Opinion

 

We get paid to see patients. So what happens when patients aren’t in the room?

This is a big, and growing, issue in medicine.

I do hospital call on weekends, and occasionally, I have a long meeting with families. In some cases, this involves a large group in a conference room. These meetings can take quite a bit of time, but since, technically, the patient isn’t present, it requires different charges than if he or she were, even if the whole meeting is about him or her.

Office visits are often the same way. It’s not uncommon for the family of an Alzheimer’s disease patient to want to meet with me without the patient. They’re reluctant to bring up the problems with him or her present or to discuss the future.

Unfortunately, these visits usually aren’t covered by insurance (although this is slowly changing), so families have to pay cash for them, even if they have a direct impact on patient care and take a lot of time.

Telemedicine is the same way. Although it’s getting easier to get visits paid, it’s still not consistent. After all, the patient isn’t physically in the room with you, either. This one, though, at least is starting to take off. But it still has a long way to go.

To date, I haven’t done telemedicine. In a small practice, I can’t afford to lose money on visits, so I don’t plan on starting these until the reimbursement is higher and more consistent. I have to keep the lights on for the patients who depend on me. There are liability issues with it as well since I am unable to examine the patient more than just by sight.

I’m surprised that it’s taking so long for these visits to catch on. If I see someone in my office, I may get paid $80, but if I do it remotely, even for the same amount of time, I get $0. In an era in which people are pushing “patient-centric” care, you’d think telemedicine would be about as patient-centric as you can get. But, apparently, that’s not the case, given the reluctance of many insurers to cover it. And if it’s not being adequately covered, many of us can’t afford to do it.

There needs to be a better realization among payers that patient care doesn’t always involve the patient being physically present, even though we’re still trying to help them.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

 

We get paid to see patients. So what happens when patients aren’t in the room?

This is a big, and growing, issue in medicine.

I do hospital call on weekends, and occasionally, I have a long meeting with families. In some cases, this involves a large group in a conference room. These meetings can take quite a bit of time, but since, technically, the patient isn’t present, it requires different charges than if he or she were, even if the whole meeting is about him or her.

Office visits are often the same way. It’s not uncommon for the family of an Alzheimer’s disease patient to want to meet with me without the patient. They’re reluctant to bring up the problems with him or her present or to discuss the future.

Unfortunately, these visits usually aren’t covered by insurance (although this is slowly changing), so families have to pay cash for them, even if they have a direct impact on patient care and take a lot of time.

Telemedicine is the same way. Although it’s getting easier to get visits paid, it’s still not consistent. After all, the patient isn’t physically in the room with you, either. This one, though, at least is starting to take off. But it still has a long way to go.

To date, I haven’t done telemedicine. In a small practice, I can’t afford to lose money on visits, so I don’t plan on starting these until the reimbursement is higher and more consistent. I have to keep the lights on for the patients who depend on me. There are liability issues with it as well since I am unable to examine the patient more than just by sight.

I’m surprised that it’s taking so long for these visits to catch on. If I see someone in my office, I may get paid $80, but if I do it remotely, even for the same amount of time, I get $0. In an era in which people are pushing “patient-centric” care, you’d think telemedicine would be about as patient-centric as you can get. But, apparently, that’s not the case, given the reluctance of many insurers to cover it. And if it’s not being adequately covered, many of us can’t afford to do it.

There needs to be a better realization among payers that patient care doesn’t always involve the patient being physically present, even though we’re still trying to help them.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

 

We get paid to see patients. So what happens when patients aren’t in the room?

This is a big, and growing, issue in medicine.

I do hospital call on weekends, and occasionally, I have a long meeting with families. In some cases, this involves a large group in a conference room. These meetings can take quite a bit of time, but since, technically, the patient isn’t present, it requires different charges than if he or she were, even if the whole meeting is about him or her.

