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Separate? Yes. Equal? Yes. Fair? No!
I learned from a recent article in the Wall Street Journal that the states of New York and Washington are considering legislation that would require judges in divorce cases to award custodial and visitation time equally between parents unless it could be demonstrated that the arrangement would not be “in the best interests of the child (“Big Shift Pushed in Custody Disputes,” by Ashby Jones, Wall Street Journal, April 16, 2015).
Although judges are no longer bound to making decisions that reflect the old notion that children should stay close their mothers during the “tender years” of infancy and toddlerhood, their decisions have apparently not kept pace with the current trend toward shared parenting and the broadening role of fathers in childrearing.
Although I am sure there are many fathers who have not been fairly treated by custody and visitation decisions, my fear is that too many decisions have been made that are not in the best interests of the child regardless of whether both parents were treated equally. For example, I have seen amicable divorce settlements result in an arrangement in which the child spends up to 10 or 12 hours a week in a car shuttling back and forth between homes and/or losing 1 or 2 hours of sleep every other night for the sake of parental equality and satisfaction. While these compromises may not have seemed like a big deal to the adults dictating the arrangement, from my perspective as a pediatrician they are unhealthy and unfair to the child.
There are scores of other custody and visitation arrangements in which the costs to the child are less obvious, but are nonetheless detrimental to the health and well-being of the child. Some arrangements that worked well for all parties when the child was a toddler may no longer give the child enough time for his interests and activities as he approaches middle school. Unfortunately, all too often, a parent may be hesitant to give up his or her hard-fought custody to accommodate these inevitable but unpredictable maturational changes.
Of course, there are thousands of situations in which parents who are keenly aware have considered the best interests of the child in crafting and adjusting their post-divorce schedules. The problem is that we need a system that guarantees that when divorces and separations occur, decisions are made that are truly in the best interests of the child.
There are judges who by training or because they possess an innate sensitivity do render decisions that truly reflect and accommodate the needs of the child. But there is no guarantee that the judge or mediator will put enough thought into the child’s situation. In rare cases, the court may appoint a guardian ad litem (also known as court-appointed special advocates [CASA]) to represent the child. Unfortunately, in my experience, this option is seldom used because of cost concerns and because lawyers are hesitant to give up any of their own turf. I also have been surprised and disappointed by how little experience and job-specific training some of these guardians ad litem have received. Some seem simply to be underemployed lawyers.
As most of you are painfully aware, in the absence of a legal mechanism to speak for the child, the task often falls into the lap of the child’s pediatrician. This can put the physician in an uncomfortable position. The pediatrician may be asked by one parent or his or her lawyer to make a statement about the appropriateness of a proposed custody arrangement. Without knowing all the facts, or at least hearing the other parent’s side of the story, rendering an opinion can be risky business. It is very likely to not sit well with one or both parents. While our perspective may be valuable, who is going to pay for the time it takes for us to gather the information necessary to render a quality decision?
The perfect system would assign a guardian ad litem for every child in a separating or divorcing family. That individual should be well trained specifically for that role and encouraged to consult and fairly reimburse the child’s pediatrician in the cases in which a child-appropriate arrangement may not be obvious. That arrangement should be reviewed every few years by the guardian ad litem to ensure it continues to be in the child’s best interest. It would be an expensive system and the lawyers wouldn’t like it because it would diminish their role, but children of divorce deserve a seat at the table and a voice to speak for them.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.”
I learned from a recent article in the Wall Street Journal that the states of New York and Washington are considering legislation that would require judges in divorce cases to award custodial and visitation time equally between parents unless it could be demonstrated that the arrangement would not be “in the best interests of the child (“Big Shift Pushed in Custody Disputes,” by Ashby Jones, Wall Street Journal, April 16, 2015).
Although judges are no longer bound to making decisions that reflect the old notion that children should stay close their mothers during the “tender years” of infancy and toddlerhood, their decisions have apparently not kept pace with the current trend toward shared parenting and the broadening role of fathers in childrearing.
Although I am sure there are many fathers who have not been fairly treated by custody and visitation decisions, my fear is that too many decisions have been made that are not in the best interests of the child regardless of whether both parents were treated equally. For example, I have seen amicable divorce settlements result in an arrangement in which the child spends up to 10 or 12 hours a week in a car shuttling back and forth between homes and/or losing 1 or 2 hours of sleep every other night for the sake of parental equality and satisfaction. While these compromises may not have seemed like a big deal to the adults dictating the arrangement, from my perspective as a pediatrician they are unhealthy and unfair to the child.
There are scores of other custody and visitation arrangements in which the costs to the child are less obvious, but are nonetheless detrimental to the health and well-being of the child. Some arrangements that worked well for all parties when the child was a toddler may no longer give the child enough time for his interests and activities as he approaches middle school. Unfortunately, all too often, a parent may be hesitant to give up his or her hard-fought custody to accommodate these inevitable but unpredictable maturational changes.
Of course, there are thousands of situations in which parents who are keenly aware have considered the best interests of the child in crafting and adjusting their post-divorce schedules. The problem is that we need a system that guarantees that when divorces and separations occur, decisions are made that are truly in the best interests of the child.
There are judges who by training or because they possess an innate sensitivity do render decisions that truly reflect and accommodate the needs of the child. But there is no guarantee that the judge or mediator will put enough thought into the child’s situation. In rare cases, the court may appoint a guardian ad litem (also known as court-appointed special advocates [CASA]) to represent the child. Unfortunately, in my experience, this option is seldom used because of cost concerns and because lawyers are hesitant to give up any of their own turf. I also have been surprised and disappointed by how little experience and job-specific training some of these guardians ad litem have received. Some seem simply to be underemployed lawyers.
As most of you are painfully aware, in the absence of a legal mechanism to speak for the child, the task often falls into the lap of the child’s pediatrician. This can put the physician in an uncomfortable position. The pediatrician may be asked by one parent or his or her lawyer to make a statement about the appropriateness of a proposed custody arrangement. Without knowing all the facts, or at least hearing the other parent’s side of the story, rendering an opinion can be risky business. It is very likely to not sit well with one or both parents. While our perspective may be valuable, who is going to pay for the time it takes for us to gather the information necessary to render a quality decision?
The perfect system would assign a guardian ad litem for every child in a separating or divorcing family. That individual should be well trained specifically for that role and encouraged to consult and fairly reimburse the child’s pediatrician in the cases in which a child-appropriate arrangement may not be obvious. That arrangement should be reviewed every few years by the guardian ad litem to ensure it continues to be in the child’s best interest. It would be an expensive system and the lawyers wouldn’t like it because it would diminish their role, but children of divorce deserve a seat at the table and a voice to speak for them.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.”
I learned from a recent article in the Wall Street Journal that the states of New York and Washington are considering legislation that would require judges in divorce cases to award custodial and visitation time equally between parents unless it could be demonstrated that the arrangement would not be “in the best interests of the child (“Big Shift Pushed in Custody Disputes,” by Ashby Jones, Wall Street Journal, April 16, 2015).
Although judges are no longer bound to making decisions that reflect the old notion that children should stay close their mothers during the “tender years” of infancy and toddlerhood, their decisions have apparently not kept pace with the current trend toward shared parenting and the broadening role of fathers in childrearing.
Although I am sure there are many fathers who have not been fairly treated by custody and visitation decisions, my fear is that too many decisions have been made that are not in the best interests of the child regardless of whether both parents were treated equally. For example, I have seen amicable divorce settlements result in an arrangement in which the child spends up to 10 or 12 hours a week in a car shuttling back and forth between homes and/or losing 1 or 2 hours of sleep every other night for the sake of parental equality and satisfaction. While these compromises may not have seemed like a big deal to the adults dictating the arrangement, from my perspective as a pediatrician they are unhealthy and unfair to the child.
There are scores of other custody and visitation arrangements in which the costs to the child are less obvious, but are nonetheless detrimental to the health and well-being of the child. Some arrangements that worked well for all parties when the child was a toddler may no longer give the child enough time for his interests and activities as he approaches middle school. Unfortunately, all too often, a parent may be hesitant to give up his or her hard-fought custody to accommodate these inevitable but unpredictable maturational changes.
Of course, there are thousands of situations in which parents who are keenly aware have considered the best interests of the child in crafting and adjusting their post-divorce schedules. The problem is that we need a system that guarantees that when divorces and separations occur, decisions are made that are truly in the best interests of the child.
There are judges who by training or because they possess an innate sensitivity do render decisions that truly reflect and accommodate the needs of the child. But there is no guarantee that the judge or mediator will put enough thought into the child’s situation. In rare cases, the court may appoint a guardian ad litem (also known as court-appointed special advocates [CASA]) to represent the child. Unfortunately, in my experience, this option is seldom used because of cost concerns and because lawyers are hesitant to give up any of their own turf. I also have been surprised and disappointed by how little experience and job-specific training some of these guardians ad litem have received. Some seem simply to be underemployed lawyers.
As most of you are painfully aware, in the absence of a legal mechanism to speak for the child, the task often falls into the lap of the child’s pediatrician. This can put the physician in an uncomfortable position. The pediatrician may be asked by one parent or his or her lawyer to make a statement about the appropriateness of a proposed custody arrangement. Without knowing all the facts, or at least hearing the other parent’s side of the story, rendering an opinion can be risky business. It is very likely to not sit well with one or both parents. While our perspective may be valuable, who is going to pay for the time it takes for us to gather the information necessary to render a quality decision?
The perfect system would assign a guardian ad litem for every child in a separating or divorcing family. That individual should be well trained specifically for that role and encouraged to consult and fairly reimburse the child’s pediatrician in the cases in which a child-appropriate arrangement may not be obvious. That arrangement should be reviewed every few years by the guardian ad litem to ensure it continues to be in the child’s best interest. It would be an expensive system and the lawyers wouldn’t like it because it would diminish their role, but children of divorce deserve a seat at the table and a voice to speak for them.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.”
Paging Dr. Google
The 8-year-old child presented to the emergency department with bilateral ankle pain that had progressively worsened over the past 24 hours. This morning he would not walk. He also had a rash on his legs. The astute ED doctor recognized the diagnosis as Henoch-Schönlein purpura (HSP) and arranged admission to the ward. Things were flowing smoothly that day, and the child was soon on the ward and being examined by me and the resident team during morning rounds. In that 45-minute gap, the father had been on his smartphone. At that point he knew more about HSP than my senior resident. Truth be told, I was glad I had treated two cases in the previous 3 months (after going more than 2 years without any cases) so I didn’t feel foolish myself.
Technology is making progressively larger amounts of medical information available to the lay public. That information is being organized in ways that can actually impart knowledge. The Wikipedia entry on HSP has far more information, and has it arranged in a much more useful fashion, than my textbook on pediatrics. Making that comparison was the first time in 5 years that the textbook has even been taken off the shelf. If you have Googled tonsillitis, sprained ankle, or measles in the past 2 months, instead of just a list of websites, you also would have seen half the page filled with images and vetted information about those illnesses. There are apps that help you create a differential diagnosis and even estimate the probabilities of each one.
The victory of Watson, IBM's supercomputer, on Jeopardy showed how information can be organized and retrieved by a computer. It is a good facsimile for knowledge. But what about the wisdom of clinical judgment? Can a computer replace that? Keith Rabois, a member of the PayPal mafia, recently predicted that it will.
Further progress toward replacing doctors has come through changes in legislation to permit all lab tests to be offered directly to consumers. Arizona’s governor signed a law in April 2015 that will change that policy for his state. This isn’t major news, because already more than half the states allow this direct to consumer approach. But what was special about this particular signing ceremony was the involvement of billionaire Elizabeth Holmes, CEO of Theranos, a start-up company prepared to provide the lab testing service.
If done without a doctor’s order, which documents medical necessity, under current practice rules an insurance company won’t pay for these direct to consumer tests. The consumer must pay out of pocket. Of course, those rules may change. If patients want a throat swab to test for strep, maybe it is cheaper to have them go directly to the neighborhood lab than to see a doctor, especially if, when the test is positive, they then expect to phone their doctor for free and get a prescription.
Most medical tests have significant false-positive and false-negative results. Simple rapid strep throat tests and rapid influenza nasal swabs have a sensitivity of only 90%-95%. Many doctors, even those who use the results on a daily basis, cannot convert that information into a positive and negative predictive value. So if a company offers the test directly to the consumer, and reports it out with a “Just the facts, Ma’am” positive or negative result, is the consumer responsible for any misinterpretation, or has the laboratory company deceptively marketed a defective, imperfect product?
The bigger financial impact will be all the follow-up labs and imaging tests generated by the initial false-positive screening labs. Insurance probably will pay for those. Using a similar business model, a few hospitals nationwide now offer free (or close to it) low-dose chest CT scans to smokers and ex-smokers. This is done as a loss leader that generates profits for the hospital from all the follow-up tests, imaging, and biopsies. Compare this model with the old-time practice in which pediatricians in the 1950s to 1980s (and in many places, against guidelines, in the 1990s) had parents bring in a sample of the child’s urine for each well-child visit. That practice was abandoned on cost-benefit-harm arguments because of all the unnecessary subsequent testing, especially kidney ultrasounds, generated by the false positives. Now parents will be able to order the test themselves.
I’m skeptical about how soon a computer will completely replace a physician. Peter Thiel said, “We were promised flying cars and instead what we got was 140 characters.” But Google has finally created the self-driving car. And Elizabeth Holmes has averaged making more money in a week than I will in a career. So who are you going to believe?
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. E-mail him at [email protected].
The 8-year-old child presented to the emergency department with bilateral ankle pain that had progressively worsened over the past 24 hours. This morning he would not walk. He also had a rash on his legs. The astute ED doctor recognized the diagnosis as Henoch-Schönlein purpura (HSP) and arranged admission to the ward. Things were flowing smoothly that day, and the child was soon on the ward and being examined by me and the resident team during morning rounds. In that 45-minute gap, the father had been on his smartphone. At that point he knew more about HSP than my senior resident. Truth be told, I was glad I had treated two cases in the previous 3 months (after going more than 2 years without any cases) so I didn’t feel foolish myself.
