex reinforced by early and current experiences.
Another barrier to stopping hitting is that, while some adverse effects appear immediately, most occur later. Immediate effects of the child screaming, telling the parent “I hate you,” throwing things, or stomping to their room may upset the parent, but also may be seen as signs that their action was effective, if retribution is their unconscious goal. Parenting comes at you like a fire hose, and our visits with families can be a special opportunity for reflection on their goals and how well their methods are working.
We can help parents see the later effects appearing hours or days after the hitting. Children feel degraded by spanking, and they may talk back; act sassy; refuse to follow directions or cooperate; and be mean to siblings, pets, or peers. Wait, you say, those were the behaviors the parent cited for hitting the child in the first place! This “hit, act up, hit” cycle perpetuating corporal punishment2 may be invisible to the parent.
Corporal punishment effects
“But he knows I love him,” parents will say, “and he respects me because of the way I have raised him.” Those things may be true, but the residual of loving combined with fearing has been shown to result in adulthood with increased aggression towards loved ones, including child abuse, partner violence, and sadistic sexual behaviors.
We can explain the much-later effects of corporal punishment: A child who experiences pain from the person they love and count on the most in life may develop very mixed feelings in future relationships. Especially if the pain was not countered by affection and admiration from the parent most of the time, the child may become aggressive; numb to others and to him/herself; and develop low self-esteem, learning difficulties, and depression or other mental health disorders. In some cases, the emotionally wounded child is driven to cause similar pain in others through mean acts, stealing things, hurting animals, and violence. “People hurt me so I am going to hurt them” is their unconscious path. As an adult, coping with old hurts may include numbing it with alcohol, drugs, overeating, smoking, or excessive sexual activities.
Do these sound like the familiar aftereffects of having adverse childhood experiences (ACE)? In fact, data from the original ACEs group who were recalling their childhoods showed that corporal punishment had a similar but independent impact as abuse, increasing suicide, and alcohol and substance use disorder.3 And the brain changes on MRIs of children with repeated corporal punishment had similar reductions of the prefrontal cortex and similar abnormalities of stress-related cortisol release.4
Parents commonly counter our advice not to hit their child by saying they were spanked and “came out okay.” But as for other medical problems, the effects of corporal punishment vary from child to child. Feelings are more easily and permanently damaged for some than for others, and we cannot predict who will have the worst outcomes. We do know that hitting is more harmful if not counteracted with affection, that more arbitrary hitting is worse than planned hitting for breaking prespecified rules, that more frequent hitting over time and to a later age has worse outcome, and that effects are smaller in studies of African Americans. Abuse, most often an acceleration of a disciplinary encounter, of course must be stopped and reported. Considered independently of parent factors, the children most likely to get hit are those with frequent impulsive misbehavior, such as ADHD, where our counseling to distinguish intentional from ADHD-related behaviors is most crucial. Anxious children likely take hitting to heart.
Specific strategies
We can’t just count on words and a handout to counter reflexes to hit, although these have some proven benefit. We have to convince parents to take action on other invisible health conditions such as high cholesterol or blood pressure, prescribing difficult changes in family diet and exercise. While these are also challenging they are not fraught with similar emotion. Parents resorting to hitting are more likely to be depressed, stressed, or have their own histories of ACEs. While we need to advise parents in practical strategies, we need to do this while attending to their strong feelings, family loyalty, frustration with the child’s misbehavior, and personal context, not just the facts about adverse outcomes.
Before it must come eliciting a specific example (What would s/he have to do to get hit? How did it work?), empathy with their pain (That sounds really [upsetting, frustrating, embarrassing]), problem solving (What have you tried so far? What has worked best?), and connecting to family opinions (What do your parents/partner say about this? How would your/his or her parents have handled this when you/he or she were growing up?).
Often advice for daily irrevocable special time and quick attention to desirable bits of behavior are first steps to breaking negative parent-child cycles. When a behavior requires intervention, eye contact at child level, acknowledgment of the child’s point of view, brief explanation of why a behavior is not okay, and an age- and offense-relevant consequence (removal of toy, time out, chore card, loss of privileges) have best evidence for reducing misbehavior over time. Letting them know that smaller consequences work better than larger ones is a relief for both child and parent!
The new AAP policy article has references for parenting programs, videos, and handouts – all good ideas. But parents are more likely to make the effort to use these resources when you develop understanding of their situation without judging them, explain reasons for choosing noncorporal discipline, provide evidence-based alternatives, and offer return visits to support them in changing their ways.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She reported no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. Email her at [email protected].