Office visits are often the same way. It’s not uncommon for the family of an Alzheimer’s disease patient to want to meet with me without the patient. They’re reluctant to bring up the problems with him or her present or to discuss the future.

Unfortunately, these visits usually aren’t covered by insurance (although this is slowly changing), so families have to pay cash for them, even if they have a direct impact on patient care and take a lot of time.

Telemedicine is the same way. Although it’s getting easier to get visits paid, it’s still not consistent. After all, the patient isn’t physically in the room with you, either. This one, though, at least is starting to take off. But it still has a long way to go.

To date, I haven’t done telemedicine. In a small practice, I can’t afford to lose money on visits, so I don’t plan on starting these until the reimbursement is higher and more consistent. I have to keep the lights on for the patients who depend on me. There are liability issues with it as well since I am unable to examine the patient more than just by sight.

I’m surprised that it’s taking so long for these visits to catch on. If I see someone in my office, I may get paid $80, but if I do it remotely, even for the same amount of time, I get $0. In an era in which people are pushing “patient-centric” care, you’d think telemedicine would be about as patient-centric as you can get. But, apparently, that’s not the case, given the reluctance of many insurers to cover it. And if it’s not being adequately covered, many of us can’t afford to do it.

There needs to be a better realization among payers that patient care doesn’t always involve the patient being physically present, even though we’re still trying to help them.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

As clinicians who have been in practice for even a relatively short period of time know, patient compliance is an integral aspect of achieving optimal patient outcomes. However, studies show that patient compliance with treatment of many dermatologic disorders, including acne and psoriasis, is often poor.^1,2

In 2007, Feldman showed that patients are more likely to use their products in the days before and the days after their dermatologist visit.³ He suggested that more frequent office visits would boost compliance. I have found that this is true and I recommend seeing patients every 4 weeks when implementing a new treatment regimen. I have also found that combining prescription medications with the proper corresponding skin care products helps decrease side effects and speed results when patients apply the products correctly.

To increase the chance of patients using the products correctly, they should be educated about how and when to use the products. I cannot overemphasize the importance of this, as illustrated by the following story of a patient who came in with facial redness and irritation. Upon questioning, I learned that she was using her facial cleanser but was not washing it off and left it on all day. She said, “No one told me to wash it off!” While washing a cleanser off may seem obvious, cultural, gender, ethnic, and geographical differences can lead to misunderstandings.

The problem with patient education is that it takes time. It is best if education is provided by staff, but keeping them trained and up to date is also difficult. Most dermatologists only have 3-5 minutes per patient so streamlining the process of designing a treatment plan and educating the patient and recruiting your staff to help is crucial. Before I discuss how to streamline the process, let’s first look at our goals for patients.
 

To achieve good patient outcomes, the patient needs to:

• Understand what medications and products to use.
• Understand when and how to use the products.
• Understand the order in which to use the products (step 1, step 2, etc.).
• Purchase the products (from you or elsewhere).
• Tell you if they do not purchase the products, for whatever reason (insurance will not cover, too expensive, could not find them, etc.).
• Use the products consistently.
• Inform you if they do not use the products (too busy, did not have them on a trip, etc.).
• Report any side effects so you can adjust the therapy accordingly.

You can see why it is so difficult to get patients to be compliant. Many factors – such as time, memory, education level, understanding, motivation, cost, convenience, and insurance coverage – can get in the way of these important components. Giving patients a printed regimen with instructions, selling the products in your practice, and providing some sort of interaction to keep patients engaged is key. In my June 2015 Dermatology News column, I discussed why you should consider selling products in your practice. In the future, I will discuss ways to engage your patients, but for now, let’s focus on how to quickly and effectively provide your patients with printed regimens and patient instructions without increasing office visit times.
 

Streamlining the Process of Generating a Skin Care Regimen That Includes Prescription Medications

Identify patients’ phenotypes

Divide patients into phenotypes based on skin care needs to save yourself time with the recommendation process.