Technology is making progressively larger amounts of medical information available to the lay public. That information is being organized in ways that can actually impart knowledge. The Wikipedia entry on HSP has far more information, and has it arranged in a much more useful fashion, than my textbook on pediatrics. Making that comparison was the first time in 5 years that the textbook has even been taken off the shelf. If you have Googled tonsillitis, sprained ankle, or measles in the past 2 months, instead of just a list of websites, you also would have seen half the page filled with images and vetted information about those illnesses. There are apps that help you create a differential diagnosis and even estimate the probabilities of each one.
The victory of Watson, IBM's supercomputer, on Jeopardy showed how information can be organized and retrieved by a computer. It is a good facsimile for knowledge. But what about the wisdom of clinical judgment? Can a computer replace that? Keith Rabois, a member of the PayPal mafia, recently predicted that it will.
Further progress toward replacing doctors has come through changes in legislation to permit all lab tests to be offered directly to consumers. Arizona’s governor signed a law in April 2015 that will change that policy for his state. This isn’t major news, because already more than half the states allow this direct to consumer approach. But what was special about this particular signing ceremony was the involvement of billionaire Elizabeth Holmes, CEO of Theranos, a start-up company prepared to provide the lab testing service.
If done without a doctor’s order, which documents medical necessity, under current practice rules an insurance company won’t pay for these direct to consumer tests. The consumer must pay out of pocket. Of course, those rules may change. If patients want a throat swab to test for strep, maybe it is cheaper to have them go directly to the neighborhood lab than to see a doctor, especially if, when the test is positive, they then expect to phone their doctor for free and get a prescription.
Most medical tests have significant false-positive and false-negative results. Simple rapid strep throat tests and rapid influenza nasal swabs have a sensitivity of only 90%-95%. Many doctors, even those who use the results on a daily basis, cannot convert that information into a positive and negative predictive value. So if a company offers the test directly to the consumer, and reports it out with a “Just the facts, Ma’am” positive or negative result, is the consumer responsible for any misinterpretation, or has the laboratory company deceptively marketed a defective, imperfect product?
The bigger financial impact will be all the follow-up labs and imaging tests generated by the initial false-positive screening labs. Insurance probably will pay for those. Using a similar business model, a few hospitals nationwide now offer free (or close to it) low-dose chest CT scans to smokers and ex-smokers. This is done as a loss leader that generates profits for the hospital from all the follow-up tests, imaging, and biopsies. Compare this model with the old-time practice in which pediatricians in the 1950s to 1980s (and in many places, against guidelines, in the 1990s) had parents bring in a sample of the child’s urine for each well-child visit. That practice was abandoned on cost-benefit-harm arguments because of all the unnecessary subsequent testing, especially kidney ultrasounds, generated by the false positives. Now parents will be able to order the test themselves.
I’m skeptical about how soon a computer will completely replace a physician. Peter Thiel said, “We were promised flying cars and instead what we got was 140 characters.” But Google has finally created the self-driving car. And Elizabeth Holmes has averaged making more money in a week than I will in a career. So who are you going to believe?
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. E-mail him at [email protected].
The 8-year-old child presented to the emergency department with bilateral ankle pain that had progressively worsened over the past 24 hours. This morning he would not walk. He also had a rash on his legs. The astute ED doctor recognized the diagnosis as Henoch-Schönlein purpura (HSP) and arranged admission to the ward. Things were flowing smoothly that day, and the child was soon on the ward and being examined by me and the resident team during morning rounds. In that 45-minute gap, the father had been on his smartphone. At that point he knew more about HSP than my senior resident. Truth be told, I was glad I had treated two cases in the previous 3 months (after going more than 2 years without any cases) so I didn’t feel foolish myself.
Technology is making progressively larger amounts of medical information available to the lay public. That information is being organized in ways that can actually impart knowledge. The Wikipedia entry on HSP has far more information, and has it arranged in a much more useful fashion, than my textbook on pediatrics. Making that comparison was the first time in 5 years that the textbook has even been taken off the shelf. If you have Googled tonsillitis, sprained ankle, or measles in the past 2 months, instead of just a list of websites, you also would have seen half the page filled with images and vetted information about those illnesses. There are apps that help you create a differential diagnosis and even estimate the probabilities of each one.
The victory of Watson, IBM's supercomputer, on Jeopardy showed how information can be organized and retrieved by a computer. It is a good facsimile for knowledge. But what about the wisdom of clinical judgment? Can a computer replace that? Keith Rabois, a member of the PayPal mafia, recently predicted that it will.
Further progress toward replacing doctors has come through changes in legislation to permit all lab tests to be offered directly to consumers. Arizona’s governor signed a law in April 2015 that will change that policy for his state. This isn’t major news, because already more than half the states allow this direct to consumer approach. But what was special about this particular signing ceremony was the involvement of billionaire Elizabeth Holmes, CEO of Theranos, a start-up company prepared to provide the lab testing service.
If done without a doctor’s order, which documents medical necessity, under current practice rules an insurance company won’t pay for these direct to consumer tests. The consumer must pay out of pocket. Of course, those rules may change. If patients want a throat swab to test for strep, maybe it is cheaper to have them go directly to the neighborhood lab than to see a doctor, especially if, when the test is positive, they then expect to phone their doctor for free and get a prescription.
Most medical tests have significant false-positive and false-negative results. Simple rapid strep throat tests and rapid influenza nasal swabs have a sensitivity of only 90%-95%. Many doctors, even those who use the results on a daily basis, cannot convert that information into a positive and negative predictive value. So if a company offers the test directly to the consumer, and reports it out with a “Just the facts, Ma’am” positive or negative result, is the consumer responsible for any misinterpretation, or has the laboratory company deceptively marketed a defective, imperfect product?
The bigger financial impact will be all the follow-up labs and imaging tests generated by the initial false-positive screening labs. Insurance probably will pay for those. Using a similar business model, a few hospitals nationwide now offer free (or close to it) low-dose chest CT scans to smokers and ex-smokers. This is done as a loss leader that generates profits for the hospital from all the follow-up tests, imaging, and biopsies. Compare this model with the old-time practice in which pediatricians in the 1950s to 1980s (and in many places, against guidelines, in the 1990s) had parents bring in a sample of the child’s urine for each well-child visit. That practice was abandoned on cost-benefit-harm arguments because of all the unnecessary subsequent testing, especially kidney ultrasounds, generated by the false positives. Now parents will be able to order the test themselves.
I’m skeptical about how soon a computer will completely replace a physician. Peter Thiel said, “We were promised flying cars and instead what we got was 140 characters.” But Google has finally created the self-driving car. And Elizabeth Holmes has averaged making more money in a week than I will in a career. So who are you going to believe?
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. E-mail him at [email protected].
Emerging Biologics in Orthopedics
The discipline of orthopedic medicine and surgery has dramatically advanced over the last several decades. Improved understanding of biomechanics, tissue healing, and the pathogenesis of musculoskeletal diseases has allowed us to make significant progress in the diagnosis, treatment, and rehabilitation of our patients. Despite these advancements, there is still much to be learned, especially in the field of orthobiologics and regenerative medicine. As our understanding of existing technologies, such as bone marrow aspirate, platelet-rich plasma, and adult stem cells, continues to evolve, even newer biologic treatment options are being developed. This issue of The American Journal of Orthopedics focuses on emerging biologics across the spectrum of orthopedic care.
In this issue, on pages 202-205, Mansour and Conway describe a new prone retrograde technique for obtaining bone graft using the Reamer/Irrigator/Aspirator (RIA) system (Synthes, West Chester, Pennsylvania). While iliac crest bone graft has been the gold standard for many years, use of the RIA system to obtain bone graft has been studied and has been shown to have decreased morbidity when compared with iliac crest harvest.1 Additionally, intramedullary bone graft from the femur appears to be just as concentrated with biologically active bone marrow as iliac crest harvest.2 This new technique allows increased efficiency, especially for surgeries that are done in the prone position.
Melamed and colleagues examine a new biologic to augment repair of rotator cuff tears (see pages 212-216). Chitosan, a linear polysaccharide, has been shown to help with soft-tissue healing. Although in the past its use has been limited secondary to problems with the compound precipitating at physiologic pH, new formulations mitigate that problem. In the authors’ animal model of acute supraspinatus repair, the use of chitosan gel increased the number of fibroblasts and the amount of repair tissue when compared with untreated controls. Additionally, the experimental group showed a decreased inflammatory response when compared with the control group. This is very exciting research as the biologic enhancement of rotator cuff tendon healing could potentially help decrease the rate of rotator cuff repair failure.
Lenehan and colleagues analyze the long-term outcomes of anterior cruciate ligament reconstruction in a cohort of patients studied over an 8-year period (see pages 217-222). During this period, 99 patients were reconstructed with allograft tissue and 24 with autograft. Their analysis, like other recently published work, shows that the rates of revision were much higher for patients under 25 years of age who were reconstructed using allograft tissue. The rate of revision for NCAA (National Collegiate Athletic Association) Division I athletes reconstructed with allograft tissue was found to be 62%, while the revision rate for all patients under the age of 25 years who received an allograft was found to be 20.5%. Clearly, there is still a great deal to learn about the biology of graft incorporation and healing, especially as it relates to allograft tissue.
These 3 articles exemplify the breadth of orthopedic biologics and their potential role in orthopedic surgery. Through efforts of investigators highlighted in this journal and in others, biologics will become better understood and more widely used when appropriate, leading to improved patient outcomes.
1. Calori GM, Colombo M, Mazza EL, Mazzola S, Malagoli E, Mineo GV. Incidence of donor site morbidity following harvesting from iliac crest or RIA graft. Injury. 2014;45 Suppl 6:S116-S120.
2. van der Bel R, Blokhuis TJ. Increased osteogenic capacity of Reamer/Irrigator/Aspirator derived mesenchymal stem cells. Injury. 2014;45(12):2060-2064.
The discipline of orthopedic medicine and surgery has dramatically advanced over the last several decades. Improved understanding of biomechanics, tissue healing, and the pathogenesis of musculoskeletal diseases has allowed us to make significant progress in the diagnosis, treatment, and rehabilitation of our patients. Despite these advancements, there is still much to be learned, especially in the field of orthobiologics and regenerative medicine. As our understanding of existing technologies, such as bone marrow aspirate, platelet-rich plasma, and adult stem cells, continues to evolve, even newer biologic treatment options are being developed. This issue of The American Journal of Orthopedics focuses on emerging biologics across the spectrum of orthopedic care.
In this issue, on pages 202-205, Mansour and Conway describe a new prone retrograde technique for obtaining bone graft using the Reamer/Irrigator/Aspirator (RIA) system (Synthes, West Chester, Pennsylvania). While iliac crest bone graft has been the gold standard for many years, use of the RIA system to obtain bone graft has been studied and has been shown to have decreased morbidity when compared with iliac crest harvest.1 Additionally, intramedullary bone graft from the femur appears to be just as concentrated with biologically active bone marrow as iliac crest harvest.2 This new technique allows increased efficiency, especially for surgeries that are done in the prone position.
Melamed and colleagues examine a new biologic to augment repair of rotator cuff tears (see pages 212-216). Chitosan, a linear polysaccharide, has been shown to help with soft-tissue healing. Although in the past its use has been limited secondary to problems with the compound precipitating at physiologic pH, new formulations mitigate that problem. In the authors’ animal model of acute supraspinatus repair, the use of chitosan gel increased the number of fibroblasts and the amount of repair tissue when compared with untreated controls. Additionally, the experimental group showed a decreased inflammatory response when compared with the control group. This is very exciting research as the biologic enhancement of rotator cuff tendon healing could potentially help decrease the rate of rotator cuff repair failure.
Lenehan and colleagues analyze the long-term outcomes of anterior cruciate ligament reconstruction in a cohort of patients studied over an 8-year period (see pages 217-222). During this period, 99 patients were reconstructed with allograft tissue and 24 with autograft. Their analysis, like other recently published work, shows that the rates of revision were much higher for patients under 25 years of age who were reconstructed using allograft tissue. The rate of revision for NCAA (National Collegiate Athletic Association) Division I athletes reconstructed with allograft tissue was found to be 62%, while the revision rate for all patients under the age of 25 years who received an allograft was found to be 20.5%. Clearly, there is still a great deal to learn about the biology of graft incorporation and healing, especially as it relates to allograft tissue.
These 3 articles exemplify the breadth of orthopedic biologics and their potential role in orthopedic surgery. Through efforts of investigators highlighted in this journal and in others, biologics will become better understood and more widely used when appropriate, leading to improved patient outcomes.
The discipline of orthopedic medicine and surgery has dramatically advanced over the last several decades. Improved understanding of biomechanics, tissue healing, and the pathogenesis of musculoskeletal diseases has allowed us to make significant progress in the diagnosis, treatment, and rehabilitation of our patients. Despite these advancements, there is still much to be learned, especially in the field of orthobiologics and regenerative medicine. As our understanding of existing technologies, such as bone marrow aspirate, platelet-rich plasma, and adult stem cells, continues to evolve, even newer biologic treatment options are being developed. This issue of The American Journal of Orthopedics focuses on emerging biologics across the spectrum of orthopedic care.
In this issue, on pages 202-205, Mansour and Conway describe a new prone retrograde technique for obtaining bone graft using the Reamer/Irrigator/Aspirator (RIA) system (Synthes, West Chester, Pennsylvania). While iliac crest bone graft has been the gold standard for many years, use of the RIA system to obtain bone graft has been studied and has been shown to have decreased morbidity when compared with iliac crest harvest.1 Additionally, intramedullary bone graft from the femur appears to be just as concentrated with biologically active bone marrow as iliac crest harvest.2 This new technique allows increased efficiency, especially for surgeries that are done in the prone position.
Melamed and colleagues examine a new biologic to augment repair of rotator cuff tears (see pages 212-216). Chitosan, a linear polysaccharide, has been shown to help with soft-tissue healing. Although in the past its use has been limited secondary to problems with the compound precipitating at physiologic pH, new formulations mitigate that problem. In the authors’ animal model of acute supraspinatus repair, the use of chitosan gel increased the number of fibroblasts and the amount of repair tissue when compared with untreated controls. Additionally, the experimental group showed a decreased inflammatory response when compared with the control group. This is very exciting research as the biologic enhancement of rotator cuff tendon healing could potentially help decrease the rate of rotator cuff repair failure.
