Commentary

I’d like to add several comments to Dr. John Hickner’s editorial, “We need to treat gun violence like an epidemic” (J Fam Pract. 2018;67:198).

First, when I hear gun rights advocates (GRAs) discuss the shooting deaths of innocent fellow Americans, I hear the same type of language that I hear from people with substance, tobacco, or alcohol use disorders. They blame everyone else rather than looking at themselves and what their love of weapons does to those around them. When confronted with ever-increasing numbers of gun-related deaths, they say, “Guns don’t kill people; people kill people.” But when used in the way they were intended to be used, guns—especially semi-automatic weapons—will maim or kill people.

And GRAs will not give up their gun rights—even if it means that their friends, neighbors, or relatives might die. GRAs ignore the unalienable rights described in the Declaration of Independence that guarantee “life, liberty, and the pursuit of happiness”—rights that are potentially annihilated when a person is the target of a loaded gun.

Because GRAs will not give up their weapons voluntarily, the only way to escape the continuously widening web of gun violence is to repeal the Second Amendment and allow local communities to vote either in favor or against gun control, setting whatever limits they deem appropriate on gun possession. Repealing the Second Amendment will not eliminate the killing of innocent Americans, but hopefully it will reduce the number of people who die from gun violence.

W.E. Feeman Jr., MD
Bowling Green, Ohio

I’d like to add several comments to Dr. John Hickner’s editorial, “We need to treat gun violence like an epidemic” (J Fam Pract. 2018;67:198).

First, when I hear gun rights advocates (GRAs) discuss the shooting deaths of innocent fellow Americans, I hear the same type of language that I hear from people with substance, tobacco, or alcohol use disorders. They blame everyone else rather than looking at themselves and what their love of weapons does to those around them. When confronted with ever-increasing numbers of gun-related deaths, they say, “Guns don’t kill people; people kill people.” But when used in the way they were intended to be used, guns—especially semi-automatic weapons—will maim or kill people.

And GRAs will not give up their gun rights—even if it means that their friends, neighbors, or relatives might die. GRAs ignore the unalienable rights described in the Declaration of Independence that guarantee “life, liberty, and the pursuit of happiness”—rights that are potentially annihilated when a person is the target of a loaded gun.

Because GRAs will not give up their weapons voluntarily, the only way to escape the continuously widening web of gun violence is to repeal the Second Amendment and allow local communities to vote either in favor or against gun control, setting whatever limits they deem appropriate on gun possession. Repealing the Second Amendment will not eliminate the killing of innocent Americans, but hopefully it will reduce the number of people who die from gun violence.

W.E. Feeman Jr., MD
Bowling Green, Ohio

I’d like to add several comments to Dr. John Hickner’s editorial, “We need to treat gun violence like an epidemic” (J Fam Pract. 2018;67:198).

First, when I hear gun rights advocates (GRAs) discuss the shooting deaths of innocent fellow Americans, I hear the same type of language that I hear from people with substance, tobacco, or alcohol use disorders. They blame everyone else rather than looking at themselves and what their love of weapons does to those around them. When confronted with ever-increasing numbers of gun-related deaths, they say, “Guns don’t kill people; people kill people.” But when used in the way they were intended to be used, guns—especially semi-automatic weapons—will maim or kill people.

And GRAs will not give up their gun rights—even if it means that their friends, neighbors, or relatives might die. GRAs ignore the unalienable rights described in the Declaration of Independence that guarantee “life, liberty, and the pursuit of happiness”—rights that are potentially annihilated when a person is the target of a loaded gun.

Because GRAs will not give up their weapons voluntarily, the only way to escape the continuously widening web of gun violence is to repeal the Second Amendment and allow local communities to vote either in favor or against gun control, setting whatever limits they deem appropriate on gun possession. Repealing the Second Amendment will not eliminate the killing of innocent Americans, but hopefully it will reduce the number of people who die from gun violence.

W.E. Feeman Jr., MD
Bowling Green, Ohio

In this issue of JFP, MacLaughlin and colleagues echo the recommendations of the 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines on high blood pressure (BP).¹

This guideline, however, is not endorsed by primary care organizations. Both the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) released their own evidence-based guideline in 2017.² (The European Society of Cardiology also declined to endorse the ACC/AHA guideline.³) So how do we make sense of the different recommendations? And how do we decide which guideline is most trustworthy?⁴

Evidence based vs evidence informed

Both guideline writing groups are highly respected and affiliated with influential organizations. Both claim their guidelines are based on scientific evidence and are crafted with the intention to improve health. The 2 guidelines, however, differ in their fidelity to the evidence-based process and in their willingness to generalize disease-centered interventions to non-diseased populations.

Evidence-based guidelines differ from evidence-informed guidelines.

Evidence-based guidelines differ from evidence-informed guidelines. Evidence-based guidelines have an established methodology that includes well-designed specific critical questions, a literature review with clearly defined inclusion and exclusion criteria, an evidence grading system, and a systematic approach to creating recommendations. Evidence-based guidelines are limited in scope and are often controversial because the evidence may not comport with the narrative promulgated by experts. Indeed, the controversy surrounding the 2014 Eighth Joint National Committee (JNC 8) guideline that I co-chaired focused on the one recommendation with the strongest evidence.^5,6

Comprehensive guidelines written by experts are by their very nature evidence-informed guidelines. The ACC/AHA guidelines are comprehensive, providing a panoply of recommendations. When such guidelines are written for primary care, the generalizability of specialized disease-centered knowledge is limited,⁷ and the risk of overdiagnosis and overtreatment rises,⁸ especially when the primary care community is not invited as equal partners in the guideline development process.

Trustworthy guidelines require management of conflicts of interests. A hidden contributor to guideline panel membership and content is organizational sponsorship. Advocacy organizations and specialty societies have governing boards that have fiduciary responsibilities to their organizations. Such responsibilities may supersede the responsibilities of guideline panel members and influence content. JNC 8’s appointed panel members chose to release the 2014 guideline independently, so as not to cede editorial authority to governing boards of associations with potential conflicts of interest.

As Paul Frame said, “An ounce of prevention is a ton of work.”⁹

Dr. Frame, a family medicine pioneer who applied evidence-based medicine to preventive practice, encouraged us to ask critical questions that must be supported by scientific evidence before implementing these practices in healthy populations.¹⁰ The ACC/AHA guidelines advocate recommendations based on untested assumptions: that improved health results from earlier “diagnosis” and disease labeling of individuals with risks (healthy patients), and that such patients should receive aggressive “prevention” with daily and lifelong medications requiring physician monitoring.¹¹ To support their new diagnostic standards, the authors cite similar relative risk (RR) reductions (an outcome-based measure), while discounting the smaller absolute risk (AR) reductions (a population-based measure) in studies supporting lower BP goals.

Continue to: Let's examine what this means

Let’s examine what this means

In 1967, a study of 143 hypertensive patients showed that treating high BP (average diastolic BP between 115 and 129 mm Hg) dramatically improved important health outcomes.¹² The number needed to treat (NNT) after about 1.5 years showed that for every 1.4 people treated, 1 benefited.⁸ This is strong and effective medicine.

We must all advocate for better guideline processes.

Successive randomized controlled trials of lower BP goals showed consistent RR reductions; however, AR reductions were much lower, reflecting a higher NNT.⁸ To prove BP-lowering benefits were not a random effect, higher numbers of participants were needed (SPRINT required over 9300 participants).¹³ The AR reduction in SPRINT was 1.6% (meaning no benefit was seen in 98.4% receiving the intensive intervention). One participant with high cardiovascular disease risk benefited for every 63 subjects given the intensive therapy compared with usual care (BP goal of 120 mm Hg vs 140 mm Hg).^13,14 The researchers noted serious harms in 1 of 22 subjects treated. Treating younger patients to lower BP goals labels healthy people with risk factors as “sick” and commits them to lifelong medications. It exposes them to more frequent harms than benefits. For healthy patients who are unlikely to benefit from taking more antihypertensive medication, these harms matter.

Interpreting the benefits of BP Tx when the benefit to individuals appears small

If only there were a biomarker that could tell us who is most likely to benefit from antihypertensive medication treatment, FPs could ensure that the correct patients are treated. The ACP/AAFP guideline points the way. There is a biomarker, and it is called BP. Systolic BP above 150 mm Hg signals urgency to treat with medications.

A call to advocate. We must all advocate for better guideline processes. The status quo in guideline development and its reliance on special interest funding requires ongoing vigilance to advocate on behalf of our patients. High-value medical care is expensive and hard work. When it is applied to the wrong people at the wrong time, we don’t deliver on our promises.

In this issue of JFP, MacLaughlin and colleagues echo the recommendations of the 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines on high blood pressure (BP).¹

This guideline, however, is not endorsed by primary care organizations. Both the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) released their own evidence-based guideline in 2017.² (The European Society of Cardiology also declined to endorse the ACC/AHA guideline.³) So how do we make sense of the different recommendations? And how do we decide which guideline is most trustworthy?⁴

Evidence based vs evidence informed

Both guideline writing groups are highly respected and affiliated with influential organizations. Both claim their guidelines are based on scientific evidence and are crafted with the intention to improve health. The 2 guidelines, however, differ in their fidelity to the evidence-based process and in their willingness to generalize disease-centered interventions to non-diseased populations.

Evidence-based guidelines differ from evidence-informed guidelines.

Evidence-based guidelines differ from evidence-informed guidelines. Evidence-based guidelines have an established methodology that includes well-designed specific critical questions, a literature review with clearly defined inclusion and exclusion criteria, an evidence grading system, and a systematic approach to creating recommendations. Evidence-based guidelines are limited in scope and are often controversial because the evidence may not comport with the narrative promulgated by experts. Indeed, the controversy surrounding the 2014 Eighth Joint National Committee (JNC 8) guideline that I co-chaired focused on the one recommendation with the strongest evidence.^5,6

Comprehensive guidelines written by experts are by their very nature evidence-informed guidelines. The ACC/AHA guidelines are comprehensive, providing a panoply of recommendations. When such guidelines are written for primary care, the generalizability of specialized disease-centered knowledge is limited,⁷ and the risk of overdiagnosis and overtreatment rises,⁸ especially when the primary care community is not invited as equal partners in the guideline development process.

Trustworthy guidelines require management of conflicts of interests. A hidden contributor to guideline panel membership and content is organizational sponsorship. Advocacy organizations and specialty societies have governing boards that have fiduciary responsibilities to their organizations. Such responsibilities may supersede the responsibilities of guideline panel members and influence content. JNC 8’s appointed panel members chose to release the 2014 guideline independently, so as not to cede editorial authority to governing boards of associations with potential conflicts of interest.