Many doctors do this with a disease-based approach, such as acne, rosacea, eczema, psoriasis, etc. I prefer to classify my patients according to 16 Baumann Skin Types based on four parameters: hydration status, propensity for inflammation; presence or absence of uneven pigmentation; and presence of lifestyle habits, such as sun exposure, that increase an individual’s risk of skin aging.^4,5,6 To quickly diagnose the patient as a particular Baumann Skin Type, I use a tablet-based validated questionnaire called the Baumann Skin Type Indicator (BSTI).⁷ This questionnaire is self-administered by the patient in the waiting room and serves several purposes that facilitate my practice:

• To collect historical and current data.
• To diagnose skin type.
• To ask specifically about skin allergies.
• To learn preferences such as tinted vs. nontinted, or chemical vs. physical sunscreen.
• To inquire about what issues the patient wants to discuss, such as thinning eyelashes, hair loss, dry body skin, toenail fungus, warts, eczema, and other topics that might not come up during the appointment.
• To learn and document habits that affect the skin, such as tanning bed exposure, sun exposure, and smoking.
• To stimulate the patient to think about how daily actions such as sunscreen use and sun exposure affect their skin health.

 

Whether you choose to use my questionnaire or one of your own, using a validated method that can be initiated by staff in the waiting room saves time in the exam room.
 

Include prescription medications in the skin care regimen

Often, we think of skin care regimens and prescription medications as two different entities. In actuality, these should be combined.

For example, when treating acne, every item the patient uses plays a role. For example, if they are washing the face with Ivory soap and then applying benzoyl peroxide and a retinoid they will experience dryness and irritation. Then they will buy a moisturizer that might cause acne. (It is very hard for them to know which moisturizers and sunscreens will not worsen acne). By providing them with the exact names of cleansers, moisturizers, and sunscreens to use, they will be better able to tolerate their prescription acne medications.

The same is true with psoriasis, eczema, seborrheic dermatitis, contact dermatitis, and most of the other ailments that dermatologists treat. You must also tell them the order to use them in. For example, I always have patients apply the retinoid over the noncomedogenic moisturizer for the first few weeks to help them adjust to the retinoid. Later, once they have passed the high-risk period of retinoid dermatitis, I move the retinoid to under the moisturizer.

Psoriasis treatment (topical) is another good example. If they are going to use a surfactant-laden soap on their skin, they will impair their barrier and absorb more of the topically applied drug. Conversely, if they use a barrier repair moisturizer, they will absorb less. Telling the patients exactly which body cleansers and moisturizers to use with topical psoriasis medications will help standardize the response. For this reason, giving patients printed regimens is not limited to treatment of acne, rosacea, and photoaging, but rather should be done for patients with all skin issues and phenotypes.

Have informational material for each phenotype at your fingertips

You can have a plan for each patient phenotype that is designed ahead of time. You will save yourself hours of time if you have preprinted instructions sheets made for each of these phenotypes. You can use Touch MD, The Canfield Visia Camera Patient Portal, your EMR, or other systems to organize this material and deliver it to patients.

I personally use the Skin Type Solutions Software System (STSFranchise.com) that I developed and patented to house and export my patient instructions. Using a standardized methodology to provide educational information through video, preprinted sheets, emails, and other methods allows you to educate your patients at their pace and in the media with which they are most comfortable. To have this flexibility, the educational information must be developed prior to the patient visit. Categorizing the education information by phenotype makes this possible.

What the informational material should contain

Educational information should include important information about the phenotype, the do’s and don’ts for the phenotype, an exact skin care regimen containing clear steps that include product names including brand names, prescription medications, the order in which the products should be applied, and clear instructions on how to use the products.