Lenehan and colleagues analyze the long-term outcomes of anterior cruciate ligament reconstruction in a cohort of patients studied over an 8-year period (see pages 217-222). During this period, 99 patients were reconstructed with allograft tissue and 24 with autograft. Their analysis, like other recently published work, shows that the rates of revision were much higher for patients under 25 years of age who were reconstructed using allograft tissue. The rate of revision for NCAA (National Collegiate Athletic Association) Division I athletes reconstructed with allograft tissue was found to be 62%, while the revision rate for all patients under the age of 25 years who received an allograft was found to be 20.5%. Clearly, there is still a great deal to learn about the biology of graft incorporation and healing, especially as it relates to allograft tissue.
These 3 articles exemplify the breadth of orthopedic biologics and their potential role in orthopedic surgery. Through efforts of investigators highlighted in this journal and in others, biologics will become better understood and more widely used when appropriate, leading to improved patient outcomes.
1. Calori GM, Colombo M, Mazza EL, Mazzola S, Malagoli E, Mineo GV. Incidence of donor site morbidity following harvesting from iliac crest or RIA graft. Injury. 2014;45 Suppl 6:S116-S120.
2. van der Bel R, Blokhuis TJ. Increased osteogenic capacity of Reamer/Irrigator/Aspirator derived mesenchymal stem cells. Injury. 2014;45(12):2060-2064.
1. Calori GM, Colombo M, Mazza EL, Mazzola S, Malagoli E, Mineo GV. Incidence of donor site morbidity following harvesting from iliac crest or RIA graft. Injury. 2014;45 Suppl 6:S116-S120.
2. van der Bel R, Blokhuis TJ. Increased osteogenic capacity of Reamer/Irrigator/Aspirator derived mesenchymal stem cells. Injury. 2014;45(12):2060-2064.
NSAIDs for depression
At the risk of stating the obvious, our patients are becoming increasingly complex. Life is prolonged and comorbidities accumulate, creating dizzying laundry lists of medical problems.
Within the context of clinical or, increasingly, nonreimbursed telephonic or electronic visits, we attack the medical problem with the worst severity in an attempt to tamp it down to the level of its comorbid brethren.
Almost without exception, depression rears its ugly head in our sickest patients. Antidepressants will be started and added to the three pages (double-spaced, with 1-inch margins) of medications.
But in all of these patients, are we treating the disease or just the symptom? What if inflammation is causing the depression? Will reduction of inflammation treat the depression?
Dr. Ole Köhler of Aarhus University Hospital, Denmark, and his colleagues conducted a systematic review on the antidepressant effects of anti-inflammatory medications (JAMA Psychiatry 2014;71:1381-91). Fourteen trials informed the meta-analysis, 10 that evaluated NSAID drugs (for example, celecoxib, naproxen, ibuprofen), and 4 that investigated cytokine inhibitors (for example, etanercept, infliximab). Six of the 10 NSAID studies evaluated NSAIDs as monotherapy. All four of the cytokine-inhibitor trials evaluated them as monotherapy. Length of treatment was between 6 and 12 weeks.
The pooled effect suggests that anti-inflammatory treatment reduced depressive symptoms. Celecoxib seemed to have the strongest effect on remission and clinical response. No increase in adverse events was reported.
We know that proinflammatory drugs can induce depression. So the opposite is quite possibly true, and these data suggest it to be so. Findings suggest that reducing the inflammatory state among our patients with depression may be a useful adjunct to antidepressant therapy, at least in the initial period.
Whatever we can do to facilitate depressive symptom relief seems a worthy goal. So, here again, we could tell our patients presenting with depression to take two (with an SSRI, perhaps) and call us in the morning. But how best to do this and in what patients remains uncertain.
Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified, practicing clinician.
At the risk of stating the obvious, our patients are becoming increasingly complex. Life is prolonged and comorbidities accumulate, creating dizzying laundry lists of medical problems.
Within the context of clinical or, increasingly, nonreimbursed telephonic or electronic visits, we attack the medical problem with the worst severity in an attempt to tamp it down to the level of its comorbid brethren.
Almost without exception, depression rears its ugly head in our sickest patients. Antidepressants will be started and added to the three pages (double-spaced, with 1-inch margins) of medications.
But in all of these patients, are we treating the disease or just the symptom? What if inflammation is causing the depression? Will reduction of inflammation treat the depression?
Dr. Ole Köhler of Aarhus University Hospital, Denmark, and his colleagues conducted a systematic review on the antidepressant effects of anti-inflammatory medications (JAMA Psychiatry 2014;71:1381-91). Fourteen trials informed the meta-analysis, 10 that evaluated NSAID drugs (for example, celecoxib, naproxen, ibuprofen), and 4 that investigated cytokine inhibitors (for example, etanercept, infliximab). Six of the 10 NSAID studies evaluated NSAIDs as monotherapy. All four of the cytokine-inhibitor trials evaluated them as monotherapy. Length of treatment was between 6 and 12 weeks.
The pooled effect suggests that anti-inflammatory treatment reduced depressive symptoms. Celecoxib seemed to have the strongest effect on remission and clinical response. No increase in adverse events was reported.
We know that proinflammatory drugs can induce depression. So the opposite is quite possibly true, and these data suggest it to be so. Findings suggest that reducing the inflammatory state among our patients with depression may be a useful adjunct to antidepressant therapy, at least in the initial period.
Whatever we can do to facilitate depressive symptom relief seems a worthy goal. So, here again, we could tell our patients presenting with depression to take two (with an SSRI, perhaps) and call us in the morning. But how best to do this and in what patients remains uncertain.
Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified, practicing clinician.
At the risk of stating the obvious, our patients are becoming increasingly complex. Life is prolonged and comorbidities accumulate, creating dizzying laundry lists of medical problems.
Within the context of clinical or, increasingly, nonreimbursed telephonic or electronic visits, we attack the medical problem with the worst severity in an attempt to tamp it down to the level of its comorbid brethren.
Almost without exception, depression rears its ugly head in our sickest patients. Antidepressants will be started and added to the three pages (double-spaced, with 1-inch margins) of medications.
But in all of these patients, are we treating the disease or just the symptom? What if inflammation is causing the depression? Will reduction of inflammation treat the depression?
Dr. Ole Köhler of Aarhus University Hospital, Denmark, and his colleagues conducted a systematic review on the antidepressant effects of anti-inflammatory medications (JAMA Psychiatry 2014;71:1381-91). Fourteen trials informed the meta-analysis, 10 that evaluated NSAID drugs (for example, celecoxib, naproxen, ibuprofen), and 4 that investigated cytokine inhibitors (for example, etanercept, infliximab). Six of the 10 NSAID studies evaluated NSAIDs as monotherapy. All four of the cytokine-inhibitor trials evaluated them as monotherapy. Length of treatment was between 6 and 12 weeks.
The pooled effect suggests that anti-inflammatory treatment reduced depressive symptoms. Celecoxib seemed to have the strongest effect on remission and clinical response. No increase in adverse events was reported.
We know that proinflammatory drugs can induce depression. So the opposite is quite possibly true, and these data suggest it to be so. Findings suggest that reducing the inflammatory state among our patients with depression may be a useful adjunct to antidepressant therapy, at least in the initial period.
Whatever we can do to facilitate depressive symptom relief seems a worthy goal. So, here again, we could tell our patients presenting with depression to take two (with an SSRI, perhaps) and call us in the morning. But how best to do this and in what patients remains uncertain.
Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified, practicing clinician.
Vitamin D for prevention of falls
Older adults are at an increased risk for falls and fractures. The estimated medical cost of falls in 2010 was $28.2 billion. The lost quality of life, high rate of institutionalization, and cost to society caused by falls makes this an important topic to address. Low vitamin D can lead to balance problems, weakness, and low bone mineral density with higher fall and fracture rates. Vitamin D supplementation has been found to decrease falls sustained by elderly patients. The American Geriatrics Society has released a consensus statement, based on findings of a work group of researchers and clinicians with expertise in vitamin D and older adults, on the use of vitamin D for prevention of falls in elderly patients in either the community or institutions.
Recommendations to reduce falls and fractures in older people
The consensus statement recommends that patients 65 years and older in the community as well as in institutions should receive supplementation of at least 1,000 IU/day to help decrease the risk of falls and subsequent fractures. It was found in studies that less than 600 IU/day did not prevent falls. Calcium should be administered with the vitamin D at a dose of 1,000-1,200 mg/day. There are insufficient data to recommend vitamin D supplementation without calcium.
Optimizing vitamin D status
The goal vitamin D serum level is 30 ng/mL, and this is based on a review of trials with serum levels of > 24 ng/mL that showed lower fall rates and trials that showed higher relative risk for falls with vitamin D levels < 25 ng/mL. The vitamin D total intake found to achieve a level > 30 ng/mL (75 nmol/L) in 92% of older adults was 4,000 IU/day. This took into account dietary vitamin D, sun exposure, and supplementation. Taking 4,000 IU/day of vitamin D is well below 10,000 IU/day, the highest tolerable amount. There has not been shown to be any cases of vitamin D intoxication at levels less than 200 ng/mL or at supplement levels of less than 30,000 IU/day.
In patients without the comorbidities mentioned below, there was not found to be a role in checking vitamin D levels, before supplementation or for monitoring, if the recommended supplementation is given. For those who wish to monitor levels, you should check the vitamin 25(OH)D levels 4 months after vitamin D3 supplementation.
Special populations
Patients who take medicines such as cholestyramine, phenytoin, and phenobarbital should have their levels monitored, as these drugs can decrease vitamin D levels. Also obese patients and patients with malabsorption syndromes may need more frequent monitoring.
Vitamin D supplementation individualized
To prescribe a personalized vitamin D3 supplementation regimen, first start with 3,000 IU and then add or subtract to determine the adequate supplementation. Subtract 150-225 IU/day for dietary intake and subtract vitamin D in multivitamins and calcium combination tablets. It is not recommended to encourage sun exposure to increase vitamin D levels, but you can subtract about 500-1,000 IU/day in the summer months for patients with regular unprotected sun exposure. About 500-800 IU/day should be added for obesity and about 300-600 IU/day should be added for darker skin pigmentation. A total of 4,000 IU/day supplementation should not be exceeded except in special populations.
Vitamin D2 vs. D3
Vitamin D3 has been shown to provide higher serum levels of 25(OH)D than vitamin D2. Vitamin D3 is available without prescription in 400, 800, 1,000, 2,000, 5,000, and 10,000 IU formulations. Vitamin D2 is available by prescription at a dose of 50,000 IU.
Vitamin D2 at a dose of 50,000 IU has not been FDA approved to increase serum 25(OH)D levels. Avoid giving vitamin D with cholestyramine, high-fiber cereals, and fiber-based stool softeners. It is best to be taken with meals with oil for better absorption. Daily, weekly, and monthly vitamin D3 supplementation has been shown to equally achieve target blood levels of vitamin D.
The bottom line
Preventing falls in our older adult population is important for many reasons including maintaining quality of life, limiting institutionalization, and helping to decrease medical cost. Maintaining adequate vitamin D serum levels has been shown to help reduce falls and fractures in older adults. A goal level of > 30 ng/mL has been shown to help with the prevention of falls and fractures. The work group came to a different conclusion from the Institute of Medicine Report, which recommended vitamin D serum levels > 20 ng/mL in older adults. In trials with serum levels of 24 ng/mL, there was a clear lower fall rate seen. In trials with levels < 25 ng/mL, there was a higher relative risk of falls. A total daily intake of vitamin D3 of 4,000 IU has been shown to reach a serum level of 30 ng/mL in 92% on patients 65 years and older. In order to reach this goal, older adults in the community and in institutions require about 1,000 IU of vitamin D3 supplementation daily. However, it is ideal to individualize the supplementation amount based on each person’s sun exposure, daily dietary intake, and other medications or comorbidities that they have.
Reference
American Geriatrics Society Consensus Statement on Vitamin D for Prevention of Falls and Their Consequences – American Geriatrics Society Workgroup on Vitamin D Supplementation for Older Adults. J. Am. Geriatr. Soc. 2014;62:147-52.
Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Dr. Bowry is a third year resident in the family medicine residency at Abington Memorial Hospital.
Older adults are at an increased risk for falls and fractures. The estimated medical cost of falls in 2010 was $28.2 billion. The lost quality of life, high rate of institutionalization, and cost to society caused by falls makes this an important topic to address. Low vitamin D can lead to balance problems, weakness, and low bone mineral density with higher fall and fracture rates. Vitamin D supplementation has been found to decrease falls sustained by elderly patients. The American Geriatrics Society has released a consensus statement, based on findings of a work group of researchers and clinicians with expertise in vitamin D and older adults, on the use of vitamin D for prevention of falls in elderly patients in either the community or institutions.
Recommendations to reduce falls and fractures in older people
The consensus statement recommends that patients 65 years and older in the community as well as in institutions should receive supplementation of at least 1,000 IU/day to help decrease the risk of falls and subsequent fractures. It was found in studies that less than 600 IU/day did not prevent falls. Calcium should be administered with the vitamin D at a dose of 1,000-1,200 mg/day. There are insufficient data to recommend vitamin D supplementation without calcium.
Optimizing vitamin D status
The goal vitamin D serum level is 30 ng/mL, and this is based on a review of trials with serum levels of > 24 ng/mL that showed lower fall rates and trials that showed higher relative risk for falls with vitamin D levels < 25 ng/mL. The vitamin D total intake found to achieve a level > 30 ng/mL (75 nmol/L) in 92% of older adults was 4,000 IU/day. This took into account dietary vitamin D, sun exposure, and supplementation. Taking 4,000 IU/day of vitamin D is well below 10,000 IU/day, the highest tolerable amount. There has not been shown to be any cases of vitamin D intoxication at levels less than 200 ng/mL or at supplement levels of less than 30,000 IU/day.
In patients without the comorbidities mentioned below, there was not found to be a role in checking vitamin D levels, before supplementation or for monitoring, if the recommended supplementation is given. For those who wish to monitor levels, you should check the vitamin 25(OH)D levels 4 months after vitamin D3 supplementation.
Special populations
Patients who take medicines such as cholestyramine, phenytoin, and phenobarbital should have their levels monitored, as these drugs can decrease vitamin D levels. Also obese patients and patients with malabsorption syndromes may need more frequent monitoring.