References
1. Pediatrics. 2018 Dec 1;142[6]: e20183112.
2. J Youth Adolesc. 2015 Mar;44(3):658-69.
3. Child Abuse Negl. 2017 Sep;71:24-31.
4. Neuroimage. 2009 Aug;47 Suppl 2:T66-71.
The American Academy of Pediatrics recently issued an updated policy statement on discipline,1 calling for us to teach parents not to use corporal punishment or verbally abuse their children. While a 2016 survey of 787 pediatricians found only 6% endorsed spanking as a positive, and, in a 2013 Harris Poll, fewer parents (72%) endorsed spanking, compared with 87% in 1995, we still have a lot of work to do given the even clearer adverse effects of painful discipline.
One of the difficult things about teaching parents to stop corporal punishment is that it works. A smack instantly stops many misbehaviors, but, when asked closely, parents admit that the pause is only about 10 minutes. Instant results are highly reinforcing, and smacking gives welcome emotional release for adults. Most parents who hit their children also were hit growing up. Hitting seems a natural and appropriate method of parenting because this is what their own beloved parents did. Hitting is not a logical decision but a reflex reinforced by early and current experiences.
Another barrier to stopping hitting is that, while some adverse effects appear immediately, most occur later. Immediate effects of the child screaming, telling the parent “I hate you,” throwing things, or stomping to their room may upset the parent, but also may be seen as signs that their action was effective, if retribution is their unconscious goal. Parenting comes at you like a fire hose, and our visits with families can be a special opportunity for reflection on their goals and how well their methods are working.
We can help parents see the later effects appearing hours or days after the hitting. Children feel degraded by spanking, and they may talk back; act sassy; refuse to follow directions or cooperate; and be mean to siblings, pets, or peers. Wait, you say, those were the behaviors the parent cited for hitting the child in the first place! This “hit, act up, hit” cycle perpetuating corporal punishment2 may be invisible to the parent.
Corporal punishment effects
“But he knows I love him,” parents will say, “and he respects me because of the way I have raised him.” Those things may be true, but the residual of loving combined with fearing has been shown to result in adulthood with increased aggression towards loved ones, including child abuse, partner violence, and sadistic sexual behaviors.
We can explain the much-later effects of corporal punishment: A child who experiences pain from the person they love and count on the most in life may develop very mixed feelings in future relationships. Especially if the pain was not countered by affection and admiration from the parent most of the time, the child may become aggressive; numb to others and to him/herself; and develop low self-esteem, learning difficulties, and depression or other mental health disorders. In some cases, the emotionally wounded child is driven to cause similar pain in others through mean acts, stealing things, hurting animals, and violence. “People hurt me so I am going to hurt them” is their unconscious path. As an adult, coping with old hurts may include numbing it with alcohol, drugs, overeating, smoking, or excessive sexual activities.
Do these sound like the familiar aftereffects of having adverse childhood experiences (ACE)? In fact, data from the original ACEs group who were recalling their childhoods showed that corporal punishment had a similar but independent impact as abuse, increasing suicide, and alcohol and substance use disorder.3 And the brain changes on MRIs of children with repeated corporal punishment had similar reductions of the prefrontal cortex and similar abnormalities of stress-related cortisol release.4
Parents commonly counter our advice not to hit their child by saying they were spanked and “came out okay.” But as for other medical problems, the effects of corporal punishment vary from child to child. Feelings are more easily and permanently damaged for some than for others, and we cannot predict who will have the worst outcomes. We do know that hitting is more harmful if not counteracted with affection, that more arbitrary hitting is worse than planned hitting for breaking prespecified rules, that more frequent hitting over time and to a later age has worse outcome, and that effects are smaller in studies of African Americans. Abuse, most often an acceleration of a disciplinary encounter, of course must be stopped and reported. Considered independently of parent factors, the children most likely to get hit are those with frequent impulsive misbehavior, such as ADHD, where our counseling to distinguish intentional from ADHD-related behaviors is most crucial. Anxious children likely take hitting to heart.
Specific strategies
We can’t just count on words and a handout to counter reflexes to hit, although these have some proven benefit. We have to convince parents to take action on other invisible health conditions such as high cholesterol or blood pressure, prescribing difficult changes in family diet and exercise. While these are also challenging they are not fraught with similar emotion. Parents resorting to hitting are more likely to be depressed, stressed, or have their own histories of ACEs. While we need to advise parents in practical strategies, we need to do this while attending to their strong feelings, family loyalty, frustration with the child’s misbehavior, and personal context, not just the facts about adverse outcomes.