The patient should be informed about what to do if anticipated adverse events occur, such as redness and peeling from retinoids or dryness from benzoyl peroxide. The same is true about injectable biologic medications for psoriasis. The patients need information on where to inject the product, how often, how to clean the skin beforehand, and what to put on the skin after the injections. It is always important with any skin issue for the patient to know when to contact the office. The American Academy of Dermatology and other organizations offer educational brochures for patients, but they cannot be customized. Patients prefer a customized approach to educational material. They don’t want to read information that does not apply to them. I have found that dividing patients into 16 distinct Baumann Skin Types helps target the right information to the corresponding skin phenotypes.

Summary

Patients need education and guidance to be compliant and improve their outcomes. Your staff needs to be a part of the education process, but taking the time to train your staff and educate your patients is always an issue. Developing a standardized methodology will help overcome these hurdles and solve this problem. The methodology should provide directed education and clear communication with written instructions delivered in the media of the patient’s choice. Doing this will yield better compliance and outcomes.

If you have any questions, suggestions or ideas of how to solve these issues, please share them with me at DrB@skintypesolutions.com.

 

Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.

References

1. JAMA Dermatol. 2015 Jun;151(6):623-6.

2. J Am Acad Dermatol. 2004 Aug;51(2):212-6.

3. J Am Acad Dermatol. 2007 Jul;57(1):81-3.

4. Dermatol Clin. 2008 Jul;26(3):359-73.

5. Baumann L. Cosmetics and skin care in dermatology. In: Wolff K, ed. Fitzpatrick’s Dermatology in General Medicine, 7th ed. New York, NY: McGraw-Hill; 2008:2357-2364.

6. Baumann L. The Baumann skin typing system. In: Farage MA, Miller KW, Maibach HI, eds. Textbook of Aging Skin. Berling, Germany: Springer-Verlag; 2010:929-944.

7. Journal of Cosmetics, Dermatological Sciences and Applications. 2016;6(1):34-40.

As clinicians who have been in practice for even a relatively short period of time know, patient compliance is an integral aspect of achieving optimal patient outcomes. However, studies show that patient compliance with treatment of many dermatologic disorders, including acne and psoriasis, is often poor.^1,2

In 2007, Feldman showed that patients are more likely to use their products in the days before and the days after their dermatologist visit.³ He suggested that more frequent office visits would boost compliance. I have found that this is true and I recommend seeing patients every 4 weeks when implementing a new treatment regimen. I have also found that combining prescription medications with the proper corresponding skin care products helps decrease side effects and speed results when patients apply the products correctly.

To increase the chance of patients using the products correctly, they should be educated about how and when to use the products. I cannot overemphasize the importance of this, as illustrated by the following story of a patient who came in with facial redness and irritation. Upon questioning, I learned that she was using her facial cleanser but was not washing it off and left it on all day. She said, “No one told me to wash it off!” While washing a cleanser off may seem obvious, cultural, gender, ethnic, and geographical differences can lead to misunderstandings.

The problem with patient education is that it takes time. It is best if education is provided by staff, but keeping them trained and up to date is also difficult. Most dermatologists only have 3-5 minutes per patient so streamlining the process of designing a treatment plan and educating the patient and recruiting your staff to help is crucial. Before I discuss how to streamline the process, let’s first look at our goals for patients.
 

To achieve good patient outcomes, the patient needs to:

• Understand what medications and products to use.
• Understand when and how to use the products.
• Understand the order in which to use the products (step 1, step 2, etc.).
• Purchase the products (from you or elsewhere).
• Tell you if they do not purchase the products, for whatever reason (insurance will not cover, too expensive, could not find them, etc.).
• Use the products consistently.
• Inform you if they do not use the products (too busy, did not have them on a trip, etc.).
• Report any side effects so you can adjust the therapy accordingly.

You can see why it is so difficult to get patients to be compliant. Many factors – such as time, memory, education level, understanding, motivation, cost, convenience, and insurance coverage – can get in the way of these important components. Giving patients a printed regimen with instructions, selling the products in your practice, and providing some sort of interaction to keep patients engaged is key. In my June 2015 Dermatology News column, I discussed why you should consider selling products in your practice. In the future, I will discuss ways to engage your patients, but for now, let’s focus on how to quickly and effectively provide your patients with printed regimens and patient instructions without increasing office visit times.
 