Vitamin D supplementation individualized
To prescribe a personalized vitamin D3 supplementation regimen, first start with 3,000 IU and then add or subtract to determine the adequate supplementation. Subtract 150-225 IU/day for dietary intake and subtract vitamin D in multivitamins and calcium combination tablets. It is not recommended to encourage sun exposure to increase vitamin D levels, but you can subtract about 500-1,000 IU/day in the summer months for patients with regular unprotected sun exposure. About 500-800 IU/day should be added for obesity and about 300-600 IU/day should be added for darker skin pigmentation. A total of 4,000 IU/day supplementation should not be exceeded except in special populations.
Vitamin D2 vs. D3
Vitamin D3 has been shown to provide higher serum levels of 25(OH)D than vitamin D2. Vitamin D3 is available without prescription in 400, 800, 1,000, 2,000, 5,000, and 10,000 IU formulations. Vitamin D2 is available by prescription at a dose of 50,000 IU.
Vitamin D2 at a dose of 50,000 IU has not been FDA approved to increase serum 25(OH)D levels. Avoid giving vitamin D with cholestyramine, high-fiber cereals, and fiber-based stool softeners. It is best to be taken with meals with oil for better absorption. Daily, weekly, and monthly vitamin D3 supplementation has been shown to equally achieve target blood levels of vitamin D.
The bottom line
Preventing falls in our older adult population is important for many reasons including maintaining quality of life, limiting institutionalization, and helping to decrease medical cost. Maintaining adequate vitamin D serum levels has been shown to help reduce falls and fractures in older adults. A goal level of > 30 ng/mL has been shown to help with the prevention of falls and fractures. The work group came to a different conclusion from the Institute of Medicine Report, which recommended vitamin D serum levels > 20 ng/mL in older adults. In trials with serum levels of 24 ng/mL, there was a clear lower fall rate seen. In trials with levels < 25 ng/mL, there was a higher relative risk of falls. A total daily intake of vitamin D3 of 4,000 IU has been shown to reach a serum level of 30 ng/mL in 92% on patients 65 years and older. In order to reach this goal, older adults in the community and in institutions require about 1,000 IU of vitamin D3 supplementation daily. However, it is ideal to individualize the supplementation amount based on each person’s sun exposure, daily dietary intake, and other medications or comorbidities that they have.
Reference
American Geriatrics Society Consensus Statement on Vitamin D for Prevention of Falls and Their Consequences – American Geriatrics Society Workgroup on Vitamin D Supplementation for Older Adults. J. Am. Geriatr. Soc. 2014;62:147-52.
Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Dr. Bowry is a third year resident in the family medicine residency at Abington Memorial Hospital.
Older adults are at an increased risk for falls and fractures. The estimated medical cost of falls in 2010 was $28.2 billion. The lost quality of life, high rate of institutionalization, and cost to society caused by falls makes this an important topic to address. Low vitamin D can lead to balance problems, weakness, and low bone mineral density with higher fall and fracture rates. Vitamin D supplementation has been found to decrease falls sustained by elderly patients. The American Geriatrics Society has released a consensus statement, based on findings of a work group of researchers and clinicians with expertise in vitamin D and older adults, on the use of vitamin D for prevention of falls in elderly patients in either the community or institutions.
Recommendations to reduce falls and fractures in older people
The consensus statement recommends that patients 65 years and older in the community as well as in institutions should receive supplementation of at least 1,000 IU/day to help decrease the risk of falls and subsequent fractures. It was found in studies that less than 600 IU/day did not prevent falls. Calcium should be administered with the vitamin D at a dose of 1,000-1,200 mg/day. There are insufficient data to recommend vitamin D supplementation without calcium.
Optimizing vitamin D status
The goal vitamin D serum level is 30 ng/mL, and this is based on a review of trials with serum levels of > 24 ng/mL that showed lower fall rates and trials that showed higher relative risk for falls with vitamin D levels < 25 ng/mL. The vitamin D total intake found to achieve a level > 30 ng/mL (75 nmol/L) in 92% of older adults was 4,000 IU/day. This took into account dietary vitamin D, sun exposure, and supplementation. Taking 4,000 IU/day of vitamin D is well below 10,000 IU/day, the highest tolerable amount. There has not been shown to be any cases of vitamin D intoxication at levels less than 200 ng/mL or at supplement levels of less than 30,000 IU/day.
In patients without the comorbidities mentioned below, there was not found to be a role in checking vitamin D levels, before supplementation or for monitoring, if the recommended supplementation is given. For those who wish to monitor levels, you should check the vitamin 25(OH)D levels 4 months after vitamin D3 supplementation.
Special populations
Patients who take medicines such as cholestyramine, phenytoin, and phenobarbital should have their levels monitored, as these drugs can decrease vitamin D levels. Also obese patients and patients with malabsorption syndromes may need more frequent monitoring.
Vitamin D supplementation individualized
To prescribe a personalized vitamin D3 supplementation regimen, first start with 3,000 IU and then add or subtract to determine the adequate supplementation. Subtract 150-225 IU/day for dietary intake and subtract vitamin D in multivitamins and calcium combination tablets. It is not recommended to encourage sun exposure to increase vitamin D levels, but you can subtract about 500-1,000 IU/day in the summer months for patients with regular unprotected sun exposure. About 500-800 IU/day should be added for obesity and about 300-600 IU/day should be added for darker skin pigmentation. A total of 4,000 IU/day supplementation should not be exceeded except in special populations.
Vitamin D2 vs. D3
Vitamin D3 has been shown to provide higher serum levels of 25(OH)D than vitamin D2. Vitamin D3 is available without prescription in 400, 800, 1,000, 2,000, 5,000, and 10,000 IU formulations. Vitamin D2 is available by prescription at a dose of 50,000 IU.
Vitamin D2 at a dose of 50,000 IU has not been FDA approved to increase serum 25(OH)D levels. Avoid giving vitamin D with cholestyramine, high-fiber cereals, and fiber-based stool softeners. It is best to be taken with meals with oil for better absorption. Daily, weekly, and monthly vitamin D3 supplementation has been shown to equally achieve target blood levels of vitamin D.
The bottom line
Preventing falls in our older adult population is important for many reasons including maintaining quality of life, limiting institutionalization, and helping to decrease medical cost. Maintaining adequate vitamin D serum levels has been shown to help reduce falls and fractures in older adults. A goal level of > 30 ng/mL has been shown to help with the prevention of falls and fractures. The work group came to a different conclusion from the Institute of Medicine Report, which recommended vitamin D serum levels > 20 ng/mL in older adults. In trials with serum levels of 24 ng/mL, there was a clear lower fall rate seen. In trials with levels < 25 ng/mL, there was a higher relative risk of falls. A total daily intake of vitamin D3 of 4,000 IU has been shown to reach a serum level of 30 ng/mL in 92% on patients 65 years and older. In order to reach this goal, older adults in the community and in institutions require about 1,000 IU of vitamin D3 supplementation daily. However, it is ideal to individualize the supplementation amount based on each person’s sun exposure, daily dietary intake, and other medications or comorbidities that they have.
Reference
American Geriatrics Society Consensus Statement on Vitamin D for Prevention of Falls and Their Consequences – American Geriatrics Society Workgroup on Vitamin D Supplementation for Older Adults. J. Am. Geriatr. Soc. 2014;62:147-52.
Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Dr. Bowry is a third year resident in the family medicine residency at Abington Memorial Hospital.
Pregnancy in the cancer survivor
Obstetric providers are being called upon to care for an increasing number of cancer survivors. Whether it was a childhood cancer or one faced in early adulthood, pregnant cancer survivors raise a unique set of questions and concerns. A general knowledge about management is essential in counseling these women prior to and early in pregnancy.
For the woman who presents preconception, one of the most common questions is when is the best time for pregnancy. Importantly, there are no absolute guidelines on how long a woman should be “disease free.” Many providers suggest waiting 2 years from the time of diagnosis. This “conventional wisdom” is not based on evidence (Oncology 2005;19:693-7). Instead, the type of cancer and the length of treatment can help determine the answer.
Many oncologists prefer a specific time for monitoring after treatment to ensure that initial treatment has been successful. For example, in the case of melanoma, after 2 years, the estimate of recurrence risk may be more accurate (Cancer Causes Control 2008;19:437-42). After breast cancer, women are often followed with MRI with contrast and mammogram. Since both are problematic in pregnancy, 3-5 years may be more appropriate.
Many patients are concerned about the risk of recurrence during pregnancy. Though data are limited, pregnancy does not appear to increase the risk of disease recurrence or decrease disease-free survival, even in the case of more aggressive cancers such as melanoma. This remains true in the setting of hormone receptor–positive cancers, specifically breast cancer (Lancet 1997;350:319-22).
Preconception counseling
The risks for a cancer survivor during pregnancy will vary depending on the treatments she has received. Preconception evaluation should be modified for the specific oncologic therapies. For example, women who received chest radiation, or anthracycline-based chemotherapies (or any cardiotoxic medications) should have a cardiac evaluation as they are at risk of cardiac dysfunction prior to and during pregnancy (Matern. Child. Health J. 2006;10[suppl. 1]:165-8).
Additionally, because chemotherapy may be hepatotoxic or nephrotoxic, baseline liver and renal function tests should almost always be performed. It is not unreasonable to follow these during pregnancy given the physiologic changes.
Many women also are concerned about the risks that prior cancer therapies may have for their baby. Prior chemotherapy and radiation therapy do not appear to confer any increased risk for genetic conditions, anomalies, or childhood cancer (Am. J. Obstet. Gynecol. 2002;187:1070-80). Additionally, previous chemotherapy alone does not increase the risk of adverse pregnancy outcomes.
In contrast, prior radiation to the abdomen and pelvis has been associated with an increased risk of miscarriage, growth restriction, preterm delivery, and stillbirth (J. Natl. Cancer Instit. Monogr. 2005;34:64-8; Lancet 2010;376:624-30). There is an increased risk of cancer in the offspring of women whose cancer is the result of hereditary cancer syndromes, such as BRCA or hereditary nonpolyposis colorectal cancer. Discussions with a genetics counselor may be helpful if there are any questions related to these syndromes.
Pregnancy management
Once pregnant, management requires a multidisciplinary approach. Surveillance options are limited during pregnancy. CT should be avoided, and radiographs limited. Ultrasound of the abdomen is safe, but optimal images are often obscured in later trimesters. Ultimately, indicated imaging should not be forsaken if there are any signs or symptoms that raise concerns for recurrence. Additionally, many tumor markers may be unreliable during pregnancy, such as CA-125 in the first trimester, or alpha-FP and CEA anytime.
Specific recommendations for antenatal testing do not exist and should be assessed on a case-by-case basis; especially in the case of women who have had prior radiation therapy. Our recommendation is to perform growth surveillance, which may include sonography at varying intervals. Also consider weekly fetal testing from 32 weeks in normally growing fetuses.
Solely being a cancer survivor is not an indication for early delivery or induction of labor. In the majority of cases, mode of delivery should be guided by obstetric indications, though previous pelvic surgery and reconstruction may be indications for cesarean delivery. Despite being in remission, some cancers metastasize to the placenta, most commonly melanoma and hematologic cancers. Very rarely, these cancers can also metastasize to the fetus. Thus, the placenta should be sent for histologic evaluation, with a notation to the pathologist about the patient’s prior cancer (Obstet. Gynecol. Surv. 1989;44:535-40; Ultrasound. Obstet. Gynecol. 2009;33:235-44).
In most cases, pregnancy after cancer is uncomplicated with good outcomes for both mother and baby. However, there are potential medical and obstetric complications that cannot be overlooked. Interdisciplinary management is crucial to ensure a safe transition from cancer survivor to mother.
What to consider when counseling cancer survivors about pregnancy
• The recommended disease-free interval prior to pregnancy may vary by cancer type, and is largely driven by disease surveillance needs and recurrence intervals.
• Prior cancer, associated operations, and chemotherapies do not typically confer additional risks in pregnancy. Exceptions include melanoma and blood cell cancers, which may metastasize to the placenta and fetus, even following periods of remission.
• Radiation therapy to the abdomen and pelvis may induce changes that predispose to growth restriction, preterm birth, and stillbirth. Enhanced surveillance may be reasonable in these cases.
• Preconception or early pregnancy assessment for end organ dysfunction is recommended for women who have received certain therapies: cardiac evaluation following chest radiation or anthracycline-based therapy; liver and kidney function for most chemotherapies.
Dr. Ivester is an associate professor of maternal-fetal medicine and an associate professor of maternal and child health at the University of North Carolina at Chapel Hill. Dr. Dotters-Katz is a maternal-fetal medicine fellow at University of North Carolina at Chapel Hill, who completed her ob.gyn. residency at Duke University. Her academic interests include oncology and infectious diseases as they relate to pregnancy. The authors reported having no financial disclosures. Email them at [email protected].
Obstetric providers are being called upon to care for an increasing number of cancer survivors. Whether it was a childhood cancer or one faced in early adulthood, pregnant cancer survivors raise a unique set of questions and concerns. A general knowledge about management is essential in counseling these women prior to and early in pregnancy.
For the woman who presents preconception, one of the most common questions is when is the best time for pregnancy. Importantly, there are no absolute guidelines on how long a woman should be “disease free.” Many providers suggest waiting 2 years from the time of diagnosis. This “conventional wisdom” is not based on evidence (Oncology 2005;19:693-7). Instead, the type of cancer and the length of treatment can help determine the answer.
Many oncologists prefer a specific time for monitoring after treatment to ensure that initial treatment has been successful. For example, in the case of melanoma, after 2 years, the estimate of recurrence risk may be more accurate (Cancer Causes Control 2008;19:437-42). After breast cancer, women are often followed with MRI with contrast and mammogram. Since both are problematic in pregnancy, 3-5 years may be more appropriate.
Many patients are concerned about the risk of recurrence during pregnancy. Though data are limited, pregnancy does not appear to increase the risk of disease recurrence or decrease disease-free survival, even in the case of more aggressive cancers such as melanoma. This remains true in the setting of hormone receptor–positive cancers, specifically breast cancer (Lancet 1997;350:319-22).