Before it must come eliciting a specific example (What would s/he have to do to get hit? How did it work?), empathy with their pain (That sounds really [upsetting, frustrating, embarrassing]), problem solving (What have you tried so far? What has worked best?), and connecting to family opinions (What do your parents/partner say about this? How would your/his or her parents have handled this when you/he or she were growing up?).
Often advice for daily irrevocable special time and quick attention to desirable bits of behavior are first steps to breaking negative parent-child cycles. When a behavior requires intervention, eye contact at child level, acknowledgment of the child’s point of view, brief explanation of why a behavior is not okay, and an age- and offense-relevant consequence (removal of toy, time out, chore card, loss of privileges) have best evidence for reducing misbehavior over time. Letting them know that smaller consequences work better than larger ones is a relief for both child and parent!
The new AAP policy article has references for parenting programs, videos, and handouts – all good ideas. But parents are more likely to make the effort to use these resources when you develop understanding of their situation without judging them, explain reasons for choosing noncorporal discipline, provide evidence-based alternatives, and offer return visits to support them in changing their ways.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She reported no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. Email her at [email protected].
References
1. Pediatrics. 2018 Dec 1;142[6]: e20183112.
2. J Youth Adolesc. 2015 Mar;44(3):658-69.
3. Child Abuse Negl. 2017 Sep;71:24-31.
4. Neuroimage. 2009 Aug;47 Suppl 2:T66-71.
Consider caffeine effects on children and adolescents
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.
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.
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.
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).
Opioid crisis offers poignant lessons for public health
Populations and circumstances matter
As a medical student in New York City in the mid-1980s, I did several of my clinical clerkships at Memorial Sloan Kettering Cancer Center. One night during my general surgery rotation, there was a young woman with anal cancer who complained of pain.
My resident did not want to give her more medication and I asked why. After all, this was a cancer center with progressive ideas about pain management, this patient was suffering, and she was ill enough to be hospitalized.
The resident responded to my inquiry: “She doesn’t have a terminal condition and she has an addictive personality.” It seemed to me a draconian (and perhaps sexist) response in a hospital where patient-controlled analgesia was becoming routine and, as an aspiring psychiatrist, I didn’t quite trust the surgical resident’s evaluation of the patient’s personality or his ability to predict if she might become addicted to opiates.
This encounter happened about 6 years after Jane Porter and Hershel Jink, MD, had published a letter titled, “Addiction Rare in Patients Treated with Narcotics” in the New England Journal of Medicine (1980 Jan 10;302:123) with the following finding: “... of 11,800 patients given narcotic painkillers while in hospital, only four developed an addiction to those drugs.” This fragment of a sentence, published as a one-paragraph letter and not as a full, peer-reviewed study, was in the process of changing how all of American medicine responded to pain.
In his book, “Dreamland: The True Tale of America’s Opiate Epidemic” (Bloomsbury Press, 2015), journalist Sam Quinones was quick to point out that these findings were made at a time when doctors, like my surgical resident, were hesitant to use opiates for fear of addiction. Their use was limited to cancer patients, postoperative patients, and those suffering from an acute injury. This finding that prescribed opiates did not cause addiction was true in these hospitalized patients, at a time when pills were doled out with caution for short-term use, and their use for chronic pain had not yet been tested.
Nearly 40 years later, we know that the answer to that national experiment did not work out so well: A proportion of patients given long-term, sometimes high-dose, opiates for chronic pain do sometimes become addicted. Some chronic pain patients received narcotics at “pill mills,” and some went on to use heroin obtained illegally. Furthermore, the widespread use of these medicines made them more readily available to those looking for something besides pain relief.
I would like to suggest that the opioid epidemic is not solely the fault of the medical community: We had drug addiction long before we had the Porter and Jink paragraph and not all addiction starts with a prescription pad. Still, the lesson for public health is a poignant one: Populations and circumstances matter. Be careful with generalizations.
Still, we see these generalizations all the time. I am sometimes surprised at how many people have “the answer.” Whether it’s more widespread availability of Narcan, medication-assisted treatment (MAT), safe injection sites, 12-step programs, or “Just Say No,” every method has its proponents. I always wonder when I see public health officials propose safe injection sites as something that would surely save thousands of lives, citing data out of cities such as Vancouver, as well as in Europe, and Australia, if results in those places would transfer to my city – Baltimore – where drug addiction, violence, and poverty are rampant. Perhaps they would, and I would love to see Baltimore try anything that might work. But I hope cities that do set up such sites will follow the numbers and halt any program that does not offer robust results.