Streamlining the Process of Generating a Skin Care Regimen That Includes Prescription Medications

Identify patients’ phenotypes

Divide patients into phenotypes based on skin care needs to save yourself time with the recommendation process.

Many doctors do this with a disease-based approach, such as acne, rosacea, eczema, psoriasis, etc. I prefer to classify my patients according to 16 Baumann Skin Types based on four parameters: hydration status, propensity for inflammation; presence or absence of uneven pigmentation; and presence of lifestyle habits, such as sun exposure, that increase an individual’s risk of skin aging.^4,5,6 To quickly diagnose the patient as a particular Baumann Skin Type, I use a tablet-based validated questionnaire called the Baumann Skin Type Indicator (BSTI).⁷ This questionnaire is self-administered by the patient in the waiting room and serves several purposes that facilitate my practice:

• To collect historical and current data.
• To diagnose skin type.
• To ask specifically about skin allergies.
• To learn preferences such as tinted vs. nontinted, or chemical vs. physical sunscreen.
• To inquire about what issues the patient wants to discuss, such as thinning eyelashes, hair loss, dry body skin, toenail fungus, warts, eczema, and other topics that might not come up during the appointment.
• To learn and document habits that affect the skin, such as tanning bed exposure, sun exposure, and smoking.
• To stimulate the patient to think about how daily actions such as sunscreen use and sun exposure affect their skin health.

 

Whether you choose to use my questionnaire or one of your own, using a validated method that can be initiated by staff in the waiting room saves time in the exam room.
 

Include prescription medications in the skin care regimen

Often, we think of skin care regimens and prescription medications as two different entities. In actuality, these should be combined.

For example, when treating acne, every item the patient uses plays a role. For example, if they are washing the face with Ivory soap and then applying benzoyl peroxide and a retinoid they will experience dryness and irritation. Then they will buy a moisturizer that might cause acne. (It is very hard for them to know which moisturizers and sunscreens will not worsen acne). By providing them with the exact names of cleansers, moisturizers, and sunscreens to use, they will be better able to tolerate their prescription acne medications.

The same is true with psoriasis, eczema, seborrheic dermatitis, contact dermatitis, and most of the other ailments that dermatologists treat. You must also tell them the order to use them in. For example, I always have patients apply the retinoid over the noncomedogenic moisturizer for the first few weeks to help them adjust to the retinoid. Later, once they have passed the high-risk period of retinoid dermatitis, I move the retinoid to under the moisturizer.

Psoriasis treatment (topical) is another good example. If they are going to use a surfactant-laden soap on their skin, they will impair their barrier and absorb more of the topically applied drug. Conversely, if they use a barrier repair moisturizer, they will absorb less. Telling the patients exactly which body cleansers and moisturizers to use with topical psoriasis medications will help standardize the response. For this reason, giving patients printed regimens is not limited to treatment of acne, rosacea, and photoaging, but rather should be done for patients with all skin issues and phenotypes.

Have informational material for each phenotype at your fingertips

You can have a plan for each patient phenotype that is designed ahead of time. You will save yourself hours of time if you have preprinted instructions sheets made for each of these phenotypes. You can use Touch MD, The Canfield Visia Camera Patient Portal, your EMR, or other systems to organize this material and deliver it to patients.

I personally use the Skin Type Solutions Software System (STSFranchise.com) that I developed and patented to house and export my patient instructions. Using a standardized methodology to provide educational information through video, preprinted sheets, emails, and other methods allows you to educate your patients at their pace and in the media with which they are most comfortable. To have this flexibility, the educational information must be developed prior to the patient visit. Categorizing the education information by phenotype makes this possible.