Preconception counseling
The risks for a cancer survivor during pregnancy will vary depending on the treatments she has received. Preconception evaluation should be modified for the specific oncologic therapies. For example, women who received chest radiation, or anthracycline-based chemotherapies (or any cardiotoxic medications) should have a cardiac evaluation as they are at risk of cardiac dysfunction prior to and during pregnancy (Matern. Child. Health J. 2006;10[suppl. 1]:165-8).
Additionally, because chemotherapy may be hepatotoxic or nephrotoxic, baseline liver and renal function tests should almost always be performed. It is not unreasonable to follow these during pregnancy given the physiologic changes.
Many women also are concerned about the risks that prior cancer therapies may have for their baby. Prior chemotherapy and radiation therapy do not appear to confer any increased risk for genetic conditions, anomalies, or childhood cancer (Am. J. Obstet. Gynecol. 2002;187:1070-80). Additionally, previous chemotherapy alone does not increase the risk of adverse pregnancy outcomes.
In contrast, prior radiation to the abdomen and pelvis has been associated with an increased risk of miscarriage, growth restriction, preterm delivery, and stillbirth (J. Natl. Cancer Instit. Monogr. 2005;34:64-8; Lancet 2010;376:624-30). There is an increased risk of cancer in the offspring of women whose cancer is the result of hereditary cancer syndromes, such as BRCA or hereditary nonpolyposis colorectal cancer. Discussions with a genetics counselor may be helpful if there are any questions related to these syndromes.
Pregnancy management
Once pregnant, management requires a multidisciplinary approach. Surveillance options are limited during pregnancy. CT should be avoided, and radiographs limited. Ultrasound of the abdomen is safe, but optimal images are often obscured in later trimesters. Ultimately, indicated imaging should not be forsaken if there are any signs or symptoms that raise concerns for recurrence. Additionally, many tumor markers may be unreliable during pregnancy, such as CA-125 in the first trimester, or alpha-FP and CEA anytime.
Specific recommendations for antenatal testing do not exist and should be assessed on a case-by-case basis; especially in the case of women who have had prior radiation therapy. Our recommendation is to perform growth surveillance, which may include sonography at varying intervals. Also consider weekly fetal testing from 32 weeks in normally growing fetuses.
Solely being a cancer survivor is not an indication for early delivery or induction of labor. In the majority of cases, mode of delivery should be guided by obstetric indications, though previous pelvic surgery and reconstruction may be indications for cesarean delivery. Despite being in remission, some cancers metastasize to the placenta, most commonly melanoma and hematologic cancers. Very rarely, these cancers can also metastasize to the fetus. Thus, the placenta should be sent for histologic evaluation, with a notation to the pathologist about the patient’s prior cancer (Obstet. Gynecol. Surv. 1989;44:535-40; Ultrasound. Obstet. Gynecol. 2009;33:235-44).
In most cases, pregnancy after cancer is uncomplicated with good outcomes for both mother and baby. However, there are potential medical and obstetric complications that cannot be overlooked. Interdisciplinary management is crucial to ensure a safe transition from cancer survivor to mother.
What to consider when counseling cancer survivors about pregnancy
• The recommended disease-free interval prior to pregnancy may vary by cancer type, and is largely driven by disease surveillance needs and recurrence intervals.
• Prior cancer, associated operations, and chemotherapies do not typically confer additional risks in pregnancy. Exceptions include melanoma and blood cell cancers, which may metastasize to the placenta and fetus, even following periods of remission.
• Radiation therapy to the abdomen and pelvis may induce changes that predispose to growth restriction, preterm birth, and stillbirth. Enhanced surveillance may be reasonable in these cases.
• Preconception or early pregnancy assessment for end organ dysfunction is recommended for women who have received certain therapies: cardiac evaluation following chest radiation or anthracycline-based therapy; liver and kidney function for most chemotherapies.
Dr. Ivester is an associate professor of maternal-fetal medicine and an associate professor of maternal and child health at the University of North Carolina at Chapel Hill. Dr. Dotters-Katz is a maternal-fetal medicine fellow at University of North Carolina at Chapel Hill, who completed her ob.gyn. residency at Duke University. Her academic interests include oncology and infectious diseases as they relate to pregnancy. The authors reported having no financial disclosures. Email them at [email protected].
Obstetric providers are being called upon to care for an increasing number of cancer survivors. Whether it was a childhood cancer or one faced in early adulthood, pregnant cancer survivors raise a unique set of questions and concerns. A general knowledge about management is essential in counseling these women prior to and early in pregnancy.
For the woman who presents preconception, one of the most common questions is when is the best time for pregnancy. Importantly, there are no absolute guidelines on how long a woman should be “disease free.” Many providers suggest waiting 2 years from the time of diagnosis. This “conventional wisdom” is not based on evidence (Oncology 2005;19:693-7). Instead, the type of cancer and the length of treatment can help determine the answer.
Many oncologists prefer a specific time for monitoring after treatment to ensure that initial treatment has been successful. For example, in the case of melanoma, after 2 years, the estimate of recurrence risk may be more accurate (Cancer Causes Control 2008;19:437-42). After breast cancer, women are often followed with MRI with contrast and mammogram. Since both are problematic in pregnancy, 3-5 years may be more appropriate.
Many patients are concerned about the risk of recurrence during pregnancy. Though data are limited, pregnancy does not appear to increase the risk of disease recurrence or decrease disease-free survival, even in the case of more aggressive cancers such as melanoma. This remains true in the setting of hormone receptor–positive cancers, specifically breast cancer (Lancet 1997;350:319-22).
Preconception counseling
The risks for a cancer survivor during pregnancy will vary depending on the treatments she has received. Preconception evaluation should be modified for the specific oncologic therapies. For example, women who received chest radiation, or anthracycline-based chemotherapies (or any cardiotoxic medications) should have a cardiac evaluation as they are at risk of cardiac dysfunction prior to and during pregnancy (Matern. Child. Health J. 2006;10[suppl. 1]:165-8).
Additionally, because chemotherapy may be hepatotoxic or nephrotoxic, baseline liver and renal function tests should almost always be performed. It is not unreasonable to follow these during pregnancy given the physiologic changes.
Many women also are concerned about the risks that prior cancer therapies may have for their baby. Prior chemotherapy and radiation therapy do not appear to confer any increased risk for genetic conditions, anomalies, or childhood cancer (Am. J. Obstet. Gynecol. 2002;187:1070-80). Additionally, previous chemotherapy alone does not increase the risk of adverse pregnancy outcomes.
In contrast, prior radiation to the abdomen and pelvis has been associated with an increased risk of miscarriage, growth restriction, preterm delivery, and stillbirth (J. Natl. Cancer Instit. Monogr. 2005;34:64-8; Lancet 2010;376:624-30). There is an increased risk of cancer in the offspring of women whose cancer is the result of hereditary cancer syndromes, such as BRCA or hereditary nonpolyposis colorectal cancer. Discussions with a genetics counselor may be helpful if there are any questions related to these syndromes.
Pregnancy management
Once pregnant, management requires a multidisciplinary approach. Surveillance options are limited during pregnancy. CT should be avoided, and radiographs limited. Ultrasound of the abdomen is safe, but optimal images are often obscured in later trimesters. Ultimately, indicated imaging should not be forsaken if there are any signs or symptoms that raise concerns for recurrence. Additionally, many tumor markers may be unreliable during pregnancy, such as CA-125 in the first trimester, or alpha-FP and CEA anytime.
Specific recommendations for antenatal testing do not exist and should be assessed on a case-by-case basis; especially in the case of women who have had prior radiation therapy. Our recommendation is to perform growth surveillance, which may include sonography at varying intervals. Also consider weekly fetal testing from 32 weeks in normally growing fetuses.
Solely being a cancer survivor is not an indication for early delivery or induction of labor. In the majority of cases, mode of delivery should be guided by obstetric indications, though previous pelvic surgery and reconstruction may be indications for cesarean delivery. Despite being in remission, some cancers metastasize to the placenta, most commonly melanoma and hematologic cancers. Very rarely, these cancers can also metastasize to the fetus. Thus, the placenta should be sent for histologic evaluation, with a notation to the pathologist about the patient’s prior cancer (Obstet. Gynecol. Surv. 1989;44:535-40; Ultrasound. Obstet. Gynecol. 2009;33:235-44).
In most cases, pregnancy after cancer is uncomplicated with good outcomes for both mother and baby. However, there are potential medical and obstetric complications that cannot be overlooked. Interdisciplinary management is crucial to ensure a safe transition from cancer survivor to mother.
What to consider when counseling cancer survivors about pregnancy
• The recommended disease-free interval prior to pregnancy may vary by cancer type, and is largely driven by disease surveillance needs and recurrence intervals.
• Prior cancer, associated operations, and chemotherapies do not typically confer additional risks in pregnancy. Exceptions include melanoma and blood cell cancers, which may metastasize to the placenta and fetus, even following periods of remission.
• Radiation therapy to the abdomen and pelvis may induce changes that predispose to growth restriction, preterm birth, and stillbirth. Enhanced surveillance may be reasonable in these cases.
• Preconception or early pregnancy assessment for end organ dysfunction is recommended for women who have received certain therapies: cardiac evaluation following chest radiation or anthracycline-based therapy; liver and kidney function for most chemotherapies.
Dr. Ivester is an associate professor of maternal-fetal medicine and an associate professor of maternal and child health at the University of North Carolina at Chapel Hill. Dr. Dotters-Katz is a maternal-fetal medicine fellow at University of North Carolina at Chapel Hill, who completed her ob.gyn. residency at Duke University. Her academic interests include oncology and infectious diseases as they relate to pregnancy. The authors reported having no financial disclosures. Email them at [email protected].
Medication compliance
Introduction
Stimulant medications are an important part of attention-deficit/hyperactivity disorder (ADHD) treatment for most affected children and teens. But studies suggest that children and teens may not take their prescribed medication anywhere from 13% to as much as 64% of the time. As teenagers develop an appropriate increased desire for autonomy, they wish to have greater participation in their medication decisions, sometimes to the dismay of their parents.
Case
Will is an engaging young man who has been on stimulants for many years. However, he is frequently in conflict with his parents over an array of issues, including being annoyed at being reminded to take his medications. Although he is willing to take medication some of the time, he often forgets. He commonly fails to complete his homework, a further source of conflict.
Discussion
Parents can get frustrated with their teens and drawn into a control struggle over medication and other issues. Teenagers want to have more control of their lives, and sometimes this takes the form of not wanting to take medication. The No. 1 goal is to help the family move away from digging themselves further into conflict, and instead to have a genuine discussion about the pros and cons of medication.
This starts with listening seriously to the teenager. It helps to reassure teens that you are not going to get mad at them for not taking medication, but that instead you really value the information about how often they are taking it and, if they are skipping some doses or not taking it at all, the reason for that.
It is crucial to find out the real reason why someone is not taking his medication. Sometimes teens are genuinely forgetting. Here it can be helpful to be sure that the medication has to be taken as few times a day as possible, and then to set some kind of alarm reminder. This is one area where the omnipresence of cell phones is very useful. Help parents and teens negotiate about whether the parent will remind the teen, as repeated reminders can be irritating. Divided pill containers help both the parent and teen know whether the medication has been taken or not. If you formulate a plan with the family, write it down so that you can ask next time how it worked out, because if you are asking someone to make a behavior change, it is important to pay attention to whether they did it or not.
Other times it is clear that the teen doesn’t want to take the medication. In this situation, it is important to get the specifics. It is key to convey that the teen’s point of view is very important.
Reasons for not wanting to take a medication include some type of side effect, embarrassment about having to take the medication in school, inconvenience, or a general feeling that the teen doesn’t want to be on medication.
A genuinely collaborative attitude is the best approach. Restate what you have heard from the teen about his or her viewpoint. Help the parents state their concerns (for instance, about school success, driving safety, or the potential for impulsive behavior) in a noncritical manner. Then outline options and discuss the possible pros and cons of the different choices, including going off the medication as one option. By considering this as an option, you will have an opportunity to discuss what the drawbacks, as well as the advantages, might be.
When it comes to ADHD, there are many choices. These can include trying a different stimulant or using a nonstimulant such as atomoxetine or an alpha-adrenergic agonist. Because these medications have very different side effect profiles, they may be more acceptable to the teenager, although they also may have different efficacy. There are also psychotherapeutic options such as organizational skills training. By discussing a variety of choices and listening to the teen’s concerns and hopes, the teenager is engaged in taking responsibility for his own choices.
Once a choice is decided upon, it is important to follow up and review how well the plan is working and revise if necessary.
When to consult
If parents and teens are unable to participate in discussion and come up with a plan, family therapy to improve communication and address parenting issues can be recommended.
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Hall said that she had no relevant financial disclosures. To comment, e-mail her at [email protected].
Introduction
Stimulant medications are an important part of attention-deficit/hyperactivity disorder (ADHD) treatment for most affected children and teens. But studies suggest that children and teens may not take their prescribed medication anywhere from 13% to as much as 64% of the time. As teenagers develop an appropriate increased desire for autonomy, they wish to have greater participation in their medication decisions, sometimes to the dismay of their parents.
Case
Will is an engaging young man who has been on stimulants for many years. However, he is frequently in conflict with his parents over an array of issues, including being annoyed at being reminded to take his medications. Although he is willing to take medication some of the time, he often forgets. He commonly fails to complete his homework, a further source of conflict.
Discussion
Parents can get frustrated with their teens and drawn into a control struggle over medication and other issues. Teenagers want to have more control of their lives, and sometimes this takes the form of not wanting to take medication. The No. 1 goal is to help the family move away from digging themselves further into conflict, and instead to have a genuine discussion about the pros and cons of medication.
This starts with listening seriously to the teenager. It helps to reassure teens that you are not going to get mad at them for not taking medication, but that instead you really value the information about how often they are taking it and, if they are skipping some doses or not taking it at all, the reason for that.
It is crucial to find out the real reason why someone is not taking his medication. Sometimes teens are genuinely forgetting. Here it can be helpful to be sure that the medication has to be taken as few times a day as possible, and then to set some kind of alarm reminder. This is one area where the omnipresence of cell phones is very useful. Help parents and teens negotiate about whether the parent will remind the teen, as repeated reminders can be irritating. Divided pill containers help both the parent and teen know whether the medication has been taken or not. If you formulate a plan with the family, write it down so that you can ask next time how it worked out, because if you are asking someone to make a behavior change, it is important to pay attention to whether they did it or not.