I wonder, as well, why, with the clear success of MAT strategies in reducing mortality, we don’t experiment with ways of making these methods more accessible. Might Suboxone work if doctors could prescribe it as easily as they can prescribe oxycodone, with no 8-hour course or DEA waiver? Might methadone both work and be more acceptable to patients if given in a way that didn’t require daily travel to a clinic for administration? With such a deadly pervasive epidemic, I wonder also about our focus on treating addiction, when it seems we should have a parallel focus on understanding and addressing the factors that cause addiction. Medical prescribing is but one avenue to addiction, yet we have no understanding as to why some people become addicted when others do not. Shouldn’t we be able to prevent addiction? From Richard Nixon’s “war on drugs” to Donald Trump’s physical border wall, there are many answers, but few solutions.
There are other public health issues that suffer from the same generalizations. In psychiatry, advocacy groups tout involuntary outpatient treatment as a successful way of getting treatment to vulnerable individuals who will not willingly negotiate their own care. While a pilot study at Bellevue showed no benefit to mandated care, a follow-up study showed that mandated treatment was effective at reducing hospital days. While outpatient commitment studies look at rates of hospitalization, incarceration, and quality-of-life measures, mandated treatment is often cited as a means to prevent all forms of violence, including mass shootings, while there is no evidence to support these ideas. Still, 47 states and the District of Columbia now have outpatient commitment laws.
Does involuntary care benefit those with substance use disorders? In Massachusetts, Section 35 allows for civil commitment for drug treatment, and many of the treatment facilities are run by the Department of Corrections. It would be good to know if these measures worked. So far, it looks like opioid deaths in Massachusetts have stabilized, while the overdose death rate continues to rise in other states. Whether this is a result of Section 35 or other measures is unknown.
I’m not against innovation, and desperate situations call for creative responses. We need to be careful that our responses are measured and these experiments are contained while ascertaining what really does work and what does not cause unintended harms. Will a concrete wall stem the flow of illegal heroin? I imagine a new world of drones making drug drops.
Sometimes our innovative best guesses don’t work, and sometimes they do. Despite easy access to antidepressant medications, a national suicide hotline, increased numbers of mental health professionals, and anti-stigma/awareness campaigns, suicide rates continue to rise. Efforts to end smoking, however, have been quite successful, as have measures to get Americans to buckle their seat belts, and these measures have decreased mortality rates. The recommendation for healthy women to take hormone therapy is a good example: It was an innovative recommendation to help cardiac and orthopedic outcomes, yet studies that were run alongside these recommendations were quick to show an unintended increased risk of breast and uterine cancer.
I don’t know what happened to the young woman on my surgical rotation. If the decision were mine, I would have given her more pain medication, even now, but I don’t know if that would have been the right thing to do., and to look carefully at our outcomes in a variety of populations and circumstances.
Dr. Miller is the coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice in Baltimore.
Populations and circumstances matter
Populations and circumstances matter
As a medical student in New York City in the mid-1980s, I did several of my clinical clerkships at Memorial Sloan Kettering Cancer Center. One night during my general surgery rotation, there was a young woman with anal cancer who complained of pain.
My resident did not want to give her more medication and I asked why. After all, this was a cancer center with progressive ideas about pain management, this patient was suffering, and she was ill enough to be hospitalized.
The resident responded to my inquiry: “She doesn’t have a terminal condition and she has an addictive personality.” It seemed to me a draconian (and perhaps sexist) response in a hospital where patient-controlled analgesia was becoming routine and, as an aspiring psychiatrist, I didn’t quite trust the surgical resident’s evaluation of the patient’s personality or his ability to predict if she might become addicted to opiates.
This encounter happened about 6 years after Jane Porter and Hershel Jink, MD, had published a letter titled, “Addiction Rare in Patients Treated with Narcotics” in the New England Journal of Medicine (1980 Jan 10;302:123) with the following finding: “... of 11,800 patients given narcotic painkillers while in hospital, only four developed an addiction to those drugs.” This fragment of a sentence, published as a one-paragraph letter and not as a full, peer-reviewed study, was in the process of changing how all of American medicine responded to pain.