As Paul Frame said, “An ounce of prevention is a ton of work.”⁹

Dr. Frame, a family medicine pioneer who applied evidence-based medicine to preventive practice, encouraged us to ask critical questions that must be supported by scientific evidence before implementing these practices in healthy populations.¹⁰ The ACC/AHA guidelines advocate recommendations based on untested assumptions: that improved health results from earlier “diagnosis” and disease labeling of individuals with risks (healthy patients), and that such patients should receive aggressive “prevention” with daily and lifelong medications requiring physician monitoring.¹¹ To support their new diagnostic standards, the authors cite similar relative risk (RR) reductions (an outcome-based measure), while discounting the smaller absolute risk (AR) reductions (a population-based measure) in studies supporting lower BP goals.

Continue to: Let's examine what this means

Let’s examine what this means

In 1967, a study of 143 hypertensive patients showed that treating high BP (average diastolic BP between 115 and 129 mm Hg) dramatically improved important health outcomes.¹² The number needed to treat (NNT) after about 1.5 years showed that for every 1.4 people treated, 1 benefited.⁸ This is strong and effective medicine.

We must all advocate for better guideline processes.

Successive randomized controlled trials of lower BP goals showed consistent RR reductions; however, AR reductions were much lower, reflecting a higher NNT.⁸ To prove BP-lowering benefits were not a random effect, higher numbers of participants were needed (SPRINT required over 9300 participants).¹³ The AR reduction in SPRINT was 1.6% (meaning no benefit was seen in 98.4% receiving the intensive intervention). One participant with high cardiovascular disease risk benefited for every 63 subjects given the intensive therapy compared with usual care (BP goal of 120 mm Hg vs 140 mm Hg).^13,14 The researchers noted serious harms in 1 of 22 subjects treated. Treating younger patients to lower BP goals labels healthy people with risk factors as “sick” and commits them to lifelong medications. It exposes them to more frequent harms than benefits. For healthy patients who are unlikely to benefit from taking more antihypertensive medication, these harms matter.

Interpreting the benefits of BP Tx when the benefit to individuals appears small

If only there were a biomarker that could tell us who is most likely to benefit from antihypertensive medication treatment, FPs could ensure that the correct patients are treated. The ACP/AAFP guideline points the way. There is a biomarker, and it is called BP. Systolic BP above 150 mm Hg signals urgency to treat with medications.

A call to advocate. We must all advocate for better guideline processes. The status quo in guideline development and its reliance on special interest funding requires ongoing vigilance to advocate on behalf of our patients. High-value medical care is expensive and hard work. When it is applied to the wrong people at the wrong time, we don’t deliver on our promises.

In this issue of JFP, MacLaughlin and colleagues echo the recommendations of the 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines on high blood pressure (BP).¹

This guideline, however, is not endorsed by primary care organizations. Both the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) released their own evidence-based guideline in 2017.² (The European Society of Cardiology also declined to endorse the ACC/AHA guideline.³) So how do we make sense of the different recommendations? And how do we decide which guideline is most trustworthy?⁴

Evidence based vs evidence informed

Both guideline writing groups are highly respected and affiliated with influential organizations. Both claim their guidelines are based on scientific evidence and are crafted with the intention to improve health. The 2 guidelines, however, differ in their fidelity to the evidence-based process and in their willingness to generalize disease-centered interventions to non-diseased populations.

Evidence-based guidelines differ from evidence-informed guidelines.

Evidence-based guidelines differ from evidence-informed guidelines. Evidence-based guidelines have an established methodology that includes well-designed specific critical questions, a literature review with clearly defined inclusion and exclusion criteria, an evidence grading system, and a systematic approach to creating recommendations. Evidence-based guidelines are limited in scope and are often controversial because the evidence may not comport with the narrative promulgated by experts. Indeed, the controversy surrounding the 2014 Eighth Joint National Committee (JNC 8) guideline that I co-chaired focused on the one recommendation with the strongest evidence.^5,6

Comprehensive guidelines written by experts are by their very nature evidence-informed guidelines. The ACC/AHA guidelines are comprehensive, providing a panoply of recommendations. When such guidelines are written for primary care, the generalizability of specialized disease-centered knowledge is limited,⁷ and the risk of overdiagnosis and overtreatment rises,⁸ especially when the primary care community is not invited as equal partners in the guideline development process.

Trustworthy guidelines require management of conflicts of interests. A hidden contributor to guideline panel membership and content is organizational sponsorship. Advocacy organizations and specialty societies have governing boards that have fiduciary responsibilities to their organizations. Such responsibilities may supersede the responsibilities of guideline panel members and influence content. JNC 8’s appointed panel members chose to release the 2014 guideline independently, so as not to cede editorial authority to governing boards of associations with potential conflicts of interest.

As Paul Frame said, “An ounce of prevention is a ton of work.”⁹

Dr. Frame, a family medicine pioneer who applied evidence-based medicine to preventive practice, encouraged us to ask critical questions that must be supported by scientific evidence before implementing these practices in healthy populations.¹⁰ The ACC/AHA guidelines advocate recommendations based on untested assumptions: that improved health results from earlier “diagnosis” and disease labeling of individuals with risks (healthy patients), and that such patients should receive aggressive “prevention” with daily and lifelong medications requiring physician monitoring.¹¹ To support their new diagnostic standards, the authors cite similar relative risk (RR) reductions (an outcome-based measure), while discounting the smaller absolute risk (AR) reductions (a population-based measure) in studies supporting lower BP goals.

Continue to: Let's examine what this means

Let’s examine what this means

In 1967, a study of 143 hypertensive patients showed that treating high BP (average diastolic BP between 115 and 129 mm Hg) dramatically improved important health outcomes.¹² The number needed to treat (NNT) after about 1.5 years showed that for every 1.4 people treated, 1 benefited.⁸ This is strong and effective medicine.

We must all advocate for better guideline processes.

Successive randomized controlled trials of lower BP goals showed consistent RR reductions; however, AR reductions were much lower, reflecting a higher NNT.⁸ To prove BP-lowering benefits were not a random effect, higher numbers of participants were needed (SPRINT required over 9300 participants).¹³ The AR reduction in SPRINT was 1.6% (meaning no benefit was seen in 98.4% receiving the intensive intervention). One participant with high cardiovascular disease risk benefited for every 63 subjects given the intensive therapy compared with usual care (BP goal of 120 mm Hg vs 140 mm Hg).^13,14 The researchers noted serious harms in 1 of 22 subjects treated. Treating younger patients to lower BP goals labels healthy people with risk factors as “sick” and commits them to lifelong medications. It exposes them to more frequent harms than benefits. For healthy patients who are unlikely to benefit from taking more antihypertensive medication, these harms matter.

Interpreting the benefits of BP Tx when the benefit to individuals appears small

If only there were a biomarker that could tell us who is most likely to benefit from antihypertensive medication treatment, FPs could ensure that the correct patients are treated. The ACP/AAFP guideline points the way. There is a biomarker, and it is called BP. Systolic BP above 150 mm Hg signals urgency to treat with medications.

A call to advocate. We must all advocate for better guideline processes. The status quo in guideline development and its reliance on special interest funding requires ongoing vigilance to advocate on behalf of our patients. High-value medical care is expensive and hard work. When it is applied to the wrong people at the wrong time, we don’t deliver on our promises.

Research shows the ocean’s cod population is diminishing to dangerously low levels. In response, several countries (the United States, Iceland, and others) have instituted a resource allocation system termed “catch share,” where each fisherman is allotted an annual number of fish. Shares can be leased, bought, and traded. Consequently, there has been horizontal and vertical consolidation within the industry and huge fishing corporations have emerged while independent small-boat fishermen have virtually disappeared. Once consolidation occurred, venture capital entered the market. Parallels to what is happening to independent medical practices should not be ignored.

We have closed the book on DDW^® 2018. Researchers presented new and innovative studies that will directly affect our practices. I was honored to give the “Best of AGA – DDW” lecture where I chose only seven of hundreds of abstracts to present. All DDW lectures are located at https://watch.ondemand.org/ddw. GI & Hepatology News will highlight several high-impact presentations in this and subsequent issues.

John I. Allen, MD, MBA, AGAF

Editor in Chief

Research shows the ocean’s cod population is diminishing to dangerously low levels. In response, several countries (the United States, Iceland, and others) have instituted a resource allocation system termed “catch share,” where each fisherman is allotted an annual number of fish. Shares can be leased, bought, and traded. Consequently, there has been horizontal and vertical consolidation within the industry and huge fishing corporations have emerged while independent small-boat fishermen have virtually disappeared. Once consolidation occurred, venture capital entered the market. Parallels to what is happening to independent medical practices should not be ignored.

We have closed the book on DDW^® 2018. Researchers presented new and innovative studies that will directly affect our practices. I was honored to give the “Best of AGA – DDW” lecture where I chose only seven of hundreds of abstracts to present. All DDW lectures are located at https://watch.ondemand.org/ddw. GI & Hepatology News will highlight several high-impact presentations in this and subsequent issues.

John I. Allen, MD, MBA, AGAF

Editor in Chief

Research shows the ocean’s cod population is diminishing to dangerously low levels. In response, several countries (the United States, Iceland, and others) have instituted a resource allocation system termed “catch share,” where each fisherman is allotted an annual number of fish. Shares can be leased, bought, and traded. Consequently, there has been horizontal and vertical consolidation within the industry and huge fishing corporations have emerged while independent small-boat fishermen have virtually disappeared. Once consolidation occurred, venture capital entered the market. Parallels to what is happening to independent medical practices should not be ignored.

We have closed the book on DDW^® 2018. Researchers presented new and innovative studies that will directly affect our practices. I was honored to give the “Best of AGA – DDW” lecture where I chose only seven of hundreds of abstracts to present. All DDW lectures are located at https://watch.ondemand.org/ddw. GI & Hepatology News will highlight several high-impact presentations in this and subsequent issues.

John I. Allen, MD, MBA, AGAF

Editor in Chief

I am a nurse practitioner living in the South; I am also a concealed carry permit holder and an NRA pistol instructor who competes. I own an AR15; it is not an assault rifle—it’s just a rifle. 

I often see articles about the “ease” of purchasing a gun, but this is just not true. Even with the laxer gun control of the South, obtaining a concealed carry license entails going through both the FBI and local police, a review of mental health rec­ords, a long questionnaire, and an eight-hour class that involves shooting. So, yes, I can purchase a gun in 30 minutes—but only because I’ve already been through this process.

If I wanted to purchase a gun without a permit, I would have to go to the courthouse and be fingerprinted and run through the system before I could get a one-time purchase permit. I could not get a permit if I had a mental illness, had ever been arrested or accused of domestic violence, etc.