Other times it is clear that the teen doesn’t want to take the medication. In this situation, it is important to get the specifics. It is key to convey that the teen’s point of view is very important.
Reasons for not wanting to take a medication include some type of side effect, embarrassment about having to take the medication in school, inconvenience, or a general feeling that the teen doesn’t want to be on medication.
A genuinely collaborative attitude is the best approach. Restate what you have heard from the teen about his or her viewpoint. Help the parents state their concerns (for instance, about school success, driving safety, or the potential for impulsive behavior) in a noncritical manner. Then outline options and discuss the possible pros and cons of the different choices, including going off the medication as one option. By considering this as an option, you will have an opportunity to discuss what the drawbacks, as well as the advantages, might be.
When it comes to ADHD, there are many choices. These can include trying a different stimulant or using a nonstimulant such as atomoxetine or an alpha-adrenergic agonist. Because these medications have very different side effect profiles, they may be more acceptable to the teenager, although they also may have different efficacy. There are also psychotherapeutic options such as organizational skills training. By discussing a variety of choices and listening to the teen’s concerns and hopes, the teenager is engaged in taking responsibility for his own choices.
Once a choice is decided upon, it is important to follow up and review how well the plan is working and revise if necessary.
When to consult
If parents and teens are unable to participate in discussion and come up with a plan, family therapy to improve communication and address parenting issues can be recommended.
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Hall said that she had no relevant financial disclosures. To comment, e-mail her at [email protected].
Introduction
Stimulant medications are an important part of attention-deficit/hyperactivity disorder (ADHD) treatment for most affected children and teens. But studies suggest that children and teens may not take their prescribed medication anywhere from 13% to as much as 64% of the time. As teenagers develop an appropriate increased desire for autonomy, they wish to have greater participation in their medication decisions, sometimes to the dismay of their parents.
Case
Will is an engaging young man who has been on stimulants for many years. However, he is frequently in conflict with his parents over an array of issues, including being annoyed at being reminded to take his medications. Although he is willing to take medication some of the time, he often forgets. He commonly fails to complete his homework, a further source of conflict.
Discussion
Parents can get frustrated with their teens and drawn into a control struggle over medication and other issues. Teenagers want to have more control of their lives, and sometimes this takes the form of not wanting to take medication. The No. 1 goal is to help the family move away from digging themselves further into conflict, and instead to have a genuine discussion about the pros and cons of medication.
This starts with listening seriously to the teenager. It helps to reassure teens that you are not going to get mad at them for not taking medication, but that instead you really value the information about how often they are taking it and, if they are skipping some doses or not taking it at all, the reason for that.
It is crucial to find out the real reason why someone is not taking his medication. Sometimes teens are genuinely forgetting. Here it can be helpful to be sure that the medication has to be taken as few times a day as possible, and then to set some kind of alarm reminder. This is one area where the omnipresence of cell phones is very useful. Help parents and teens negotiate about whether the parent will remind the teen, as repeated reminders can be irritating. Divided pill containers help both the parent and teen know whether the medication has been taken or not. If you formulate a plan with the family, write it down so that you can ask next time how it worked out, because if you are asking someone to make a behavior change, it is important to pay attention to whether they did it or not.
Other times it is clear that the teen doesn’t want to take the medication. In this situation, it is important to get the specifics. It is key to convey that the teen’s point of view is very important.
Reasons for not wanting to take a medication include some type of side effect, embarrassment about having to take the medication in school, inconvenience, or a general feeling that the teen doesn’t want to be on medication.
A genuinely collaborative attitude is the best approach. Restate what you have heard from the teen about his or her viewpoint. Help the parents state their concerns (for instance, about school success, driving safety, or the potential for impulsive behavior) in a noncritical manner. Then outline options and discuss the possible pros and cons of the different choices, including going off the medication as one option. By considering this as an option, you will have an opportunity to discuss what the drawbacks, as well as the advantages, might be.
When it comes to ADHD, there are many choices. These can include trying a different stimulant or using a nonstimulant such as atomoxetine or an alpha-adrenergic agonist. Because these medications have very different side effect profiles, they may be more acceptable to the teenager, although they also may have different efficacy. There are also psychotherapeutic options such as organizational skills training. By discussing a variety of choices and listening to the teen’s concerns and hopes, the teenager is engaged in taking responsibility for his own choices.
Once a choice is decided upon, it is important to follow up and review how well the plan is working and revise if necessary.
When to consult
If parents and teens are unable to participate in discussion and come up with a plan, family therapy to improve communication and address parenting issues can be recommended.
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Hall said that she had no relevant financial disclosures. To comment, e-mail her at [email protected].
Shared decision making? Part two
In a previous editorial I outlined the problem with performance measures that demand that we incorporate the patient into our decision-making process. From the responses received I have found that most vascular surgeons do indeed attempt to explain their choice of procedure and outline the various risks, consequences, and alternatives. However, it is apparent that both patients and physicians may no longer have control over their decisions. As a group, physicians and surgeons are increasingly being marginalized by entities that are deciding, without our input, what we can do, to whom, and with what.
This is especially so when it involves the technologies that we employ daily – or would like to employ. Thus, if we are not given the opportunity to use a technology we believe most appropriate for our patient, then the patient is also removed from the decision-making process.
Following trips overseas and with meeting vascular surgeons at the World Federation of Vascular Associations, I am now aware that our marginalization has become a universal problem. Because it is not only hospital administrators but insurance carriers, industry, and government agencies that are involved in restricting our freedom of choice. Although cost is usually the limiting factor, sometimes perverse incentives are in effect, and these may differ depending not only in which hospital a surgeon practices but also in which state or country the surgeon resides.
Unfortunately, most surgeons are now accustomed to having hospital chief financial officers (CFOs) refuse to purchase devices that these administrators consider too expensive despite evidence demonstrating clinical superiority. In the U.S. hospitals are compensated for a procedure irrespective of whether it was performed because of a failed prior surgery or endovascular intervention.
For example, if a patient has a prosthetic infra-inguinal bypass that fails within a few months, insurance companies and Medicare will still pay for the subsequent revascularization. Strangely, it would actually be in the hospital’s financial interest that the original procedure require a revision! Accordingly, there is no incentive for a hospital to purchase grafts or endovascular devices with superior short- or long-term results, especially if they are more costly. Is it any wonder then that health care expenses in this country are spiraling out of control?
Surely vascular surgeons would not be equally motivated to use an inferior product simply to be able to bill for a repeat procedure at a later date? But are some of our colleagues or those in other specialties paying attention to the paucity of data supporting long-term outcomes of some of the new endovascular procedures such as atherectomy? Do they really care that these devices may not offer anything more than a few months of palliation necessitating that the patient make a return trip to a lucrative outpatient facility?
On the other hand a health maintenance organization (HMO) or government that pays for all health- related issues of its populace would be inclined to pay for a device that offers long-term efficacy provided that it proves to be cost effective. For example an expensive drug-eluting stent that resists restenosis may still be worth funding if it prevents the need for re-intervention. However, if the result is that every covered patient will henceforth be treated with these costly stents, the overall cost may prove uneconomical and the use of these stents will be disallowed.Moreover, I am sure most surgeons also would be amazed to learn that the availability of a technology may be limited by restrictions on foreign trade and import/export regulations. Some countries insist that devices, and even their packaging, be made in part or totally in that country. Many countries now require that their own equivalent of the FDA analyze the safety or benefit of new medical devices rather than relying on the CE mark in Europe or the U.S. FDA. These regulations may make it economically unfeasible for companies to do business in that country. Thus vascular surgeons in those countries may be denied access to devices produced by market-leading U.S .companies.
Industry also controls availability. A certain recent device was quite effective in the few patients in whom I used it. But apparently it proved to be commercially nonviable and was discontinued. The question is – how many other potentially useful devices have never made it into production?
So how do we fight back against these restrictions? Perhaps the following stratagems may work. If you practice in a city with at least two hospitals, use only the hospital that provides you with all the tools you need. Understand that vascular surgical procedures are profitable for most hospitals. As a result the second hospital will soon notice your absence and may be willing to negotiate. If you are meeting resistance from an ACO, make sure when you present the reasons for requesting a new device that you can also provide valid long-term cost-effective data.
Insurance carriers and government institutions will be more difficult to convince. Accordingly, utilize the collective power of a state or national vascular Society. When dealing with trade embargoes perhaps the European Society for Vascular Surgery, the Society for Vascular Surgery, or the World Federation of Vascular Societies may be able to assist. Appealing to the public through newspaper articles may also be beneficial. It’s time for physicians and surgeons to protest our continued marginalization. After all who knows better which device, drug, or treatment to use? The doctor or the recently graduated MBA? On behalf of our patients we need to take a stand.
In a previous editorial I outlined the problem with performance measures that demand that we incorporate the patient into our decision-making process. From the responses received I have found that most vascular surgeons do indeed attempt to explain their choice of procedure and outline the various risks, consequences, and alternatives. However, it is apparent that both patients and physicians may no longer have control over their decisions. As a group, physicians and surgeons are increasingly being marginalized by entities that are deciding, without our input, what we can do, to whom, and with what.
This is especially so when it involves the technologies that we employ daily – or would like to employ. Thus, if we are not given the opportunity to use a technology we believe most appropriate for our patient, then the patient is also removed from the decision-making process.
Following trips overseas and with meeting vascular surgeons at the World Federation of Vascular Associations, I am now aware that our marginalization has become a universal problem. Because it is not only hospital administrators but insurance carriers, industry, and government agencies that are involved in restricting our freedom of choice. Although cost is usually the limiting factor, sometimes perverse incentives are in effect, and these may differ depending not only in which hospital a surgeon practices but also in which state or country the surgeon resides.
Unfortunately, most surgeons are now accustomed to having hospital chief financial officers (CFOs) refuse to purchase devices that these administrators consider too expensive despite evidence demonstrating clinical superiority. In the U.S. hospitals are compensated for a procedure irrespective of whether it was performed because of a failed prior surgery or endovascular intervention.
For example, if a patient has a prosthetic infra-inguinal bypass that fails within a few months, insurance companies and Medicare will still pay for the subsequent revascularization. Strangely, it would actually be in the hospital’s financial interest that the original procedure require a revision! Accordingly, there is no incentive for a hospital to purchase grafts or endovascular devices with superior short- or long-term results, especially if they are more costly. Is it any wonder then that health care expenses in this country are spiraling out of control?
Surely vascular surgeons would not be equally motivated to use an inferior product simply to be able to bill for a repeat procedure at a later date? But are some of our colleagues or those in other specialties paying attention to the paucity of data supporting long-term outcomes of some of the new endovascular procedures such as atherectomy? Do they really care that these devices may not offer anything more than a few months of palliation necessitating that the patient make a return trip to a lucrative outpatient facility?
On the other hand a health maintenance organization (HMO) or government that pays for all health- related issues of its populace would be inclined to pay for a device that offers long-term efficacy provided that it proves to be cost effective. For example an expensive drug-eluting stent that resists restenosis may still be worth funding if it prevents the need for re-intervention. However, if the result is that every covered patient will henceforth be treated with these costly stents, the overall cost may prove uneconomical and the use of these stents will be disallowed.Moreover, I am sure most surgeons also would be amazed to learn that the availability of a technology may be limited by restrictions on foreign trade and import/export regulations. Some countries insist that devices, and even their packaging, be made in part or totally in that country. Many countries now require that their own equivalent of the FDA analyze the safety or benefit of new medical devices rather than relying on the CE mark in Europe or the U.S. FDA. These regulations may make it economically unfeasible for companies to do business in that country. Thus vascular surgeons in those countries may be denied access to devices produced by market-leading U.S .companies.
Industry also controls availability. A certain recent device was quite effective in the few patients in whom I used it. But apparently it proved to be commercially nonviable and was discontinued. The question is – how many other potentially useful devices have never made it into production?
So how do we fight back against these restrictions? Perhaps the following stratagems may work. If you practice in a city with at least two hospitals, use only the hospital that provides you with all the tools you need. Understand that vascular surgical procedures are profitable for most hospitals. As a result the second hospital will soon notice your absence and may be willing to negotiate. If you are meeting resistance from an ACO, make sure when you present the reasons for requesting a new device that you can also provide valid long-term cost-effective data.
Insurance carriers and government institutions will be more difficult to convince. Accordingly, utilize the collective power of a state or national vascular Society. When dealing with trade embargoes perhaps the European Society for Vascular Surgery, the Society for Vascular Surgery, or the World Federation of Vascular Societies may be able to assist. Appealing to the public through newspaper articles may also be beneficial. It’s time for physicians and surgeons to protest our continued marginalization. After all who knows better which device, drug, or treatment to use? The doctor or the recently graduated MBA? On behalf of our patients we need to take a stand.
In a previous editorial I outlined the problem with performance measures that demand that we incorporate the patient into our decision-making process. From the responses received I have found that most vascular surgeons do indeed attempt to explain their choice of procedure and outline the various risks, consequences, and alternatives. However, it is apparent that both patients and physicians may no longer have control over their decisions. As a group, physicians and surgeons are increasingly being marginalized by entities that are deciding, without our input, what we can do, to whom, and with what.
This is especially so when it involves the technologies that we employ daily – or would like to employ. Thus, if we are not given the opportunity to use a technology we believe most appropriate for our patient, then the patient is also removed from the decision-making process.
Following trips overseas and with meeting vascular surgeons at the World Federation of Vascular Associations, I am now aware that our marginalization has become a universal problem. Because it is not only hospital administrators but insurance carriers, industry, and government agencies that are involved in restricting our freedom of choice. Although cost is usually the limiting factor, sometimes perverse incentives are in effect, and these may differ depending not only in which hospital a surgeon practices but also in which state or country the surgeon resides.
Unfortunately, most surgeons are now accustomed to having hospital chief financial officers (CFOs) refuse to purchase devices that these administrators consider too expensive despite evidence demonstrating clinical superiority. In the U.S. hospitals are compensated for a procedure irrespective of whether it was performed because of a failed prior surgery or endovascular intervention.