In his book, “Dreamland: The True Tale of America’s Opiate Epidemic” (Bloomsbury Press, 2015), journalist Sam Quinones was quick to point out that these findings were made at a time when doctors, like my surgical resident, were hesitant to use opiates for fear of addiction. Their use was limited to cancer patients, postoperative patients, and those suffering from an acute injury. This finding that prescribed opiates did not cause addiction was true in these hospitalized patients, at a time when pills were doled out with caution for short-term use, and their use for chronic pain had not yet been tested.
Nearly 40 years later, we know that the answer to that national experiment did not work out so well: A proportion of patients given long-term, sometimes high-dose, opiates for chronic pain do sometimes become addicted. Some chronic pain patients received narcotics at “pill mills,” and some went on to use heroin obtained illegally. Furthermore, the widespread use of these medicines made them more readily available to those looking for something besides pain relief.
I would like to suggest that the opioid epidemic is not solely the fault of the medical community: We had drug addiction long before we had the Porter and Jink paragraph and not all addiction starts with a prescription pad. Still, the lesson for public health is a poignant one: Populations and circumstances matter. Be careful with generalizations.
Still, we see these generalizations all the time. I am sometimes surprised at how many people have “the answer.” Whether it’s more widespread availability of Narcan, medication-assisted treatment (MAT), safe injection sites, 12-step programs, or “Just Say No,” every method has its proponents. I always wonder when I see public health officials propose safe injection sites as something that would surely save thousands of lives, citing data out of cities such as Vancouver, as well as in Europe, and Australia, if results in those places would transfer to my city – Baltimore – where drug addiction, violence, and poverty are rampant. Perhaps they would, and I would love to see Baltimore try anything that might work. But I hope cities that do set up such sites will follow the numbers and halt any program that does not offer robust results.
I wonder, as well, why, with the clear success of MAT strategies in reducing mortality, we don’t experiment with ways of making these methods more accessible. Might Suboxone work if doctors could prescribe it as easily as they can prescribe oxycodone, with no 8-hour course or DEA waiver? Might methadone both work and be more acceptable to patients if given in a way that didn’t require daily travel to a clinic for administration? With such a deadly pervasive epidemic, I wonder also about our focus on treating addiction, when it seems we should have a parallel focus on understanding and addressing the factors that cause addiction. Medical prescribing is but one avenue to addiction, yet we have no understanding as to why some people become addicted when others do not. Shouldn’t we be able to prevent addiction? From Richard Nixon’s “war on drugs” to Donald Trump’s physical border wall, there are many answers, but few solutions.
There are other public health issues that suffer from the same generalizations. In psychiatry, advocacy groups tout involuntary outpatient treatment as a successful way of getting treatment to vulnerable individuals who will not willingly negotiate their own care. While a pilot study at Bellevue showed no benefit to mandated care, a follow-up study showed that mandated treatment was effective at reducing hospital days. While outpatient commitment studies look at rates of hospitalization, incarceration, and quality-of-life measures, mandated treatment is often cited as a means to prevent all forms of violence, including mass shootings, while there is no evidence to support these ideas. Still, 47 states and the District of Columbia now have outpatient commitment laws.
Does involuntary care benefit those with substance use disorders? In Massachusetts, Section 35 allows for civil commitment for drug treatment, and many of the treatment facilities are run by the Department of Corrections. It would be good to know if these measures worked. So far, it looks like opioid deaths in Massachusetts have stabilized, while the overdose death rate continues to rise in other states. Whether this is a result of Section 35 or other measures is unknown.
I’m not against innovation, and desperate situations call for creative responses. We need to be careful that our responses are measured and these experiments are contained while ascertaining what really does work and what does not cause unintended harms. Will a concrete wall stem the flow of illegal heroin? I imagine a new world of drones making drug drops.
Sometimes our innovative best guesses don’t work, and sometimes they do. Despite easy access to antidepressant medications, a national suicide hotline, increased numbers of mental health professionals, and anti-stigma/awareness campaigns, suicide rates continue to rise. Efforts to end smoking, however, have been quite successful, as have measures to get Americans to buckle their seat belts, and these measures have decreased mortality rates. The recommendation for healthy women to take hormone therapy is a good example: It was an innovative recommendation to help cardiac and orthopedic outcomes, yet studies that were run alongside these recommendations were quick to show an unintended increased risk of breast and uterine cancer.