My heart breaks every time a mass shooting, like the one at Marjory Stoneman Douglas High School, happens. Guns have been around in our area for many, many years. High school kids used to mount a shotgun in a rack on the top of their truck to hunt before school; they didn’t think of using it to hurt a person. I believe the problems we face today are multifaceted: a lack of parenting, absent fathers, people not getting the mental health services they need, and HIPAA! Mental health professionals are afraid to call authorities for fear of being sued.

I truly believe we need to stop politicizing this issue. Let’s quit blaming the guns themselves and work on real solutions. For example, parents have an obligation to lock up all firearms! Kids should never have access to guns from their own home. In my house, when we have visitors—even if they are adults—we lock our guns in our safe. Security at our schools should mimic that at courthouses, with metal detectors, armed security personnel, and limited entrance/exit areas.

Deborah Johnson, FNP-C
Kinston, NC

I am a nurse practitioner living in the South; I am also a concealed carry permit holder and an NRA pistol instructor who competes. I own an AR15; it is not an assault rifle—it’s just a rifle. 

I often see articles about the “ease” of purchasing a gun, but this is just not true. Even with the laxer gun control of the South, obtaining a concealed carry license entails going through both the FBI and local police, a review of mental health rec­ords, a long questionnaire, and an eight-hour class that involves shooting. So, yes, I can purchase a gun in 30 minutes—but only because I’ve already been through this process.

If I wanted to purchase a gun without a permit, I would have to go to the courthouse and be fingerprinted and run through the system before I could get a one-time purchase permit. I could not get a permit if I had a mental illness, had ever been arrested or accused of domestic violence, etc.

My heart breaks every time a mass shooting, like the one at Marjory Stoneman Douglas High School, happens. Guns have been around in our area for many, many years. High school kids used to mount a shotgun in a rack on the top of their truck to hunt before school; they didn’t think of using it to hurt a person. I believe the problems we face today are multifaceted: a lack of parenting, absent fathers, people not getting the mental health services they need, and HIPAA! Mental health professionals are afraid to call authorities for fear of being sued.

I truly believe we need to stop politicizing this issue. Let’s quit blaming the guns themselves and work on real solutions. For example, parents have an obligation to lock up all firearms! Kids should never have access to guns from their own home. In my house, when we have visitors—even if they are adults—we lock our guns in our safe. Security at our schools should mimic that at courthouses, with metal detectors, armed security personnel, and limited entrance/exit areas.

Deborah Johnson, FNP-C
Kinston, NC

I am a nurse practitioner living in the South; I am also a concealed carry permit holder and an NRA pistol instructor who competes. I own an AR15; it is not an assault rifle—it’s just a rifle. 

I often see articles about the “ease” of purchasing a gun, but this is just not true. Even with the laxer gun control of the South, obtaining a concealed carry license entails going through both the FBI and local police, a review of mental health rec­ords, a long questionnaire, and an eight-hour class that involves shooting. So, yes, I can purchase a gun in 30 minutes—but only because I’ve already been through this process.

If I wanted to purchase a gun without a permit, I would have to go to the courthouse and be fingerprinted and run through the system before I could get a one-time purchase permit. I could not get a permit if I had a mental illness, had ever been arrested or accused of domestic violence, etc.

My heart breaks every time a mass shooting, like the one at Marjory Stoneman Douglas High School, happens. Guns have been around in our area for many, many years. High school kids used to mount a shotgun in a rack on the top of their truck to hunt before school; they didn’t think of using it to hurt a person. I believe the problems we face today are multifaceted: a lack of parenting, absent fathers, people not getting the mental health services they need, and HIPAA! Mental health professionals are afraid to call authorities for fear of being sued.

I truly believe we need to stop politicizing this issue. Let’s quit blaming the guns themselves and work on real solutions. For example, parents have an obligation to lock up all firearms! Kids should never have access to guns from their own home. In my house, when we have visitors—even if they are adults—we lock our guns in our safe. Security at our schools should mimic that at courthouses, with metal detectors, armed security personnel, and limited entrance/exit areas.

Deborah Johnson, FNP-C
Kinston, NC

Life is full of traumas, large and small. You know this for yourself as well as for the families and children under your care. The American Academy of Pediatrics provides screening tools for trauma, also called adverse childhood experiences (ACEs). But with 68% of children exposed to a traumatic event before the age of 16 years (Arch Gen Psychiatry. 2007 May; 64[5]:577-84), what is it we should do if we find it?

Smaller traumas, such as a power outage, may frighten but be growth promoting for most children – so called “eustress” – as they see adults bring out flashlights and serve tuna from a can and learn that one can cope with scary, unfamiliar situations. Even with smaller threats some children may have intense fear, especially those already anxiety prone or with developmental differences such as autism or sensory processing disorders.

I suggest that our role when we uncover trauma is to determine if there is current danger (and take action), or if the past trauma is affecting the child’s or parent’s functioning or producing distress. Most people recover from trauma with support from family or community but without formal help.

But we can’t assume a child will recover without help as individual, family, cultural, and historical factors affect a person’s response. Someone with an anxiety disorder, or a victim of war or assault may react disproportionately to even small events. A parent with such sensitizing factors may model poor coping, increase the child’s fear, and fail to provide the support that could buffer development of sequelae. We need to check.

Larger traumas that a child is exposed to or learns about, which threatened or resulted in death or injury – such as a destructive tornado – or sexual violence can produce lasting effects, and 25%-69% develop posttraumatic stress disorder (PTSD). For preschoolers, car crashes, dog bites, and medical procedures can also be causative. To be diagnosed with PTSD, a combination and number of symptoms must appear as a result of the trauma, including: re-experiencing the event (1); avoidance of things that remind one of the event (1); arousal or reactivity (2); and negative change in thoughts or feelings (2).

“PTSD in preschool children” (DMS-5) requires 0 re-experiencing, and only 1 avoidance or negative thoughts/feelings symptom as it is harder to discern at this age. The jumpiness of reactivity can disrupt activities and often sleep. The cognitive changes can include forgetting details about the event, decline in ability to pay attention or do school work, or distorted or negative thoughts such as feeling blame. Besides anxiety or depression, mood changes can include dulled emotions or social withdrawal. These symptoms are important for us to recognize.

To be diagnosed, PTSD symptoms must impair functioning and last more than 1 month. So why are families not telling us? While symptoms usually appear within 3 months, it may be months or even years, especially for early traumas such as sexual abuse as the child cannot put the experience into context until later when sexuality becomes relevant. This delay in onset is one reason parents may not report a trauma when complaining about a behavior change. When the trauma also affected them, common in both natural disasters and psychosocial events such as partner violence, the parent may have the related forgetting or depression focusing them on their own pain rather than their child’s pain. These are important reasons to ask about possible traumas of child and parent, giving examples, when a child presents with a behavior, emotional, learning, or somatic complaint.

Pixland/Thinkstock

Traumatized children, as adolescents, are at risk for coping with this pain by cutting, or abusing substances or alcohol (other signs suggesting trauma). These harmful strategies contribute to the adult morbidity now recognized from Adverse Childhood Experiences. Fortunately, we can refer to effective parent-child therapies, such as Circle of Security and play therapy for children less than 3 years old, trauma-focused cognitive behavioral therapy for those over 3 years, and even video training such as trust-based relational intervention, as well as monitor well-being.
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at [email protected].

Life is full of traumas, large and small. You know this for yourself as well as for the families and children under your care. The American Academy of Pediatrics provides screening tools for trauma, also called adverse childhood experiences (ACEs). But with 68% of children exposed to a traumatic event before the age of 16 years (Arch Gen Psychiatry. 2007 May; 64[5]:577-84), what is it we should do if we find it?

Smaller traumas, such as a power outage, may frighten but be growth promoting for most children – so called “eustress” – as they see adults bring out flashlights and serve tuna from a can and learn that one can cope with scary, unfamiliar situations. Even with smaller threats some children may have intense fear, especially those already anxiety prone or with developmental differences such as autism or sensory processing disorders.

I suggest that our role when we uncover trauma is to determine if there is current danger (and take action), or if the past trauma is affecting the child’s or parent’s functioning or producing distress. Most people recover from trauma with support from family or community but without formal help.

But we can’t assume a child will recover without help as individual, family, cultural, and historical factors affect a person’s response. Someone with an anxiety disorder, or a victim of war or assault may react disproportionately to even small events. A parent with such sensitizing factors may model poor coping, increase the child’s fear, and fail to provide the support that could buffer development of sequelae. We need to check.

Larger traumas that a child is exposed to or learns about, which threatened or resulted in death or injury – such as a destructive tornado – or sexual violence can produce lasting effects, and 25%-69% develop posttraumatic stress disorder (PTSD). For preschoolers, car crashes, dog bites, and medical procedures can also be causative. To be diagnosed with PTSD, a combination and number of symptoms must appear as a result of the trauma, including: re-experiencing the event (1); avoidance of things that remind one of the event (1); arousal or reactivity (2); and negative change in thoughts or feelings (2).

“PTSD in preschool children” (DMS-5) requires 0 re-experiencing, and only 1 avoidance or negative thoughts/feelings symptom as it is harder to discern at this age. The jumpiness of reactivity can disrupt activities and often sleep. The cognitive changes can include forgetting details about the event, decline in ability to pay attention or do school work, or distorted or negative thoughts such as feeling blame. Besides anxiety or depression, mood changes can include dulled emotions or social withdrawal. These symptoms are important for us to recognize.

To be diagnosed, PTSD symptoms must impair functioning and last more than 1 month. So why are families not telling us? While symptoms usually appear within 3 months, it may be months or even years, especially for early traumas such as sexual abuse as the child cannot put the experience into context until later when sexuality becomes relevant. This delay in onset is one reason parents may not report a trauma when complaining about a behavior change. When the trauma also affected them, common in both natural disasters and psychosocial events such as partner violence, the parent may have the related forgetting or depression focusing them on their own pain rather than their child’s pain. These are important reasons to ask about possible traumas of child and parent, giving examples, when a child presents with a behavior, emotional, learning, or somatic complaint.

Pixland/Thinkstock

Traumatized children, as adolescents, are at risk for coping with this pain by cutting, or abusing substances or alcohol (other signs suggesting trauma). These harmful strategies contribute to the adult morbidity now recognized from Adverse Childhood Experiences. Fortunately, we can refer to effective parent-child therapies, such as Circle of Security and play therapy for children less than 3 years old, trauma-focused cognitive behavioral therapy for those over 3 years, and even video training such as trust-based relational intervention, as well as monitor well-being.
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at [email protected].