For example, if a patient has a prosthetic infra-inguinal bypass that fails within a few months, insurance companies and Medicare will still pay for the subsequent revascularization. Strangely, it would actually be in the hospital’s financial interest that the original procedure require a revision! Accordingly, there is no incentive for a hospital to purchase grafts or endovascular devices with superior short- or long-term results, especially if they are more costly. Is it any wonder then that health care expenses in this country are spiraling out of control?
Surely vascular surgeons would not be equally motivated to use an inferior product simply to be able to bill for a repeat procedure at a later date? But are some of our colleagues or those in other specialties paying attention to the paucity of data supporting long-term outcomes of some of the new endovascular procedures such as atherectomy? Do they really care that these devices may not offer anything more than a few months of palliation necessitating that the patient make a return trip to a lucrative outpatient facility?
On the other hand a health maintenance organization (HMO) or government that pays for all health- related issues of its populace would be inclined to pay for a device that offers long-term efficacy provided that it proves to be cost effective. For example an expensive drug-eluting stent that resists restenosis may still be worth funding if it prevents the need for re-intervention. However, if the result is that every covered patient will henceforth be treated with these costly stents, the overall cost may prove uneconomical and the use of these stents will be disallowed.Moreover, I am sure most surgeons also would be amazed to learn that the availability of a technology may be limited by restrictions on foreign trade and import/export regulations. Some countries insist that devices, and even their packaging, be made in part or totally in that country. Many countries now require that their own equivalent of the FDA analyze the safety or benefit of new medical devices rather than relying on the CE mark in Europe or the U.S. FDA. These regulations may make it economically unfeasible for companies to do business in that country. Thus vascular surgeons in those countries may be denied access to devices produced by market-leading U.S .companies.
Industry also controls availability. A certain recent device was quite effective in the few patients in whom I used it. But apparently it proved to be commercially nonviable and was discontinued. The question is – how many other potentially useful devices have never made it into production?
So how do we fight back against these restrictions? Perhaps the following stratagems may work. If you practice in a city with at least two hospitals, use only the hospital that provides you with all the tools you need. Understand that vascular surgical procedures are profitable for most hospitals. As a result the second hospital will soon notice your absence and may be willing to negotiate. If you are meeting resistance from an ACO, make sure when you present the reasons for requesting a new device that you can also provide valid long-term cost-effective data.
Insurance carriers and government institutions will be more difficult to convince. Accordingly, utilize the collective power of a state or national vascular Society. When dealing with trade embargoes perhaps the European Society for Vascular Surgery, the Society for Vascular Surgery, or the World Federation of Vascular Societies may be able to assist. Appealing to the public through newspaper articles may also be beneficial. It’s time for physicians and surgeons to protest our continued marginalization. After all who knows better which device, drug, or treatment to use? The doctor or the recently graduated MBA? On behalf of our patients we need to take a stand.
Helping parents manage rules across two homes
A major challenge faced by parents is the task of setting basic ground rules and expectations for their children, and then enforcing these with limits, rewards, and consequences. This task is made far more difficult when parents are separated or divorced. Agreeing upon and enforcing rules in separate homes often becomes burdened by the angry baggage that led to the divorce. When a family in your practice is going through a divorce, you have an opportunity to provide the parents with valuable strategies to manage rules effectively so that conflict is minimized.
Many happily married parents who communicate very well on most matters struggle to get on the same page when negotiating rules and limits. One parent’s sense of what is an appropriate bedtime, how children should help with chores, or even how often they can have sweets can become a deeply held belief and might be very different than their spouse’s opinions. Sometimes, a parent has old anger about how they were raised and finds it hard to distinguish what might have been better for them, compared with what is best for their own child. Cultural and family differences on how much choice children should have at different ages, criteria and severity of any consequences for misbehavior, and opportunities for redemption or amnesty all add complexity to the discussion. Once they have found common ground on what makes sense for their joint rules, values, and needs of their child, they have to manage enforcing rules and limits, agreeing upon appropriate rewards and punishments, and bearing the inevitable distress of their children when facing a limit or consequence. And, of course, once parents think they have it all figured out, their children react and grow, and they must reset the rules, expectations, and consequences.
When parents get separated or divorced, this process becomes considerably more difficult. Negotiating new rules or limits is very difficult when communication is hampered by conflict. Parental guilt about the divorce itself, anger at old hurts or disputes about money and custody, missing the child between visits, and remarriages all add baggage to the discussion of a reasonable bedtime or consequences for a poor grade at school. If the divorce required aggressive negotiation between lawyers, appointment of a guardian ad Litem to manage ongoing disputes involving the children, or a court case to reach resolution, the tensions between parents can be intense, enduring, and with no issue too small to add fuel to the arguments. Enforcing limits is much harder for a single parent than when there are two parents doing the enforcement. And divorced parents, already feeling guilty and insecure, are more likely to suspend rules or limits so that they don’t have to be the “bad parent.” For the child or children, the stress and disruptions that come with divorce can cause an increase in regressed or disrespectful behavior. While it can be a time when limits are increasingly tested, being reasonable and consistent in enforcing limits becomes more important, as it provides reassuring steadiness in the midst of turbulent change.
Let’s take the example of a 12-year-old coming home from school with poor grades. One parent may see the need for a tutor, but might be using that approach as part of a financial attack if the other parent has to pay for it. The other parent may want to limit the use of computer games or access to television until the grades go up. And one may expect movement from a D to a C average while the other may expect A’s, period. Is the poor grade based on lack of ability, effort, an attempt to get attention, a reaction to the divorce, or preoccupation with ongoing parental discord? What is the impact on the child if in one home there is a tutor and a C expectation, and in the other there is no tutor, no computer use, no TV... and these change every time the child moves from one home to the other? A child striving to overcome a poor grade needs calm, consistent, patient, and optimistic support, rather than managing the increased tension across two homes or feeling like the cause of increased conflict. Virtually any reasonable approach is better for the child than each parent doing something different as a reflection of ongoing tension. Pediatricians can be extraordinarily helpful to their patient if they can get divorced parents to agree on a single approach that is based on their child’s needs rather than past and ongoing angers. The emotional damage of ongoing discord is far worse than any C average.
As the pediatrician to a family managing divorce, you may be one of the few authority figures whom both parents and the children all still respect and trust. You are in a strong position to ask a parent during an appointment how rules and limits are being managed across two homes. Find out if they have a clear plan for handling routine communication about the children, whether about summer camps or a new curfew, so that they don’t default to communicating only once there is a crisis. See if rules are a vehicle for ongoing parental fighting so that a minor difference (an 8 o’clock bedtime in one house versus 9 o’clock in the other) carries a high emotional charge. Find out if there are certain rules that have become very hard to enforce, or if their child has been testing limits more. Ask if there has been a consequence enforced in one home, but not in another. Often simply providing a calm affirmation that increased limit testing is normal in children after a divorce is very reassuring for parents. Remind them that providing reasonably consistent rules and limits will be very helpful to their children during this period, the opposite of making them a “bad parent.”
Some divorced parents will become more rigid about rules, managing any infraction or extenuating circumstance more like a contract negotiation. These parents might benefit from a suggestion that consistency and simplicity are the keys to effective rules across two households. Rules also provide an opportunity to listen to their children’s thoughts and feelings and share the family’s values that are the basis for the rules. Parents should be curious about their children’s opinions and be ready to show thoughtful flexibility when rules become outdated or special circumstances exist.
You can suggest a rule the parents should follow. While they can talk honestly about what each parent may struggle with or acknowledge clear differences in style or personality, they should strive to never vilify the other parent. Even in circumstances in which it is very difficult for two parents to collaborate, sharing grievances with the children will only be painful and confusing for them.
Lastly, pediatricians can discuss the long-term goals that all parents, even those alienated from each other, share. Children will do best when they have a positive, honest, warm relationship with each parent, and do not carry responsibility for negotiating conflict between their parents. Ultimately, more autonomy and fewer rules will be an important part of the child’s adolescence. Discord between parents, sabotaging of rules and consequences, and explicit contempt for their children’s other parent all will lead to children feeling burdened, having lower self-esteem, and being at greater risk for serious problems in school, emotionally or with substances as they grow into adolescents and young adults. If you are frustrated in your effort to protect children from ongoing discord, suggest a referral to a mental health clinician with expertise helping parents after a divorce.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at [email protected].
A major challenge faced by parents is the task of setting basic ground rules and expectations for their children, and then enforcing these with limits, rewards, and consequences. This task is made far more difficult when parents are separated or divorced. Agreeing upon and enforcing rules in separate homes often becomes burdened by the angry baggage that led to the divorce. When a family in your practice is going through a divorce, you have an opportunity to provide the parents with valuable strategies to manage rules effectively so that conflict is minimized.
Many happily married parents who communicate very well on most matters struggle to get on the same page when negotiating rules and limits. One parent’s sense of what is an appropriate bedtime, how children should help with chores, or even how often they can have sweets can become a deeply held belief and might be very different than their spouse’s opinions. Sometimes, a parent has old anger about how they were raised and finds it hard to distinguish what might have been better for them, compared with what is best for their own child. Cultural and family differences on how much choice children should have at different ages, criteria and severity of any consequences for misbehavior, and opportunities for redemption or amnesty all add complexity to the discussion. Once they have found common ground on what makes sense for their joint rules, values, and needs of their child, they have to manage enforcing rules and limits, agreeing upon appropriate rewards and punishments, and bearing the inevitable distress of their children when facing a limit or consequence. And, of course, once parents think they have it all figured out, their children react and grow, and they must reset the rules, expectations, and consequences.
When parents get separated or divorced, this process becomes considerably more difficult. Negotiating new rules or limits is very difficult when communication is hampered by conflict. Parental guilt about the divorce itself, anger at old hurts or disputes about money and custody, missing the child between visits, and remarriages all add baggage to the discussion of a reasonable bedtime or consequences for a poor grade at school. If the divorce required aggressive negotiation between lawyers, appointment of a guardian ad Litem to manage ongoing disputes involving the children, or a court case to reach resolution, the tensions between parents can be intense, enduring, and with no issue too small to add fuel to the arguments. Enforcing limits is much harder for a single parent than when there are two parents doing the enforcement. And divorced parents, already feeling guilty and insecure, are more likely to suspend rules or limits so that they don’t have to be the “bad parent.” For the child or children, the stress and disruptions that come with divorce can cause an increase in regressed or disrespectful behavior. While it can be a time when limits are increasingly tested, being reasonable and consistent in enforcing limits becomes more important, as it provides reassuring steadiness in the midst of turbulent change.
Let’s take the example of a 12-year-old coming home from school with poor grades. One parent may see the need for a tutor, but might be using that approach as part of a financial attack if the other parent has to pay for it. The other parent may want to limit the use of computer games or access to television until the grades go up. And one may expect movement from a D to a C average while the other may expect A’s, period. Is the poor grade based on lack of ability, effort, an attempt to get attention, a reaction to the divorce, or preoccupation with ongoing parental discord? What is the impact on the child if in one home there is a tutor and a C expectation, and in the other there is no tutor, no computer use, no TV... and these change every time the child moves from one home to the other? A child striving to overcome a poor grade needs calm, consistent, patient, and optimistic support, rather than managing the increased tension across two homes or feeling like the cause of increased conflict. Virtually any reasonable approach is better for the child than each parent doing something different as a reflection of ongoing tension. Pediatricians can be extraordinarily helpful to their patient if they can get divorced parents to agree on a single approach that is based on their child’s needs rather than past and ongoing angers. The emotional damage of ongoing discord is far worse than any C average.
As the pediatrician to a family managing divorce, you may be one of the few authority figures whom both parents and the children all still respect and trust. You are in a strong position to ask a parent during an appointment how rules and limits are being managed across two homes. Find out if they have a clear plan for handling routine communication about the children, whether about summer camps or a new curfew, so that they don’t default to communicating only once there is a crisis. See if rules are a vehicle for ongoing parental fighting so that a minor difference (an 8 o’clock bedtime in one house versus 9 o’clock in the other) carries a high emotional charge. Find out if there are certain rules that have become very hard to enforce, or if their child has been testing limits more. Ask if there has been a consequence enforced in one home, but not in another. Often simply providing a calm affirmation that increased limit testing is normal in children after a divorce is very reassuring for parents. Remind them that providing reasonably consistent rules and limits will be very helpful to their children during this period, the opposite of making them a “bad parent.”
Some divorced parents will become more rigid about rules, managing any infraction or extenuating circumstance more like a contract negotiation. These parents might benefit from a suggestion that consistency and simplicity are the keys to effective rules across two households. Rules also provide an opportunity to listen to their children’s thoughts and feelings and share the family’s values that are the basis for the rules. Parents should be curious about their children’s opinions and be ready to show thoughtful flexibility when rules become outdated or special circumstances exist.
You can suggest a rule the parents should follow. While they can talk honestly about what each parent may struggle with or acknowledge clear differences in style or personality, they should strive to never vilify the other parent. Even in circumstances in which it is very difficult for two parents to collaborate, sharing grievances with the children will only be painful and confusing for them.
Lastly, pediatricians can discuss the long-term goals that all parents, even those alienated from each other, share. Children will do best when they have a positive, honest, warm relationship with each parent, and do not carry responsibility for negotiating conflict between their parents. Ultimately, more autonomy and fewer rules will be an important part of the child’s adolescence. Discord between parents, sabotaging of rules and consequences, and explicit contempt for their children’s other parent all will lead to children feeling burdened, having lower self-esteem, and being at greater risk for serious problems in school, emotionally or with substances as they grow into adolescents and young adults. If you are frustrated in your effort to protect children from ongoing discord, suggest a referral to a mental health clinician with expertise helping parents after a divorce.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at [email protected].
A major challenge faced by parents is the task of setting basic ground rules and expectations for their children, and then enforcing these with limits, rewards, and consequences. This task is made far more difficult when parents are separated or divorced. Agreeing upon and enforcing rules in separate homes often becomes burdened by the angry baggage that led to the divorce. When a family in your practice is going through a divorce, you have an opportunity to provide the parents with valuable strategies to manage rules effectively so that conflict is minimized.