I don’t know what happened to the young woman on my surgical rotation. If the decision were mine, I would have given her more pain medication, even now, but I don’t know if that would have been the right thing to do., and to look carefully at our outcomes in a variety of populations and circumstances.
Dr. Miller is the coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice in Baltimore.
As a medical student in New York City in the mid-1980s, I did several of my clinical clerkships at Memorial Sloan Kettering Cancer Center. One night during my general surgery rotation, there was a young woman with anal cancer who complained of pain.
My resident did not want to give her more medication and I asked why. After all, this was a cancer center with progressive ideas about pain management, this patient was suffering, and she was ill enough to be hospitalized.
The resident responded to my inquiry: “She doesn’t have a terminal condition and she has an addictive personality.” It seemed to me a draconian (and perhaps sexist) response in a hospital where patient-controlled analgesia was becoming routine and, as an aspiring psychiatrist, I didn’t quite trust the surgical resident’s evaluation of the patient’s personality or his ability to predict if she might become addicted to opiates.
This encounter happened about 6 years after Jane Porter and Hershel Jink, MD, had published a letter titled, “Addiction Rare in Patients Treated with Narcotics” in the New England Journal of Medicine (1980 Jan 10;302:123) with the following finding: “... of 11,800 patients given narcotic painkillers while in hospital, only four developed an addiction to those drugs.” This fragment of a sentence, published as a one-paragraph letter and not as a full, peer-reviewed study, was in the process of changing how all of American medicine responded to pain.
In his book, “Dreamland: The True Tale of America’s Opiate Epidemic” (Bloomsbury Press, 2015), journalist Sam Quinones was quick to point out that these findings were made at a time when doctors, like my surgical resident, were hesitant to use opiates for fear of addiction. Their use was limited to cancer patients, postoperative patients, and those suffering from an acute injury. This finding that prescribed opiates did not cause addiction was true in these hospitalized patients, at a time when pills were doled out with caution for short-term use, and their use for chronic pain had not yet been tested.
Nearly 40 years later, we know that the answer to that national experiment did not work out so well: A proportion of patients given long-term, sometimes high-dose, opiates for chronic pain do sometimes become addicted. Some chronic pain patients received narcotics at “pill mills,” and some went on to use heroin obtained illegally. Furthermore, the widespread use of these medicines made them more readily available to those looking for something besides pain relief.
I would like to suggest that the opioid epidemic is not solely the fault of the medical community: We had drug addiction long before we had the Porter and Jink paragraph and not all addiction starts with a prescription pad. Still, the lesson for public health is a poignant one: Populations and circumstances matter. Be careful with generalizations.
Still, we see these generalizations all the time. I am sometimes surprised at how many people have “the answer.” Whether it’s more widespread availability of Narcan, medication-assisted treatment (MAT), safe injection sites, 12-step programs, or “Just Say No,” every method has its proponents. I always wonder when I see public health officials propose safe injection sites as something that would surely save thousands of lives, citing data out of cities such as Vancouver, as well as in Europe, and Australia, if results in those places would transfer to my city – Baltimore – where drug addiction, violence, and poverty are rampant. Perhaps they would, and I would love to see Baltimore try anything that might work. But I hope cities that do set up such sites will follow the numbers and halt any program that does not offer robust results.
I wonder, as well, why, with the clear success of MAT strategies in reducing mortality, we don’t experiment with ways of making these methods more accessible. Might Suboxone work if doctors could prescribe it as easily as they can prescribe oxycodone, with no 8-hour course or DEA waiver? Might methadone both work and be more acceptable to patients if given in a way that didn’t require daily travel to a clinic for administration? With such a deadly pervasive epidemic, I wonder also about our focus on treating addiction, when it seems we should have a parallel focus on understanding and addressing the factors that cause addiction. Medical prescribing is but one avenue to addiction, yet we have no understanding as to why some people become addicted when others do not. Shouldn’t we be able to prevent addiction? From Richard Nixon’s “war on drugs” to Donald Trump’s physical border wall, there are many answers, but few solutions.
There are other public health issues that suffer from the same generalizations. In psychiatry, advocacy groups tout involuntary outpatient treatment as a successful way of getting treatment to vulnerable individuals who will not willingly negotiate their own care. While a pilot study at Bellevue showed no benefit to mandated care, a follow-up study showed that mandated treatment was effective at reducing hospital days. While outpatient commitment studies look at rates of hospitalization, incarceration, and quality-of-life measures, mandated treatment is often cited as a means to prevent all forms of violence, including mass shootings, while there is no evidence to support these ideas. Still, 47 states and the District of Columbia now have outpatient commitment laws.