Life is full of traumas, large and small. You know this for yourself as well as for the families and children under your care. The American Academy of Pediatrics provides screening tools for trauma, also called adverse childhood experiences (ACEs). But with 68% of children exposed to a traumatic event before the age of 16 years (Arch Gen Psychiatry. 2007 May; 64[5]:577-84), what is it we should do if we find it?

Smaller traumas, such as a power outage, may frighten but be growth promoting for most children – so called “eustress” – as they see adults bring out flashlights and serve tuna from a can and learn that one can cope with scary, unfamiliar situations. Even with smaller threats some children may have intense fear, especially those already anxiety prone or with developmental differences such as autism or sensory processing disorders.

I suggest that our role when we uncover trauma is to determine if there is current danger (and take action), or if the past trauma is affecting the child’s or parent’s functioning or producing distress. Most people recover from trauma with support from family or community but without formal help.

But we can’t assume a child will recover without help as individual, family, cultural, and historical factors affect a person’s response. Someone with an anxiety disorder, or a victim of war or assault may react disproportionately to even small events. A parent with such sensitizing factors may model poor coping, increase the child’s fear, and fail to provide the support that could buffer development of sequelae. We need to check.

Larger traumas that a child is exposed to or learns about, which threatened or resulted in death or injury – such as a destructive tornado – or sexual violence can produce lasting effects, and 25%-69% develop posttraumatic stress disorder (PTSD). For preschoolers, car crashes, dog bites, and medical procedures can also be causative. To be diagnosed with PTSD, a combination and number of symptoms must appear as a result of the trauma, including: re-experiencing the event (1); avoidance of things that remind one of the event (1); arousal or reactivity (2); and negative change in thoughts or feelings (2).

“PTSD in preschool children” (DMS-5) requires 0 re-experiencing, and only 1 avoidance or negative thoughts/feelings symptom as it is harder to discern at this age. The jumpiness of reactivity can disrupt activities and often sleep. The cognitive changes can include forgetting details about the event, decline in ability to pay attention or do school work, or distorted or negative thoughts such as feeling blame. Besides anxiety or depression, mood changes can include dulled emotions or social withdrawal. These symptoms are important for us to recognize.

To be diagnosed, PTSD symptoms must impair functioning and last more than 1 month. So why are families not telling us? While symptoms usually appear within 3 months, it may be months or even years, especially for early traumas such as sexual abuse as the child cannot put the experience into context until later when sexuality becomes relevant. This delay in onset is one reason parents may not report a trauma when complaining about a behavior change. When the trauma also affected them, common in both natural disasters and psychosocial events such as partner violence, the parent may have the related forgetting or depression focusing them on their own pain rather than their child’s pain. These are important reasons to ask about possible traumas of child and parent, giving examples, when a child presents with a behavior, emotional, learning, or somatic complaint.

Pixland/Thinkstock

Traumatized children, as adolescents, are at risk for coping with this pain by cutting, or abusing substances or alcohol (other signs suggesting trauma). These harmful strategies contribute to the adult morbidity now recognized from Adverse Childhood Experiences. Fortunately, we can refer to effective parent-child therapies, such as Circle of Security and play therapy for children less than 3 years old, trauma-focused cognitive behavioral therapy for those over 3 years, and even video training such as trust-based relational intervention, as well as monitor well-being.
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at [email protected].

Now that the summer is in full swing, it is incumbent upon the psychiatric and mental health community to learn about the specific effects on behavior, psychiatric risks, and outcomes – and to plan for ways to protect our patients and communities.

Extreme heat has significant effects on mental health and behavior. Research shows¹ that the number of people exposed to extreme heat is expected to rise in many American cities, particularly across the southern United States. Records were set in May 2018 across the United States and around the world. In the United States, those May temperatures were the warmest ever recorded, representing the hottest spring ever.² Around the world, the warmer-than-average conditions that engulfed much of the land and sea surfaces made May the fourth-warmest since records started being kept in 1880.²

In short, these trends are not remitting. Extreme heat and climate disruption are the new normal.

Extreme heat makes many people cranky, agitated, or listless. However, heat waves are not benign, uncomfortable periods; they have profound health risks tied to increasing rates of anxiety, depression, posttraumatic stress disorder, and even death. In fact, extreme heat is now considered to be the single largest weather-related cause of death, exceeding hurricanes, lightning, tornadoes, floods, and earthquakes combined. The Centers for Disease Control and Prevention reports 7,800 deaths attributable to extreme heat between 1999 and 2009 – and predicts more frequent and extreme heat.³

rdegrie/iStockphoto.com

In addition, extreme heat has been linked to increases in aggression and violence. One standard deviation of temperature increase and rainfall is associated with a 4% increase in interpersonal violence and 14% increase in intergroup violence.⁴ Anecdotal stories underscore the well known lore among prison staff of increased inmate violence during heat waves.⁵

Complex cognitive tasks such as working memory (spatial span test, pattern recognition) have been observed to be significantly impaired through heat stress.⁶ Increased heat also contributes to insomnia and worsens with increased humidity.⁷ A study in England and Wales showed a link between a possible association between hot weather and an increased risk of suicide.⁸ People with mental illness and those who abuse substances are considered an especially vulnerable population to the impacts of extreme heat and other climate change–related events. Co-occurring variables such as poverty, substandard housing, and lack of access to cool environments all contribute to this increased vulnerability. Homeless mentally ill have little control over their environments and have very limited ability to protect themselves from heat exposures and therefore are at extreme risk.⁹ The most protective tool against heat stress/stroke is the availability of functioning air conditioners. Regretfully, these kinds of cooling systems are out of reach for many people who live on the margins of society.

Furthermore, patients with severe psychotic or mood disorders, substance abuse disorders, and cognitive impairments who are able to compensate with marginal executive functioning during periods of normal weather are challenged during intense heat, and can lose their fragile ability to make plans, have good judgment, and care effectively for themselves. These patients are more likely to experience heat stroke and other heat-related morbidity.

Here is evidence that supports the greater impact of extreme heat on psychiatric patients:

• Increased emergency department and hospitalization for patients with preexisting psychiatric illness during heat waves.^10,11
• Preexisting mental illness alone increases the risk of mortality during extreme heat events by 2 to 3 times.^12,13
• Patients with schizophrenia might have underlying impairments in thermoregulation that are intrinsic to the disease. Such impairments would explain the perplexing sight of psychotic patients bundled up in layers on hot days.¹⁴
• Psychiatric medications (antipsychotics, anticholinergics, and antidepressants) have the potential to impair the body’s heat regulatory functioning; lithium affects fluid homeostasis.¹⁵

The negative effects of climate change are not equally distributed, and people with mental illness are among the most vulnerable. Given the predictable future of extreme heat waves (potentially increasing the population exposure by four- to sixfold by midcentury),¹ we must do everything we can to educate our patients so that they take preventive measures to protect themselves from the adverse effects of extreme heat.
 

References

1. Nature Climate Change. 2015 May 18;5:652-5.

2. National Oceanic and Atmospheric Administration Global Climate Report. May 2018.

3. “Climate Change and Extreme Heat Events.” Centers for Disease Control and Prevention.

4. Science. 2013 Sep 13;341(6151).

5. Personal communication.

6. Int J Hyperthermia. 2003 May-Jun;19(3):355-72.

7. J Physiol Anthropol. 2012 May 31;31(14).

8. Br J Psychiatry. 2007 Aug;191:106-12.

9. U.S. Global Change Research Program, 2016. “The Impacts of Climate Change on Human Health in the United States: A Scientific Assessment.” Chapters 8 and 9.

10. J Affect Disord. 2014 Feb;155:154-61.

11. Environ Health Perspect. 2008 Oct;116(10):1369-75.

12. Psychiatr Serv. 1998 Aug;49(8):1088-90.

13. Arch Intern Med. 2007 Nov. 12;167(20):2170-6.

14. Schizophr Res. 2004 Aug 1;69(2-3):149-57.

15. Eur Psychiatry. 2007 Sep;22(6):335-8.

Strategies for patients, communities

Part of the job of mental health professionals is psychoeducation, or teaching patients and families about the health risks tied to the psychological and physical impacts of heat exposure. Also, we should provide advice about effective management of psychiatric medications – such as monitoring lithium levels and considering medication dose adjustments – to reduce risks. Another key step is engaging caregivers, case managers, visiting nurses, and family members so that they closely monitor vulnerable populations. Providing information about the availability of respite care and cooling centers is another concrete step clinicians can take to help minimize the impact of extreme heat on patients.

Information that can be shared with patients about the threat include:

• A brochure from the Climate Psychiatry Alliance that offers specific ways to keep cool in extreme heat.
• A guidebook produced by the Environmental Protection Agency and the Centers for Disease Control and Prevention that explains what people can do to prepare for extreme heat.
• More extensive interventions can be found at https://www.climatepsychiatry.org/what-to-do/.

Dr. Cooper is in private practice and is affiliated with the department of psychiatry at the University of California, San Francisco. She is a Distinguished Life Fellow of the American Psychiatric Association.

Now that the summer is in full swing, it is incumbent upon the psychiatric and mental health community to learn about the specific effects on behavior, psychiatric risks, and outcomes – and to plan for ways to protect our patients and communities.

Extreme heat has significant effects on mental health and behavior. Research shows¹ that the number of people exposed to extreme heat is expected to rise in many American cities, particularly across the southern United States. Records were set in May 2018 across the United States and around the world. In the United States, those May temperatures were the warmest ever recorded, representing the hottest spring ever.² Around the world, the warmer-than-average conditions that engulfed much of the land and sea surfaces made May the fourth-warmest since records started being kept in 1880.²

In short, these trends are not remitting. Extreme heat and climate disruption are the new normal.

Extreme heat makes many people cranky, agitated, or listless. However, heat waves are not benign, uncomfortable periods; they have profound health risks tied to increasing rates of anxiety, depression, posttraumatic stress disorder, and even death. In fact, extreme heat is now considered to be the single largest weather-related cause of death, exceeding hurricanes, lightning, tornadoes, floods, and earthquakes combined. The Centers for Disease Control and Prevention reports 7,800 deaths attributable to extreme heat between 1999 and 2009 – and predicts more frequent and extreme heat.³

rdegrie/iStockphoto.com

In addition, extreme heat has been linked to increases in aggression and violence. One standard deviation of temperature increase and rainfall is associated with a 4% increase in interpersonal violence and 14% increase in intergroup violence.⁴ Anecdotal stories underscore the well known lore among prison staff of increased inmate violence during heat waves.⁵

Complex cognitive tasks such as working memory (spatial span test, pattern recognition) have been observed to be significantly impaired through heat stress.⁶ Increased heat also contributes to insomnia and worsens with increased humidity.⁷ A study in England and Wales showed a link between a possible association between hot weather and an increased risk of suicide.⁸ People with mental illness and those who abuse substances are considered an especially vulnerable population to the impacts of extreme heat and other climate change–related events. Co-occurring variables such as poverty, substandard housing, and lack of access to cool environments all contribute to this increased vulnerability. Homeless mentally ill have little control over their environments and have very limited ability to protect themselves from heat exposures and therefore are at extreme risk.⁹ The most protective tool against heat stress/stroke is the availability of functioning air conditioners. Regretfully, these kinds of cooling systems are out of reach for many people who live on the margins of society.