What the informational material should contain

Educational information should include important information about the phenotype, the do’s and don’ts for the phenotype, an exact skin care regimen containing clear steps that include product names including brand names, prescription medications, the order in which the products should be applied, and clear instructions on how to use the products.

The patient should be informed about what to do if anticipated adverse events occur, such as redness and peeling from retinoids or dryness from benzoyl peroxide. The same is true about injectable biologic medications for psoriasis. The patients need information on where to inject the product, how often, how to clean the skin beforehand, and what to put on the skin after the injections. It is always important with any skin issue for the patient to know when to contact the office. The American Academy of Dermatology and other organizations offer educational brochures for patients, but they cannot be customized. Patients prefer a customized approach to educational material. They don’t want to read information that does not apply to them. I have found that dividing patients into 16 distinct Baumann Skin Types helps target the right information to the corresponding skin phenotypes.

Summary

Patients need education and guidance to be compliant and improve their outcomes. Your staff needs to be a part of the education process, but taking the time to train your staff and educate your patients is always an issue. Developing a standardized methodology will help overcome these hurdles and solve this problem. The methodology should provide directed education and clear communication with written instructions delivered in the media of the patient’s choice. Doing this will yield better compliance and outcomes.

If you have any questions, suggestions or ideas of how to solve these issues, please share them with me at DrB@skintypesolutions.com.

 

Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.

References

1. JAMA Dermatol. 2015 Jun;151(6):623-6.

2. J Am Acad Dermatol. 2004 Aug;51(2):212-6.

3. J Am Acad Dermatol. 2007 Jul;57(1):81-3.

4. Dermatol Clin. 2008 Jul;26(3):359-73.

5. Baumann L. Cosmetics and skin care in dermatology. In: Wolff K, ed. Fitzpatrick’s Dermatology in General Medicine, 7th ed. New York, NY: McGraw-Hill; 2008:2357-2364.

6. Baumann L. The Baumann skin typing system. In: Farage MA, Miller KW, Maibach HI, eds. Textbook of Aging Skin. Berling, Germany: Springer-Verlag; 2010:929-944.

7. Journal of Cosmetics, Dermatological Sciences and Applications. 2016;6(1):34-40.

As clinicians who have been in practice for even a relatively short period of time know, patient compliance is an integral aspect of achieving optimal patient outcomes. However, studies show that patient compliance with treatment of many dermatologic disorders, including acne and psoriasis, is often poor.^1,2

In 2007, Feldman showed that patients are more likely to use their products in the days before and the days after their dermatologist visit.³ He suggested that more frequent office visits would boost compliance. I have found that this is true and I recommend seeing patients every 4 weeks when implementing a new treatment regimen. I have also found that combining prescription medications with the proper corresponding skin care products helps decrease side effects and speed results when patients apply the products correctly.

To increase the chance of patients using the products correctly, they should be educated about how and when to use the products. I cannot overemphasize the importance of this, as illustrated by the following story of a patient who came in with facial redness and irritation. Upon questioning, I learned that she was using her facial cleanser but was not washing it off and left it on all day. She said, “No one told me to wash it off!” While washing a cleanser off may seem obvious, cultural, gender, ethnic, and geographical differences can lead to misunderstandings.

The problem with patient education is that it takes time. It is best if education is provided by staff, but keeping them trained and up to date is also difficult. Most dermatologists only have 3-5 minutes per patient so streamlining the process of designing a treatment plan and educating the patient and recruiting your staff to help is crucial. Before I discuss how to streamline the process, let’s first look at our goals for patients.
 

To achieve good patient outcomes, the patient needs to:

• Understand what medications and products to use.
• Understand when and how to use the products.
• Understand the order in which to use the products (step 1, step 2, etc.).
• Purchase the products (from you or elsewhere).
• Tell you if they do not purchase the products, for whatever reason (insurance will not cover, too expensive, could not find them, etc.).
• Use the products consistently.
• Inform you if they do not use the products (too busy, did not have them on a trip, etc.).
• Report any side effects so you can adjust the therapy accordingly.