Does involuntary care benefit those with substance use disorders? In Massachusetts, Section 35 allows for civil commitment for drug treatment, and many of the treatment facilities are run by the Department of Corrections. It would be good to know if these measures worked. So far, it looks like opioid deaths in Massachusetts have stabilized, while the overdose death rate continues to rise in other states. Whether this is a result of Section 35 or other measures is unknown.
I’m not against innovation, and desperate situations call for creative responses. We need to be careful that our responses are measured and these experiments are contained while ascertaining what really does work and what does not cause unintended harms. Will a concrete wall stem the flow of illegal heroin? I imagine a new world of drones making drug drops.
Sometimes our innovative best guesses don’t work, and sometimes they do. Despite easy access to antidepressant medications, a national suicide hotline, increased numbers of mental health professionals, and anti-stigma/awareness campaigns, suicide rates continue to rise. Efforts to end smoking, however, have been quite successful, as have measures to get Americans to buckle their seat belts, and these measures have decreased mortality rates. The recommendation for healthy women to take hormone therapy is a good example: It was an innovative recommendation to help cardiac and orthopedic outcomes, yet studies that were run alongside these recommendations were quick to show an unintended increased risk of breast and uterine cancer.
I don’t know what happened to the young woman on my surgical rotation. If the decision were mine, I would have given her more pain medication, even now, but I don’t know if that would have been the right thing to do., and to look carefully at our outcomes in a variety of populations and circumstances.
Dr. Miller is the coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice in Baltimore.
Beware of the Ides of August
I suspect, like me, you have never put much stock in astrology. It just doesn’t feel like a good fit with our science-based training. But recent evidence suggests that maybe we should be paying more attention to the whether our patient is a Taurus or a Leo when we are hunting for a diagnosis.
Three researchers from Harvard’s Schools of Medicine and Public Health have followed several hundred thousand children born between 2007 and 2009 until 2016 (“Attention deficit–hyperactivity disorder and month of school enrollment,” N Engl J Med. 2018;379:2122-30). Their data revealed that, in states with a Sept. 1 school entry cutoff, children born in August had rates of diagnosis and treatment of ADHD that were 34% higher than those born in other months.
Their findings could mean that astrology deserves a lot more credibility than we have been giving it. More likely it suggests that those of us committed to the health and education of children deserve a booby prize for objectivity. In a New York Times Op-Ed piece, the study’s investigators point out that their data show that the relative immaturity of the youngest children in a class too often is interpreted as a symptom of ADHD (“The Link Between August Birthdays and ADHD,” 2018 Nov 28. Jena AB et al.).
For many of us who practiced pediatrics before the ADHD phenomenon erupted, this new study substantiates our suspicion that the condition is currently being both overdiagnosed and overtreated. The data leave unanswered the question of whom or what is to blame for starting the epidemic. However, the study does suggest that physicians and educators deserve some culpability by failing to maintain their objectivity when interpreting childhood behavior.
I clearly can recall the first time I spoke to a group of teachers about the articles I had been reading that suggested a beneficial effect of treating “hyperactive” children with stimulant medication. The teachers uniformly were incredulous and repulsed by the counterintuitive notion of medicating children whom they saw as difficult, but not out of the broad range of age and developmental maturity they could expect to see in their classrooms.
The next part of the narrative is where the story gets sad. Deceived by those success stories we – doctors, parents, and educators – began to narrow our view of normal behavior because we now had a medication to “correct” a certain constellation of problem behaviors. Pharmaceutical companies joined us with their best efforts to meet the demand we were creating.
Forgotten was the fact that children mature at different rates and that normal but less mature children can exhibit many of the behaviors we now place under the ADHD umbrella and be considered as candidates for medication. Until recently, other causes of hyperactivity such as sleep deprivation were ignored. Hopefully, this new study will rekindle an interest in how parents, pediatricians, and educators evaluate and manage those children who arrive in school several months behind their peers in emotional and behavioral development.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
I suspect, like me, you have never put much stock in astrology. It just doesn’t feel like a good fit with our science-based training. But recent evidence suggests that maybe we should be paying more attention to the whether our patient is a Taurus or a Leo when we are hunting for a diagnosis.