Furthermore, patients with severe psychotic or mood disorders, substance abuse disorders, and cognitive impairments who are able to compensate with marginal executive functioning during periods of normal weather are challenged during intense heat, and can lose their fragile ability to make plans, have good judgment, and care effectively for themselves. These patients are more likely to experience heat stroke and other heat-related morbidity.

Here is evidence that supports the greater impact of extreme heat on psychiatric patients:

• Increased emergency department and hospitalization for patients with preexisting psychiatric illness during heat waves.^10,11
• Preexisting mental illness alone increases the risk of mortality during extreme heat events by 2 to 3 times.^12,13
• Patients with schizophrenia might have underlying impairments in thermoregulation that are intrinsic to the disease. Such impairments would explain the perplexing sight of psychotic patients bundled up in layers on hot days.¹⁴
• Psychiatric medications (antipsychotics, anticholinergics, and antidepressants) have the potential to impair the body’s heat regulatory functioning; lithium affects fluid homeostasis.¹⁵

The negative effects of climate change are not equally distributed, and people with mental illness are among the most vulnerable. Given the predictable future of extreme heat waves (potentially increasing the population exposure by four- to sixfold by midcentury),¹ we must do everything we can to educate our patients so that they take preventive measures to protect themselves from the adverse effects of extreme heat.
 

References

1. Nature Climate Change. 2015 May 18;5:652-5.

2. National Oceanic and Atmospheric Administration Global Climate Report. May 2018.

3. “Climate Change and Extreme Heat Events.” Centers for Disease Control and Prevention.

4. Science. 2013 Sep 13;341(6151).

5. Personal communication.

6. Int J Hyperthermia. 2003 May-Jun;19(3):355-72.

7. J Physiol Anthropol. 2012 May 31;31(14).

8. Br J Psychiatry. 2007 Aug;191:106-12.

9. U.S. Global Change Research Program, 2016. “The Impacts of Climate Change on Human Health in the United States: A Scientific Assessment.” Chapters 8 and 9.

10. J Affect Disord. 2014 Feb;155:154-61.

11. Environ Health Perspect. 2008 Oct;116(10):1369-75.

12. Psychiatr Serv. 1998 Aug;49(8):1088-90.

13. Arch Intern Med. 2007 Nov. 12;167(20):2170-6.

14. Schizophr Res. 2004 Aug 1;69(2-3):149-57.

15. Eur Psychiatry. 2007 Sep;22(6):335-8.

Strategies for patients, communities

Part of the job of mental health professionals is psychoeducation, or teaching patients and families about the health risks tied to the psychological and physical impacts of heat exposure. Also, we should provide advice about effective management of psychiatric medications – such as monitoring lithium levels and considering medication dose adjustments – to reduce risks. Another key step is engaging caregivers, case managers, visiting nurses, and family members so that they closely monitor vulnerable populations. Providing information about the availability of respite care and cooling centers is another concrete step clinicians can take to help minimize the impact of extreme heat on patients.

Information that can be shared with patients about the threat include:

• A brochure from the Climate Psychiatry Alliance that offers specific ways to keep cool in extreme heat.
• A guidebook produced by the Environmental Protection Agency and the Centers for Disease Control and Prevention that explains what people can do to prepare for extreme heat.
• More extensive interventions can be found at https://www.climatepsychiatry.org/what-to-do/.

Dr. Cooper is in private practice and is affiliated with the department of psychiatry at the University of California, San Francisco. She is a Distinguished Life Fellow of the American Psychiatric Association.

Now that the summer is in full swing, it is incumbent upon the psychiatric and mental health community to learn about the specific effects on behavior, psychiatric risks, and outcomes – and to plan for ways to protect our patients and communities.

Extreme heat has significant effects on mental health and behavior. Research shows¹ that the number of people exposed to extreme heat is expected to rise in many American cities, particularly across the southern United States. Records were set in May 2018 across the United States and around the world. In the United States, those May temperatures were the warmest ever recorded, representing the hottest spring ever.² Around the world, the warmer-than-average conditions that engulfed much of the land and sea surfaces made May the fourth-warmest since records started being kept in 1880.²

In short, these trends are not remitting. Extreme heat and climate disruption are the new normal.

Extreme heat makes many people cranky, agitated, or listless. However, heat waves are not benign, uncomfortable periods; they have profound health risks tied to increasing rates of anxiety, depression, posttraumatic stress disorder, and even death. In fact, extreme heat is now considered to be the single largest weather-related cause of death, exceeding hurricanes, lightning, tornadoes, floods, and earthquakes combined. The Centers for Disease Control and Prevention reports 7,800 deaths attributable to extreme heat between 1999 and 2009 – and predicts more frequent and extreme heat.³

rdegrie/iStockphoto.com

In addition, extreme heat has been linked to increases in aggression and violence. One standard deviation of temperature increase and rainfall is associated with a 4% increase in interpersonal violence and 14% increase in intergroup violence.⁴ Anecdotal stories underscore the well known lore among prison staff of increased inmate violence during heat waves.⁵

Complex cognitive tasks such as working memory (spatial span test, pattern recognition) have been observed to be significantly impaired through heat stress.⁶ Increased heat also contributes to insomnia and worsens with increased humidity.⁷ A study in England and Wales showed a link between a possible association between hot weather and an increased risk of suicide.⁸ People with mental illness and those who abuse substances are considered an especially vulnerable population to the impacts of extreme heat and other climate change–related events. Co-occurring variables such as poverty, substandard housing, and lack of access to cool environments all contribute to this increased vulnerability. Homeless mentally ill have little control over their environments and have very limited ability to protect themselves from heat exposures and therefore are at extreme risk.⁹ The most protective tool against heat stress/stroke is the availability of functioning air conditioners. Regretfully, these kinds of cooling systems are out of reach for many people who live on the margins of society.

Furthermore, patients with severe psychotic or mood disorders, substance abuse disorders, and cognitive impairments who are able to compensate with marginal executive functioning during periods of normal weather are challenged during intense heat, and can lose their fragile ability to make plans, have good judgment, and care effectively for themselves. These patients are more likely to experience heat stroke and other heat-related morbidity.

Here is evidence that supports the greater impact of extreme heat on psychiatric patients:

• Increased emergency department and hospitalization for patients with preexisting psychiatric illness during heat waves.^10,11
• Preexisting mental illness alone increases the risk of mortality during extreme heat events by 2 to 3 times.^12,13
• Patients with schizophrenia might have underlying impairments in thermoregulation that are intrinsic to the disease. Such impairments would explain the perplexing sight of psychotic patients bundled up in layers on hot days.¹⁴
• Psychiatric medications (antipsychotics, anticholinergics, and antidepressants) have the potential to impair the body’s heat regulatory functioning; lithium affects fluid homeostasis.¹⁵

The negative effects of climate change are not equally distributed, and people with mental illness are among the most vulnerable. Given the predictable future of extreme heat waves (potentially increasing the population exposure by four- to sixfold by midcentury),¹ we must do everything we can to educate our patients so that they take preventive measures to protect themselves from the adverse effects of extreme heat.
 

References

1. Nature Climate Change. 2015 May 18;5:652-5.

2. National Oceanic and Atmospheric Administration Global Climate Report. May 2018.

3. “Climate Change and Extreme Heat Events.” Centers for Disease Control and Prevention.

4. Science. 2013 Sep 13;341(6151).

5. Personal communication.

6. Int J Hyperthermia. 2003 May-Jun;19(3):355-72.

7. J Physiol Anthropol. 2012 May 31;31(14).

8. Br J Psychiatry. 2007 Aug;191:106-12.

9. U.S. Global Change Research Program, 2016. “The Impacts of Climate Change on Human Health in the United States: A Scientific Assessment.” Chapters 8 and 9.

10. J Affect Disord. 2014 Feb;155:154-61.

11. Environ Health Perspect. 2008 Oct;116(10):1369-75.

12. Psychiatr Serv. 1998 Aug;49(8):1088-90.

13. Arch Intern Med. 2007 Nov. 12;167(20):2170-6.

14. Schizophr Res. 2004 Aug 1;69(2-3):149-57.

15. Eur Psychiatry. 2007 Sep;22(6):335-8.

Strategies for patients, communities

Part of the job of mental health professionals is psychoeducation, or teaching patients and families about the health risks tied to the psychological and physical impacts of heat exposure. Also, we should provide advice about effective management of psychiatric medications – such as monitoring lithium levels and considering medication dose adjustments – to reduce risks. Another key step is engaging caregivers, case managers, visiting nurses, and family members so that they closely monitor vulnerable populations. Providing information about the availability of respite care and cooling centers is another concrete step clinicians can take to help minimize the impact of extreme heat on patients.

Information that can be shared with patients about the threat include:

• A brochure from the Climate Psychiatry Alliance that offers specific ways to keep cool in extreme heat.
• A guidebook produced by the Environmental Protection Agency and the Centers for Disease Control and Prevention that explains what people can do to prepare for extreme heat.
• More extensive interventions can be found at https://www.climatepsychiatry.org/what-to-do/.

Dr. Cooper is in private practice and is affiliated with the department of psychiatry at the University of California, San Francisco. She is a Distinguished Life Fellow of the American Psychiatric Association.

Physicists have strict rules about significant figures. Medical journals lack this professional discipline and it produces distortions that mislead readers.

Whenever you measure and report something in physics, the precision of the measurement is reflected in how the value is written. Writing a result with more digits implies that a higher precision was achieved. If that wasn’t the case, you are falsely claiming skill and accomplishment. You’ve entered the zone of post-truth.

This point was taught by my high school physics teacher, Mr. Gunnar Overgaard, may he rest in peace. Suppose we measured the length of the lab table with the meter stick. We repeated the action three times. We computed an average. Our table was 243.7 cm long. If we wrote 243.73 or 243.73333 we got a lower grade. Meter sticks only have markings of 0.1 cm. So the precision of the reported measurement should properly reflect that limitation.