Many happily married parents who communicate very well on most matters struggle to get on the same page when negotiating rules and limits. One parent’s sense of what is an appropriate bedtime, how children should help with chores, or even how often they can have sweets can become a deeply held belief and might be very different than their spouse’s opinions. Sometimes, a parent has old anger about how they were raised and finds it hard to distinguish what might have been better for them, compared with what is best for their own child. Cultural and family differences on how much choice children should have at different ages, criteria and severity of any consequences for misbehavior, and opportunities for redemption or amnesty all add complexity to the discussion. Once they have found common ground on what makes sense for their joint rules, values, and needs of their child, they have to manage enforcing rules and limits, agreeing upon appropriate rewards and punishments, and bearing the inevitable distress of their children when facing a limit or consequence. And, of course, once parents think they have it all figured out, their children react and grow, and they must reset the rules, expectations, and consequences.
When parents get separated or divorced, this process becomes considerably more difficult. Negotiating new rules or limits is very difficult when communication is hampered by conflict. Parental guilt about the divorce itself, anger at old hurts or disputes about money and custody, missing the child between visits, and remarriages all add baggage to the discussion of a reasonable bedtime or consequences for a poor grade at school. If the divorce required aggressive negotiation between lawyers, appointment of a guardian ad Litem to manage ongoing disputes involving the children, or a court case to reach resolution, the tensions between parents can be intense, enduring, and with no issue too small to add fuel to the arguments. Enforcing limits is much harder for a single parent than when there are two parents doing the enforcement. And divorced parents, already feeling guilty and insecure, are more likely to suspend rules or limits so that they don’t have to be the “bad parent.” For the child or children, the stress and disruptions that come with divorce can cause an increase in regressed or disrespectful behavior. While it can be a time when limits are increasingly tested, being reasonable and consistent in enforcing limits becomes more important, as it provides reassuring steadiness in the midst of turbulent change.
Let’s take the example of a 12-year-old coming home from school with poor grades. One parent may see the need for a tutor, but might be using that approach as part of a financial attack if the other parent has to pay for it. The other parent may want to limit the use of computer games or access to television until the grades go up. And one may expect movement from a D to a C average while the other may expect A’s, period. Is the poor grade based on lack of ability, effort, an attempt to get attention, a reaction to the divorce, or preoccupation with ongoing parental discord? What is the impact on the child if in one home there is a tutor and a C expectation, and in the other there is no tutor, no computer use, no TV... and these change every time the child moves from one home to the other? A child striving to overcome a poor grade needs calm, consistent, patient, and optimistic support, rather than managing the increased tension across two homes or feeling like the cause of increased conflict. Virtually any reasonable approach is better for the child than each parent doing something different as a reflection of ongoing tension. Pediatricians can be extraordinarily helpful to their patient if they can get divorced parents to agree on a single approach that is based on their child’s needs rather than past and ongoing angers. The emotional damage of ongoing discord is far worse than any C average.
As the pediatrician to a family managing divorce, you may be one of the few authority figures whom both parents and the children all still respect and trust. You are in a strong position to ask a parent during an appointment how rules and limits are being managed across two homes. Find out if they have a clear plan for handling routine communication about the children, whether about summer camps or a new curfew, so that they don’t default to communicating only once there is a crisis. See if rules are a vehicle for ongoing parental fighting so that a minor difference (an 8 o’clock bedtime in one house versus 9 o’clock in the other) carries a high emotional charge. Find out if there are certain rules that have become very hard to enforce, or if their child has been testing limits more. Ask if there has been a consequence enforced in one home, but not in another. Often simply providing a calm affirmation that increased limit testing is normal in children after a divorce is very reassuring for parents. Remind them that providing reasonably consistent rules and limits will be very helpful to their children during this period, the opposite of making them a “bad parent.”
Some divorced parents will become more rigid about rules, managing any infraction or extenuating circumstance more like a contract negotiation. These parents might benefit from a suggestion that consistency and simplicity are the keys to effective rules across two households. Rules also provide an opportunity to listen to their children’s thoughts and feelings and share the family’s values that are the basis for the rules. Parents should be curious about their children’s opinions and be ready to show thoughtful flexibility when rules become outdated or special circumstances exist.
You can suggest a rule the parents should follow. While they can talk honestly about what each parent may struggle with or acknowledge clear differences in style or personality, they should strive to never vilify the other parent. Even in circumstances in which it is very difficult for two parents to collaborate, sharing grievances with the children will only be painful and confusing for them.
Lastly, pediatricians can discuss the long-term goals that all parents, even those alienated from each other, share. Children will do best when they have a positive, honest, warm relationship with each parent, and do not carry responsibility for negotiating conflict between their parents. Ultimately, more autonomy and fewer rules will be an important part of the child’s adolescence. Discord between parents, sabotaging of rules and consequences, and explicit contempt for their children’s other parent all will lead to children feeling burdened, having lower self-esteem, and being at greater risk for serious problems in school, emotionally or with substances as they grow into adolescents and young adults. If you are frustrated in your effort to protect children from ongoing discord, suggest a referral to a mental health clinician with expertise helping parents after a divorce.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at [email protected].
Technology misuse hinders development in very young
We often hear parents express concern that misuse of technology may be harming their children’s communication health. Despite this concern, significant numbers of parents are handing off smart phones to children as young as age 2 years and are allowing considerable use of technology at the dinner table, sacrificing what should be a prime time to provide the human interaction so vital to their children’s development of strong communication skills.
These are some of the leading findings from a national survey of parents of children aged 0-8 years that the American Speech-Language-Hearing Association (ASHA) commissioned for release during Better Hearing and Speech Month May 2015.
Is technology bad? Are smart phones, tablets, MP3 players, and other devices overtaking and quite possibly harming young children? Not exactly. The devices themselves aren’t the problem, the problem is how they are used. Our survey showed that very young children are using devices such as tablets and smart phones – and that, unfortunately, parents are often not heeding pediatrician screen time recommendations. According to survey respondents, a majority of 2-year-olds use a tablet. The survey also suggests that as children grow older, they prefer to spend more time with technology, where they are free to stare at screens or blast music into ear buds as they wish – potentially damaging their hearing and losing out on important human interaction.
While children are developing their vocabulary and communication skills, it is vital that they not be preoccupied by activities involving use of tablets, smart phones, and other personal technology. This is especially the case for young children, who experience the vast majority of their brain development in their first few years of life. We know that early verbal communication is a strong predictor of a child’s future reading ability and overall academic success. It is critical that we make parents aware of the convincing benefits of reducing screen time and increasing time spent talking, reading, and interacting verbally with children.
We applaud you addressing this subject via the American Academy of Pediatrics’ literacy toolkit and other avenues for reducing screen time (Pediatrics 2013;132:958-61).Unfortunately, according to our poll, well-meaning parents haven’t completely gotten the message – and many rely on technology for a variety of purposes. About half of them say they use technology to keep kids aged 0-3 years entertained, and many report using it to prevent behavior problems and tantrums.
Let’s join forces in raising awareness about the importance of communication health and how parents can foster it through simple, free steps like regularly engaging their kids in conversation, talking to them about the importance of keeping volume levels down, and modeling safe listening behavior themselves.
The need for action is great. A study in Pediatrics reported significant increases between 2001-2002 and 2010-2011 in disabilities associated with speech and hearing among U.S. children (Pediatrics 2014;134:530-8).
Unlike most other conditions, many communication disorders are reversible or even preventable with early treatment. Parents may delay an assessment by a speech-language pathologist or audiologist in hopes that a child will “outgrow” a problem, or they may not recognize potentially problematic signs. We want to see kids before age 3 years if the early signs are there, when it is more likely they will qualify for early intervention services. Early intervention often results in a shorter, more effective, and less expensive course of treatment for these disorders. Ideally, early intervention will assure that any issue will be resolved or significantly improved by the time a child enters school.
ASHA has a current campaign, Identify the Signs (IdentifytheSigns.org), which offers resources about identifying communication disorders for parents and professionals alike. We invite you and your patients to use these materials to help assure that children receive early intervention for communication disorders. We look forward to working together for the communication health of children.
Dr. Page is director of the division of communication sciences and disorders at the University of Kentucky, Lexington, and 2015 ASHA President. E-mail her at [email protected].
We often hear parents express concern that misuse of technology may be harming their children’s communication health. Despite this concern, significant numbers of parents are handing off smart phones to children as young as age 2 years and are allowing considerable use of technology at the dinner table, sacrificing what should be a prime time to provide the human interaction so vital to their children’s development of strong communication skills.
These are some of the leading findings from a national survey of parents of children aged 0-8 years that the American Speech-Language-Hearing Association (ASHA) commissioned for release during Better Hearing and Speech Month May 2015.
Is technology bad? Are smart phones, tablets, MP3 players, and other devices overtaking and quite possibly harming young children? Not exactly. The devices themselves aren’t the problem, the problem is how they are used. Our survey showed that very young children are using devices such as tablets and smart phones – and that, unfortunately, parents are often not heeding pediatrician screen time recommendations. According to survey respondents, a majority of 2-year-olds use a tablet. The survey also suggests that as children grow older, they prefer to spend more time with technology, where they are free to stare at screens or blast music into ear buds as they wish – potentially damaging their hearing and losing out on important human interaction.
While children are developing their vocabulary and communication skills, it is vital that they not be preoccupied by activities involving use of tablets, smart phones, and other personal technology. This is especially the case for young children, who experience the vast majority of their brain development in their first few years of life. We know that early verbal communication is a strong predictor of a child’s future reading ability and overall academic success. It is critical that we make parents aware of the convincing benefits of reducing screen time and increasing time spent talking, reading, and interacting verbally with children.
We applaud you addressing this subject via the American Academy of Pediatrics’ literacy toolkit and other avenues for reducing screen time (Pediatrics 2013;132:958-61).Unfortunately, according to our poll, well-meaning parents haven’t completely gotten the message – and many rely on technology for a variety of purposes. About half of them say they use technology to keep kids aged 0-3 years entertained, and many report using it to prevent behavior problems and tantrums.
Let’s join forces in raising awareness about the importance of communication health and how parents can foster it through simple, free steps like regularly engaging their kids in conversation, talking to them about the importance of keeping volume levels down, and modeling safe listening behavior themselves.
The need for action is great. A study in Pediatrics reported significant increases between 2001-2002 and 2010-2011 in disabilities associated with speech and hearing among U.S. children (Pediatrics 2014;134:530-8).
Unlike most other conditions, many communication disorders are reversible or even preventable with early treatment. Parents may delay an assessment by a speech-language pathologist or audiologist in hopes that a child will “outgrow” a problem, or they may not recognize potentially problematic signs. We want to see kids before age 3 years if the early signs are there, when it is more likely they will qualify for early intervention services. Early intervention often results in a shorter, more effective, and less expensive course of treatment for these disorders. Ideally, early intervention will assure that any issue will be resolved or significantly improved by the time a child enters school.
ASHA has a current campaign, Identify the Signs (IdentifytheSigns.org), which offers resources about identifying communication disorders for parents and professionals alike. We invite you and your patients to use these materials to help assure that children receive early intervention for communication disorders. We look forward to working together for the communication health of children.
Dr. Page is director of the division of communication sciences and disorders at the University of Kentucky, Lexington, and 2015 ASHA President. E-mail her at [email protected].
We often hear parents express concern that misuse of technology may be harming their children’s communication health. Despite this concern, significant numbers of parents are handing off smart phones to children as young as age 2 years and are allowing considerable use of technology at the dinner table, sacrificing what should be a prime time to provide the human interaction so vital to their children’s development of strong communication skills.
These are some of the leading findings from a national survey of parents of children aged 0-8 years that the American Speech-Language-Hearing Association (ASHA) commissioned for release during Better Hearing and Speech Month May 2015.
Is technology bad? Are smart phones, tablets, MP3 players, and other devices overtaking and quite possibly harming young children? Not exactly. The devices themselves aren’t the problem, the problem is how they are used. Our survey showed that very young children are using devices such as tablets and smart phones – and that, unfortunately, parents are often not heeding pediatrician screen time recommendations. According to survey respondents, a majority of 2-year-olds use a tablet. The survey also suggests that as children grow older, they prefer to spend more time with technology, where they are free to stare at screens or blast music into ear buds as they wish – potentially damaging their hearing and losing out on important human interaction.
While children are developing their vocabulary and communication skills, it is vital that they not be preoccupied by activities involving use of tablets, smart phones, and other personal technology. This is especially the case for young children, who experience the vast majority of their brain development in their first few years of life. We know that early verbal communication is a strong predictor of a child’s future reading ability and overall academic success. It is critical that we make parents aware of the convincing benefits of reducing screen time and increasing time spent talking, reading, and interacting verbally with children.
We applaud you addressing this subject via the American Academy of Pediatrics’ literacy toolkit and other avenues for reducing screen time (Pediatrics 2013;132:958-61).Unfortunately, according to our poll, well-meaning parents haven’t completely gotten the message – and many rely on technology for a variety of purposes. About half of them say they use technology to keep kids aged 0-3 years entertained, and many report using it to prevent behavior problems and tantrums.
Let’s join forces in raising awareness about the importance of communication health and how parents can foster it through simple, free steps like regularly engaging their kids in conversation, talking to them about the importance of keeping volume levels down, and modeling safe listening behavior themselves.
The need for action is great. A study in Pediatrics reported significant increases between 2001-2002 and 2010-2011 in disabilities associated with speech and hearing among U.S. children (Pediatrics 2014;134:530-8).
Unlike most other conditions, many communication disorders are reversible or even preventable with early treatment. Parents may delay an assessment by a speech-language pathologist or audiologist in hopes that a child will “outgrow” a problem, or they may not recognize potentially problematic signs. We want to see kids before age 3 years if the early signs are there, when it is more likely they will qualify for early intervention services. Early intervention often results in a shorter, more effective, and less expensive course of treatment for these disorders. Ideally, early intervention will assure that any issue will be resolved or significantly improved by the time a child enters school.
ASHA has a current campaign, Identify the Signs (IdentifytheSigns.org), which offers resources about identifying communication disorders for parents and professionals alike. We invite you and your patients to use these materials to help assure that children receive early intervention for communication disorders. We look forward to working together for the communication health of children.
Dr. Page is director of the division of communication sciences and disorders at the University of Kentucky, Lexington, and 2015 ASHA President. E-mail her at [email protected].