Three researchers from Harvard’s Schools of Medicine and Public Health have followed several hundred thousand children born between 2007 and 2009 until 2016 (“Attention deficit–hyperactivity disorder and month of school enrollment,” N Engl J Med. 2018;379:2122-30). Their data revealed that, in states with a Sept. 1 school entry cutoff, children born in August had rates of diagnosis and treatment of ADHD that were 34% higher than those born in other months.
Their findings could mean that astrology deserves a lot more credibility than we have been giving it. More likely it suggests that those of us committed to the health and education of children deserve a booby prize for objectivity. In a New York Times Op-Ed piece, the study’s investigators point out that their data show that the relative immaturity of the youngest children in a class too often is interpreted as a symptom of ADHD (“The Link Between August Birthdays and ADHD,” 2018 Nov 28. Jena AB et al.).
For many of us who practiced pediatrics before the ADHD phenomenon erupted, this new study substantiates our suspicion that the condition is currently being both overdiagnosed and overtreated. The data leave unanswered the question of whom or what is to blame for starting the epidemic. However, the study does suggest that physicians and educators deserve some culpability by failing to maintain their objectivity when interpreting childhood behavior.
I clearly can recall the first time I spoke to a group of teachers about the articles I had been reading that suggested a beneficial effect of treating “hyperactive” children with stimulant medication. The teachers uniformly were incredulous and repulsed by the counterintuitive notion of medicating children whom they saw as difficult, but not out of the broad range of age and developmental maturity they could expect to see in their classrooms.
The next part of the narrative is where the story gets sad. Deceived by those success stories we – doctors, parents, and educators – began to narrow our view of normal behavior because we now had a medication to “correct” a certain constellation of problem behaviors. Pharmaceutical companies joined us with their best efforts to meet the demand we were creating.
Forgotten was the fact that children mature at different rates and that normal but less mature children can exhibit many of the behaviors we now place under the ADHD umbrella and be considered as candidates for medication. Until recently, other causes of hyperactivity such as sleep deprivation were ignored. Hopefully, this new study will rekindle an interest in how parents, pediatricians, and educators evaluate and manage those children who arrive in school several months behind their peers in emotional and behavioral development.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
I suspect, like me, you have never put much stock in astrology. It just doesn’t feel like a good fit with our science-based training. But recent evidence suggests that maybe we should be paying more attention to the whether our patient is a Taurus or a Leo when we are hunting for a diagnosis.
Three researchers from Harvard’s Schools of Medicine and Public Health have followed several hundred thousand children born between 2007 and 2009 until 2016 (“Attention deficit–hyperactivity disorder and month of school enrollment,” N Engl J Med. 2018;379:2122-30). Their data revealed that, in states with a Sept. 1 school entry cutoff, children born in August had rates of diagnosis and treatment of ADHD that were 34% higher than those born in other months.
Their findings could mean that astrology deserves a lot more credibility than we have been giving it. More likely it suggests that those of us committed to the health and education of children deserve a booby prize for objectivity. In a New York Times Op-Ed piece, the study’s investigators point out that their data show that the relative immaturity of the youngest children in a class too often is interpreted as a symptom of ADHD (“The Link Between August Birthdays and ADHD,” 2018 Nov 28. Jena AB et al.).
For many of us who practiced pediatrics before the ADHD phenomenon erupted, this new study substantiates our suspicion that the condition is currently being both overdiagnosed and overtreated. The data leave unanswered the question of whom or what is to blame for starting the epidemic. However, the study does suggest that physicians and educators deserve some culpability by failing to maintain their objectivity when interpreting childhood behavior.
I clearly can recall the first time I spoke to a group of teachers about the articles I had been reading that suggested a beneficial effect of treating “hyperactive” children with stimulant medication. The teachers uniformly were incredulous and repulsed by the counterintuitive notion of medicating children whom they saw as difficult, but not out of the broad range of age and developmental maturity they could expect to see in their classrooms.
The next part of the narrative is where the story gets sad. Deceived by those success stories we – doctors, parents, and educators – began to narrow our view of normal behavior because we now had a medication to “correct” a certain constellation of problem behaviors. Pharmaceutical companies joined us with their best efforts to meet the demand we were creating.
Forgotten was the fact that children mature at different rates and that normal but less mature children can exhibit many of the behaviors we now place under the ADHD umbrella and be considered as candidates for medication. Until recently, other causes of hyperactivity such as sleep deprivation were ignored. Hopefully, this new study will rekindle an interest in how parents, pediatricians, and educators evaluate and manage those children who arrive in school several months behind their peers in emotional and behavioral development.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].