Researchers in medicine seem to have skipped that lesson in physics lab. In medical journals, the default seems to be to report measurements with two decimal points, such as 16.67%, which is a gross distortion of the precision when I know that that really means 2 out of 12 patients had the finding.

This issue of precision came up recently in two papers published about the number of deaths caused by Hurricane Maria in Puerto Rico. The official death toll was 64. This number became a political hot potato when President Trump cited it as if it was evidence that he and the current local government had managed the emergency response better than George W. Bush did for Katrina.

On May 29, 2018, some researchers at the Harvard School of Public Health, a prestigious institution, published an article in The New England Journal of Medicine, a prestigious journal. You would presume that pair could report properly. The abstract said “This rate yielded a total of 4,645 excess deaths during this period (95% CI, 793 to 8,498).”¹ Many newspapers published the number 4,645 in a headline. Most newspapers didn’t include all of the scientific mumbo jumbo about bias and confidence intervals.

Georgijevic/E+/Getty Images

So in the spirit of thinking globally but acting locally, what can I do? I love my editor. I have hinted before about how much easier it is to read, as well as more accurate scientifically, to round the numbers that we report. We've done it a few times recently, but now that the Washington Post has done it on a major news story, should this practice become the norm for journalism? If medical journal editors won't handle precision honestly, other journalists must step up. I'm distressed when I review an article that says 14.6% agreed and 79.2% strongly agreed and I know those percentages with 3 digits really mean 7/48 and 38/48, so they should be rounded to two significant figures. And isn’t it easier to read and comprehend if reporting that three treatment groups had positive findings of 4.25%, 12.08%, and 9.84% when rounded to 4%, 12%, and 10%?

Scientists using this false precision (and peer reviewers who allow it) need to be corrected. They are trying to sell their research as a Louis Vuitton handbag when we all know it is only a cheap knockoff.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected]

References

1. N Eng J Med. 2018 May 29. doi: 10.1056/NEJMsa1803972

2. “Harvard study estimates thousands died in Puerto Rico because of Hurricane Maria,” by Arelis R. Hernández and Laurie McGinley, The Washington Post, May 29, 2018.

3. “Did exactly 4,645 people die in Hurricane Maria? Nope.” by Glenn Kessler, The Washington Post, June 1, 2018.

Physicists have strict rules about significant figures. Medical journals lack this professional discipline and it produces distortions that mislead readers.

Whenever you measure and report something in physics, the precision of the measurement is reflected in how the value is written. Writing a result with more digits implies that a higher precision was achieved. If that wasn’t the case, you are falsely claiming skill and accomplishment. You’ve entered the zone of post-truth.

This point was taught by my high school physics teacher, Mr. Gunnar Overgaard, may he rest in peace. Suppose we measured the length of the lab table with the meter stick. We repeated the action three times. We computed an average. Our table was 243.7 cm long. If we wrote 243.73 or 243.73333 we got a lower grade. Meter sticks only have markings of 0.1 cm. So the precision of the reported measurement should properly reflect that limitation.

Researchers in medicine seem to have skipped that lesson in physics lab. In medical journals, the default seems to be to report measurements with two decimal points, such as 16.67%, which is a gross distortion of the precision when I know that that really means 2 out of 12 patients had the finding.

This issue of precision came up recently in two papers published about the number of deaths caused by Hurricane Maria in Puerto Rico. The official death toll was 64. This number became a political hot potato when President Trump cited it as if it was evidence that he and the current local government had managed the emergency response better than George W. Bush did for Katrina.

On May 29, 2018, some researchers at the Harvard School of Public Health, a prestigious institution, published an article in The New England Journal of Medicine, a prestigious journal. You would presume that pair could report properly. The abstract said “This rate yielded a total of 4,645 excess deaths during this period (95% CI, 793 to 8,498).”¹ Many newspapers published the number 4,645 in a headline. Most newspapers didn’t include all of the scientific mumbo jumbo about bias and confidence intervals.

Georgijevic/E+/Getty Images

So in the spirit of thinking globally but acting locally, what can I do? I love my editor. I have hinted before about how much easier it is to read, as well as more accurate scientifically, to round the numbers that we report. We've done it a few times recently, but now that the Washington Post has done it on a major news story, should this practice become the norm for journalism? If medical journal editors won't handle precision honestly, other journalists must step up. I'm distressed when I review an article that says 14.6% agreed and 79.2% strongly agreed and I know those percentages with 3 digits really mean 7/48 and 38/48, so they should be rounded to two significant figures. And isn’t it easier to read and comprehend if reporting that three treatment groups had positive findings of 4.25%, 12.08%, and 9.84% when rounded to 4%, 12%, and 10%?

Scientists using this false precision (and peer reviewers who allow it) need to be corrected. They are trying to sell their research as a Louis Vuitton handbag when we all know it is only a cheap knockoff.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected]

References

1. N Eng J Med. 2018 May 29. doi: 10.1056/NEJMsa1803972

2. “Harvard study estimates thousands died in Puerto Rico because of Hurricane Maria,” by Arelis R. Hernández and Laurie McGinley, The Washington Post, May 29, 2018.

3. “Did exactly 4,645 people die in Hurricane Maria? Nope.” by Glenn Kessler, The Washington Post, June 1, 2018.

Physicists have strict rules about significant figures. Medical journals lack this professional discipline and it produces distortions that mislead readers.

Whenever you measure and report something in physics, the precision of the measurement is reflected in how the value is written. Writing a result with more digits implies that a higher precision was achieved. If that wasn’t the case, you are falsely claiming skill and accomplishment. You’ve entered the zone of post-truth.

This point was taught by my high school physics teacher, Mr. Gunnar Overgaard, may he rest in peace. Suppose we measured the length of the lab table with the meter stick. We repeated the action three times. We computed an average. Our table was 243.7 cm long. If we wrote 243.73 or 243.73333 we got a lower grade. Meter sticks only have markings of 0.1 cm. So the precision of the reported measurement should properly reflect that limitation.

Researchers in medicine seem to have skipped that lesson in physics lab. In medical journals, the default seems to be to report measurements with two decimal points, such as 16.67%, which is a gross distortion of the precision when I know that that really means 2 out of 12 patients had the finding.

This issue of precision came up recently in two papers published about the number of deaths caused by Hurricane Maria in Puerto Rico. The official death toll was 64. This number became a political hot potato when President Trump cited it as if it was evidence that he and the current local government had managed the emergency response better than George W. Bush did for Katrina.

On May 29, 2018, some researchers at the Harvard School of Public Health, a prestigious institution, published an article in The New England Journal of Medicine, a prestigious journal. You would presume that pair could report properly. The abstract said “This rate yielded a total of 4,645 excess deaths during this period (95% CI, 793 to 8,498).”¹ Many newspapers published the number 4,645 in a headline. Most newspapers didn’t include all of the scientific mumbo jumbo about bias and confidence intervals.

Georgijevic/E+/Getty Images

So in the spirit of thinking globally but acting locally, what can I do? I love my editor. I have hinted before about how much easier it is to read, as well as more accurate scientifically, to round the numbers that we report. We've done it a few times recently, but now that the Washington Post has done it on a major news story, should this practice become the norm for journalism? If medical journal editors won't handle precision honestly, other journalists must step up. I'm distressed when I review an article that says 14.6% agreed and 79.2% strongly agreed and I know those percentages with 3 digits really mean 7/48 and 38/48, so they should be rounded to two significant figures. And isn’t it easier to read and comprehend if reporting that three treatment groups had positive findings of 4.25%, 12.08%, and 9.84% when rounded to 4%, 12%, and 10%?

Scientists using this false precision (and peer reviewers who allow it) need to be corrected. They are trying to sell their research as a Louis Vuitton handbag when we all know it is only a cheap knockoff.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected]

References

1. N Eng J Med. 2018 May 29. doi: 10.1056/NEJMsa1803972

2. “Harvard study estimates thousands died in Puerto Rico because of Hurricane Maria,” by Arelis R. Hernández and Laurie McGinley, The Washington Post, May 29, 2018.

3. “Did exactly 4,645 people die in Hurricane Maria? Nope.” by Glenn Kessler, The Washington Post, June 1, 2018.

June 28, 1969, is the day that many consider to be the origin of the modern LGBTQ (Lesbian, Gay, Bisexual, Transgender, Queer/Questioning) movement.¹ At that time, it was not uncommon for police officers to conduct raids on bars frequented by LGBTQ patrons, but this night was different. This night the patrons of the Stonewall Inn fought back. The subsequent violent clashes fueled the national organization of groups concentrated on the goal of advocating for LGBTQ rights. On June 28th, 1970, protests to commemorate the events at Stonewall occurred; many refer to these as the first Pride events. Since then the month of June has been seen as the unofficial Pride month for the LGBTQ community. These events began as demonstrations for equal rights and protections for LGBTQ individuals, but over time, events have grown also to become a celebration of queer lives and sexuality.²

Josve05a/Getty Images

Ways to get involved

Find out about local Pride events in your community and consider attending or volunteering. One of the contributing factors to LGBTQ health disparities is limited access to competent care. Many LGBTQ youth and adults have reported experiences of discrimination in the health care setting.^3,4 When we, as health care providers, are visible at Pride events, we can have important effects on our local communities by showing them that we recognize and affirm LGBTQ identities.

Consider asking your organization or institution to provide support at local Pride events, post messages of support during Pride month, or host educational sessions about the care of LGBTQ youth.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at Ohio State University, both in Columbus. She said she had no relevant financial disclosures. Email her at [email protected].

Resources

Human Rights Campaign/Pride: You can learn more about the history of Pride and events in your state and community at www.hrc.org/pride.

How to contact your elected officials: You can find contact information for your local, state, and federal government representatives at www.usa.gov/elected-officials.

National LGBT Health Education Center: You can find educational resources to help optimize care of LGBT patients at www.lgbthealtheducation.org/.

U.S. Transgender Survey: You can read the report from a survey of almost 28,000 transgender respondents in the U.S. Specific information is available about experiences with health care; state level reports also available at www.ustranssurvey.org/reports/.
 

References

1. GLAAD Pride Month Resource Kit for Jounalists: www.glaad.org/publications/pridekit

2. Human Rights Campaign: History of LGBT Pride. www.hrc.org/blog/the-history-of-lgbt-pride-from-1970-to-now

3. The Report of the 2015 U.S. Transgender Survey (Washington, DC: National Center for Transgender Equality, 2016).

4. Healthy People 2020: Lesbian, Gay, Bisexual and Transgender Health.

June 28, 1969, is the day that many consider to be the origin of the modern LGBTQ (Lesbian, Gay, Bisexual, Transgender, Queer/Questioning) movement.¹ At that time, it was not uncommon for police officers to conduct raids on bars frequented by LGBTQ patrons, but this night was different. This night the patrons of the Stonewall Inn fought back. The subsequent violent clashes fueled the national organization of groups concentrated on the goal of advocating for LGBTQ rights. On June 28th, 1970, protests to commemorate the events at Stonewall occurred; many refer to these as the first Pride events. Since then the month of June has been seen as the unofficial Pride month for the LGBTQ community. These events began as demonstrations for equal rights and protections for LGBTQ individuals, but over time, events have grown also to become a celebration of queer lives and sexuality.²

Josve05a/Getty Images

Ways to get involved

Find out about local Pride events in your community and consider attending or volunteering. One of the contributing factors to LGBTQ health disparities is limited access to competent care. Many LGBTQ youth and adults have reported experiences of discrimination in the health care setting.^3,4 When we, as health care providers, are visible at Pride events, we can have important effects on our local communities by showing them that we recognize and affirm LGBTQ identities.

Consider asking your organization or institution to provide support at local Pride events, post messages of support during Pride month, or host educational sessions about the care of LGBTQ youth.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at Ohio State University, both in Columbus. She said she had no relevant financial disclosures. Email her at [email protected].

Resources

Human Rights Campaign/Pride: You can learn more about the history of Pride and events in your state and community at www.hrc.org/pride.

How to contact your elected officials: You can find contact information for your local, state, and federal government representatives at www.usa.gov/elected-officials.

National LGBT Health Education Center: You can find educational resources to help optimize care of LGBT patients at www.lgbthealtheducation.org/.

U.S. Transgender Survey: You can read the report from a survey of almost 28,000 transgender respondents in the U.S. Specific information is available about experiences with health care; state level reports also available at www.ustranssurvey.org/reports/.
 

References

1. GLAAD Pride Month Resource Kit for Jounalists: www.glaad.org/publications/pridekit

2. Human Rights Campaign: History of LGBT Pride. www.hrc.org/blog/the-history-of-lgbt-pride-from-1970-to-now

3. The Report of the 2015 U.S. Transgender Survey (Washington, DC: National Center for Transgender Equality, 2016).

4. Healthy People 2020: Lesbian, Gay, Bisexual and Transgender Health.

June 28, 1969, is the day that many consider to be the origin of the modern LGBTQ (Lesbian, Gay, Bisexual, Transgender, Queer/Questioning) movement.¹ At that time, it was not uncommon for police officers to conduct raids on bars frequented by LGBTQ patrons, but this night was different. This night the patrons of the Stonewall Inn fought back. The subsequent violent clashes fueled the national organization of groups concentrated on the goal of advocating for LGBTQ rights. On June 28th, 1970, protests to commemorate the events at Stonewall occurred; many refer to these as the first Pride events. Since then the month of June has been seen as the unofficial Pride month for the LGBTQ community. These events began as demonstrations for equal rights and protections for LGBTQ individuals, but over time, events have grown also to become a celebration of queer lives and sexuality.²

Josve05a/Getty Images

Ways to get involved

Find out about local Pride events in your community and consider attending or volunteering. One of the contributing factors to LGBTQ health disparities is limited access to competent care. Many LGBTQ youth and adults have reported experiences of discrimination in the health care setting.^3,4 When we, as health care providers, are visible at Pride events, we can have important effects on our local communities by showing them that we recognize and affirm LGBTQ identities.

Consider asking your organization or institution to provide support at local Pride events, post messages of support during Pride month, or host educational sessions about the care of LGBTQ youth.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at Ohio State University, both in Columbus. She said she had no relevant financial disclosures. Email her at [email protected].

Resources

Human Rights Campaign/Pride: You can learn more about the history of Pride and events in your state and community at www.hrc.org/pride.

How to contact your elected officials: You can find contact information for your local, state, and federal government representatives at www.usa.gov/elected-officials.

National LGBT Health Education Center: You can find educational resources to help optimize care of LGBT patients at www.lgbthealtheducation.org/.

U.S. Transgender Survey: You can read the report from a survey of almost 28,000 transgender respondents in the U.S. Specific information is available about experiences with health care; state level reports also available at www.ustranssurvey.org/reports/.
 

References

1. GLAAD Pride Month Resource Kit for Jounalists: www.glaad.org/publications/pridekit

2. Human Rights Campaign: History of LGBT Pride. www.hrc.org/blog/the-history-of-lgbt-pride-from-1970-to-now

3. The Report of the 2015 U.S. Transgender Survey (Washington, DC: National Center for Transgender Equality, 2016).

4. Healthy People 2020: Lesbian, Gay, Bisexual and Transgender Health.

The recent crises of the separation of stressed children from their equally stressed parents at this country’s southern border raises the specter of emotional and cognitive reactions within these children – the negative ramifications of which will manifest themselves for years to come.

Stress is ubiquitous. Children experience stress in the normal everyday frustrations that come their way: going to day care for a few hours and leaving mommy, the tripping and falling as they learn to walk, a toy breaking. These stresses help a child develop the capacity for emotional regulation and are termed “tolerable stress.” There is, however, a big difference between tolerable stress and toxic stress.

When the stress reaction in response to perceived or actual danger is beyond tolerable levels by virtue of its quality, intensity, and longevity, it saps the body’s ability to rally or handle the trauma that is being faced because of depleted neurotransmitters that normally assist the body to fight or flee from danger. Unfortunately, that’s not the end of the story: As the stressor persists, it has the capacity to produce long-term alterations in the resilience of the brain and body of the young child. This change often is irreversible.

Scientists and the lay public have begun to actively discuss the impact of adverse childhood experiences and their causal link to irreversible negative adult health outcomes. We now know without a doubt the impact of toxic versus tolerable stress on the hypothalamic-pituitary-adrenal axis of the young child. We are aware that the brain of a young child is particularly vulnerable to stress during critical and sensitive periods of development and that downstream effects of early trauma show up as disorganized behavior and cognitive underperformance.

Development plays a central role in children’s behavioral response to separation from parents. Infants develop a sense of stranger anxiety and the primacy of one central figure between ages 8 and 10 months. The baby chooses the parent over strangers for comfort and care. Roughly between ages 3 and 4, a child develops an internal representation of the parent as the primary figure in their lives so that they can tolerate short periods of being away from the primary caregiver for, let’s say, half a day. They depend on the parent for all their physical and emotional needs, which includes the need for a stable, nurturing, and predictable presence.

Familiarity of the environment, family rituals, consistency of daily routines provided by the parent help neural pathways responsible for the biologic unfolding of developmental milestones. Only recently, the science of early brain development and the role of early childhood trauma on brain biology has caught up with the longitudinal observational studies of bereaved children who lost their parents under circumstances of acute stress (the blitzkrieg, the Yom Kippur War, the Hungarian orphans) followed by the chronic stress phase of no primary caregiver for months to years. These observational studies coupled by the emerging neuroscience of early brain development and trauma are powerful informants of what is tolerable stress for children and what is not.

As a psychiatrist and expert in early child development, I am concerned about these long-term effects on migrant children. Research shows that young children who are nonverbal react to the stress of separation by death or absence of parents with anxiety; frantically seeking the parent/comforting familiar caregiver. Gradually as that possibility fades, with their limited ability to verbalize needs, episodic weeping can give way to disorganized behavior, despondence, and finally apathy and regression of milestones and cognitive abilities already achieved. The separation is merely the proxy face of other disasters that are probably co-occurring for the child/family and multiplies the dose of the stress: loss of siblings, loss of familiar physical elements of the landscape, loss of adequate physical sustenance, loss of routine, loss of consistency, increased vulnerability for physical illness, and the list goes on.

By age 2 and above, children are more vocal in their desire for reunification and will weep inconsolably upon separation. At this time their bodies and the psychological lens through which they view the world is changing irrevocably. Stress hormones, noxious at high levels such as cortisol/adrenocorticotropic hormone and glutamate rise to levels that no longer respond to the traditional negative feedback loop of the body and reach levels that lead to cell death in areas of the brain responsible for modulating emotions that can permanently change brain architecture.

Psychologically, the child seeks out the parent by any means (crying, flailing, tantruming). When no positive outcome occurs, this is replaced by an unwillingness to engage with the world, or the child engages but by behavior that is aggressive, disorganized, and regressed. In their own way, young children’s mistrust of the world leads to a variety of behaviors that impede normal development: rejection of others, disengagement from social connections by quietly sitting in a corner, being unwilling to eat or sleeping fitfully.

As separation from the primary caregiver continues, there is a deepening sense of hopelessness. Generally, no amount of physical props (toys, playgrounds) without the human familiar faces can rectify the feeling of abandonment and hopelessness that children in these conditions face. Assuming they are no strangers to trauma experienced through the lives of their asylum-seeking parents, this separation refreshes all the wounds of days gone by. At least in those moments of initial trauma, they had the parent as a buffer. But with this new separation, they are left to emotionally fend for themselves with no tools to manage their emotions.

We have to deal with the aftereffects of so many natural disasters that cannot be avoided: earthquakes, tornadoes, tsunamis that displace children and families with horrific outcomes. Did we really need a man-made disaster that will irrevocably change the brains and behaviors of a generation of children who just happen to be on our southern borders because of an accident of birth? If parents abandoned their children this way it would be called child abuse. Deliberate policy decisions that have such dire effects on children also take on the label of child abuse.

Although images of my years as a young parent of three boys are turning a sepia color in faded memory, in my new role as a grandmother observing my son and his wife so in love with their 2-year-old reinforces how much mutual dependency of a child and parent on each other strengthens the very fabric of life. Children are our future and are the building blocks of a just and humane society.

As of this writing, the administration has vowed to end these separations. But how will children who have been separated be reunited with their families?

The education of decision makers about the far-reaching emotional and physical consequences on normative childhood development must be a top priority for all scientists and professionals interested in kids and families: I think that means all of us.
 

Dr. Sood is professor of psychiatry and pediatrics, and senior professor of child mental health policy at the Virginia Treatment Center at Virginia Commonwealth University, Richmond. She also is affiliated with the department of psychiatry at VCU and Children’s Hospital of Richmond.

The recent crises of the separation of stressed children from their equally stressed parents at this country’s southern border raises the specter of emotional and cognitive reactions within these children – the negative ramifications of which will manifest themselves for years to come.

Stress is ubiquitous. Children experience stress in the normal everyday frustrations that come their way: going to day care for a few hours and leaving mommy, the tripping and falling as they learn to walk, a toy breaking. These stresses help a child develop the capacity for emotional regulation and are termed “tolerable stress.” There is, however, a big difference between tolerable stress and toxic stress.

When the stress reaction in response to perceived or actual danger is beyond tolerable levels by virtue of its quality, intensity, and longevity, it saps the body’s ability to rally or handle the trauma that is being faced because of depleted neurotransmitters that normally assist the body to fight or flee from danger. Unfortunately, that’s not the end of the story: As the stressor persists, it has the capacity to produce long-term alterations in the resilience of the brain and body of the young child. This change often is irreversible.

Scientists and the lay public have begun to actively discuss the impact of adverse childhood experiences and their causal link to irreversible negative adult health outcomes. We now know without a doubt the impact of toxic versus tolerable stress on the hypothalamic-pituitary-adrenal axis of the young child. We are aware that the brain of a young child is particularly vulnerable to stress during critical and sensitive periods of development and that downstream effects of early trauma show up as disorganized behavior and cognitive underperformance.

Development plays a central role in children’s behavioral response to separation from parents. Infants develop a sense of stranger anxiety and the primacy of one central figure between ages 8 and 10 months. The baby chooses the parent over strangers for comfort and care. Roughly between ages 3 and 4, a child develops an internal representation of the parent as the primary figure in their lives so that they can tolerate short periods of being away from the primary caregiver for, let’s say, half a day. They depend on the parent for all their physical and emotional needs, which includes the need for a stable, nurturing, and predictable presence.

Familiarity of the environment, family rituals, consistency of daily routines provided by the parent help neural pathways responsible for the biologic unfolding of developmental milestones. Only recently, the science of early brain development and the role of early childhood trauma on brain biology has caught up with the longitudinal observational studies of bereaved children who lost their parents under circumstances of acute stress (the blitzkrieg, the Yom Kippur War, the Hungarian orphans) followed by the chronic stress phase of no primary caregiver for months to years. These observational studies coupled by the emerging neuroscience of early brain development and trauma are powerful informants of what is tolerable stress for children and what is not.

As a psychiatrist and expert in early child development, I am concerned about these long-term effects on migrant children. Research shows that young children who are nonverbal react to the stress of separation by death or absence of parents with anxiety; frantically seeking the parent/comforting familiar caregiver. Gradually as that possibility fades, with their limited ability to verbalize needs, episodic weeping can give way to disorganized behavior, despondence, and finally apathy and regression of milestones and cognitive abilities already achieved. The separation is merely the proxy face of other disasters that are probably co-occurring for the child/family and multiplies the dose of the stress: loss of siblings, loss of familiar physical elements of the landscape, loss of adequate physical sustenance, loss of routine, loss of consistency, increased vulnerability for physical illness, and the list goes on.

By age 2 and above, children are more vocal in their desire for reunification and will weep inconsolably upon separation. At this time their bodies and the psychological lens through which they view the world is changing irrevocably. Stress hormones, noxious at high levels such as cortisol/adrenocorticotropic hormone and glutamate rise to levels that no longer respond to the traditional negative feedback loop of the body and reach levels that lead to cell death in areas of the brain responsible for modulating emotions that can permanently change brain architecture.

Psychologically, the child seeks out the parent by any means (crying, flailing, tantruming). When no positive outcome occurs, this is replaced by an unwillingness to engage with the world, or the child engages but by behavior that is aggressive, disorganized, and regressed. In their own way, young children’s mistrust of the world leads to a variety of behaviors that impede normal development: rejection of others, disengagement from social connections by quietly sitting in a corner, being unwilling to eat or sleeping fitfully.

As separation from the primary caregiver continues, there is a deepening sense of hopelessness. Generally, no amount of physical props (toys, playgrounds) without the human familiar faces can rectify the feeling of abandonment and hopelessness that children in these conditions face. Assuming they are no strangers to trauma experienced through the lives of their asylum-seeking parents, this separation refreshes all the wounds of days gone by. At least in those moments of initial trauma, they had the parent as a buffer. But with this new separation, they are left to emotionally fend for themselves with no tools to manage their emotions.

We have to deal with the aftereffects of so many natural disasters that cannot be avoided: earthquakes, tornadoes, tsunamis that displace children and families with horrific outcomes. Did we really need a man-made disaster that will irrevocably change the brains and behaviors of a generation of children who just happen to be on our southern borders because of an accident of birth? If parents abandoned their children this way it would be called child abuse. Deliberate policy decisions that have such dire effects on children also take on the label of child abuse.

Although images of my years as a young parent of three boys are turning a sepia color in faded memory, in my new role as a grandmother observing my son and his wife so in love with their 2-year-old reinforces how much mutual dependency of a child and parent on each other strengthens the very fabric of life. Children are our future and are the building blocks of a just and humane society.

As of this writing, the administration has vowed to end these separations. But how will children who have been separated be reunited with their families?

The education of decision makers about the far-reaching emotional and physical consequences on normative childhood development must be a top priority for all scientists and professionals interested in kids and families: I think that means all of us.
 

Dr. Sood is professor of psychiatry and pediatrics, and senior professor of child mental health policy at the Virginia Treatment Center at Virginia Commonwealth University, Richmond. She also is affiliated with the department of psychiatry at VCU and Children’s Hospital of Richmond.

The recent crises of the separation of stressed children from their equally stressed parents at this country’s southern border raises the specter of emotional and cognitive reactions within these children – the negative ramifications of which will manifest themselves for years to come.

Stress is ubiquitous. Children experience stress in the normal everyday frustrations that come their way: going to day care for a few hours and leaving mommy, the tripping and falling as they learn to walk, a toy breaking. These stresses help a child develop the capacity for emotional regulation and are termed “tolerable stress.” There is, however, a big difference between tolerable stress and toxic stress.

When the stress reaction in response to perceived or actual danger is beyond tolerable levels by virtue of its quality, intensity, and longevity, it saps the body’s ability to rally or handle the trauma that is being faced because of depleted neurotransmitters that normally assist the body to fight or flee from danger. Unfortunately, that’s not the end of the story: As the stressor persists, it has the capacity to produce long-term alterations in the resilience of the brain and body of the young child. This change often is irreversible.

Scientists and the lay public have begun to actively discuss the impact of adverse childhood experiences and their causal link to irreversible negative adult health outcomes. We now know without a doubt the impact of toxic versus tolerable stress on the hypothalamic-pituitary-adrenal axis of the young child. We are aware that the brain of a young child is particularly vulnerable to stress during critical and sensitive periods of development and that downstream effects of early trauma show up as disorganized behavior and cognitive underperformance.

Development plays a central role in children’s behavioral response to separation from parents. Infants develop a sense of stranger anxiety and the primacy of one central figure between ages 8 and 10 months. The baby chooses the parent over strangers for comfort and care. Roughly between ages 3 and 4, a child develops an internal representation of the parent as the primary figure in their lives so that they can tolerate short periods of being away from the primary caregiver for, let’s say, half a day. They depend on the parent for all their physical and emotional needs, which includes the need for a stable, nurturing, and predictable presence.

Familiarity of the environment, family rituals, consistency of daily routines provided by the parent help neural pathways responsible for the biologic unfolding of developmental milestones. Only recently, the science of early brain development and the role of early childhood trauma on brain biology has caught up with the longitudinal observational studies of bereaved children who lost their parents under circumstances of acute stress (the blitzkrieg, the Yom Kippur War, the Hungarian orphans) followed by the chronic stress phase of no primary caregiver for months to years. These observational studies coupled by the emerging neuroscience of early brain development and trauma are powerful informants of what is tolerable stress for children and what is not.

As a psychiatrist and expert in early child development, I am concerned about these long-term effects on migrant children. Research shows that young children who are nonverbal react to the stress of separation by death or absence of parents with anxiety; frantically seeking the parent/comforting familiar caregiver. Gradually as that possibility fades, with their limited ability to verbalize needs, episodic weeping can give way to disorganized behavior, despondence, and finally apathy and regression of milestones and cognitive abilities already achieved. The separation is merely the proxy face of other disasters that are probably co-occurring for the child/family and multiplies the dose of the stress: loss of siblings, loss of familiar physical elements of the landscape, loss of adequate physical sustenance, loss of routine, loss of consistency, increased vulnerability for physical illness, and the list goes on.

By age 2 and above, children are more vocal in their desire for reunification and will weep inconsolably upon separation. At this time their bodies and the psychological lens through which they view the world is changing irrevocably. Stress hormones, noxious at high levels such as cortisol/adrenocorticotropic hormone and glutamate rise to levels that no longer respond to the traditional negative feedback loop of the body and reach levels that lead to cell death in areas of the brain responsible for modulating emotions that can permanently change brain architecture.

Psychologically, the child seeks out the parent by any means (crying, flailing, tantruming). When no positive outcome occurs, this is replaced by an unwillingness to engage with the world, or the child engages but by behavior that is aggressive, disorganized, and regressed. In their own way, young children’s mistrust of the world leads to a variety of behaviors that impede normal development: rejection of others, disengagement from social connections by quietly sitting in a corner, being unwilling to eat or sleeping fitfully.

As separation from the primary caregiver continues, there is a deepening sense of hopelessness. Generally, no amount of physical props (toys, playgrounds) without the human familiar faces can rectify the feeling of abandonment and hopelessness that children in these conditions face. Assuming they are no strangers to trauma experienced through the lives of their asylum-seeking parents, this separation refreshes all the wounds of days gone by. At least in those moments of initial trauma, they had the parent as a buffer. But with this new separation, they are left to emotionally fend for themselves with no tools to manage their emotions.

We have to deal with the aftereffects of so many natural disasters that cannot be avoided: earthquakes, tornadoes, tsunamis that displace children and families with horrific outcomes. Did we really need a man-made disaster that will irrevocably change the brains and behaviors of a generation of children who just happen to be on our southern borders because of an accident of birth? If parents abandoned their children this way it would be called child abuse. Deliberate policy decisions that have such dire effects on children also take on the label of child abuse.

Although images of my years as a young parent of three boys are turning a sepia color in faded memory, in my new role as a grandmother observing my son and his wife so in love with their 2-year-old reinforces how much mutual dependency of a child and parent on each other strengthens the very fabric of life. Children are our future and are the building blocks of a just and humane society.

As of this writing, the administration has vowed to end these separations. But how will children who have been separated be reunited with their families?

The education of decision makers about the far-reaching emotional and physical consequences on normative childhood development must be a top priority for all scientists and professionals interested in kids and families: I think that means all of us.
 

Dr. Sood is professor of psychiatry and pediatrics, and senior professor of child mental health policy at the Virginia Treatment Center at Virginia Commonwealth University, Richmond. She also is affiliated with the department of psychiatry at VCU and Children’s Hospital of Richmond.