You can see why it is so difficult to get patients to be compliant. Many factors – such as time, memory, education level, understanding, motivation, cost, convenience, and insurance coverage – can get in the way of these important components. Giving patients a printed regimen with instructions, selling the products in your practice, and providing some sort of interaction to keep patients engaged is key. In my June 2015 Dermatology News column, I discussed why you should consider selling products in your practice. In the future, I will discuss ways to engage your patients, but for now, let’s focus on how to quickly and effectively provide your patients with printed regimens and patient instructions without increasing office visit times.
 

Streamlining the Process of Generating a Skin Care Regimen That Includes Prescription Medications

Identify patients’ phenotypes

Divide patients into phenotypes based on skin care needs to save yourself time with the recommendation process.

Many doctors do this with a disease-based approach, such as acne, rosacea, eczema, psoriasis, etc. I prefer to classify my patients according to 16 Baumann Skin Types based on four parameters: hydration status, propensity for inflammation; presence or absence of uneven pigmentation; and presence of lifestyle habits, such as sun exposure, that increase an individual’s risk of skin aging.^4,5,6 To quickly diagnose the patient as a particular Baumann Skin Type, I use a tablet-based validated questionnaire called the Baumann Skin Type Indicator (BSTI).⁷ This questionnaire is self-administered by the patient in the waiting room and serves several purposes that facilitate my practice:

• To collect historical and current data.
• To diagnose skin type.
• To ask specifically about skin allergies.
• To learn preferences such as tinted vs. nontinted, or chemical vs. physical sunscreen.
• To inquire about what issues the patient wants to discuss, such as thinning eyelashes, hair loss, dry body skin, toenail fungus, warts, eczema, and other topics that might not come up during the appointment.
• To learn and document habits that affect the skin, such as tanning bed exposure, sun exposure, and smoking.
• To stimulate the patient to think about how daily actions such as sunscreen use and sun exposure affect their skin health.

 

Whether you choose to use my questionnaire or one of your own, using a validated method that can be initiated by staff in the waiting room saves time in the exam room.
 

Include prescription medications in the skin care regimen

Often, we think of skin care regimens and prescription medications as two different entities. In actuality, these should be combined.

For example, when treating acne, every item the patient uses plays a role. For example, if they are washing the face with Ivory soap and then applying benzoyl peroxide and a retinoid they will experience dryness and irritation. Then they will buy a moisturizer that might cause acne. (It is very hard for them to know which moisturizers and sunscreens will not worsen acne). By providing them with the exact names of cleansers, moisturizers, and sunscreens to use, they will be better able to tolerate their prescription acne medications.

The same is true with psoriasis, eczema, seborrheic dermatitis, contact dermatitis, and most of the other ailments that dermatologists treat. You must also tell them the order to use them in. For example, I always have patients apply the retinoid over the noncomedogenic moisturizer for the first few weeks to help them adjust to the retinoid. Later, once they have passed the high-risk period of retinoid dermatitis, I move the retinoid to under the moisturizer.

Psoriasis treatment (topical) is another good example. If they are going to use a surfactant-laden soap on their skin, they will impair their barrier and absorb more of the topically applied drug. Conversely, if they use a barrier repair moisturizer, they will absorb less. Telling the patients exactly which body cleansers and moisturizers to use with topical psoriasis medications will help standardize the response. For this reason, giving patients printed regimens is not limited to treatment of acne, rosacea, and photoaging, but rather should be done for patients with all skin issues and phenotypes.

Have informational material for each phenotype at your fingertips

You can have a plan for each patient phenotype that is designed ahead of time. You will save yourself hours of time if you have preprinted instructions sheets made for each of these phenotypes. You can use Touch MD, The Canfield Visia Camera Patient Portal, your EMR, or other systems to organize this material and deliver it to patients.

I personally use the Skin Type Solutions Software System (STSFranchise.com) that I developed and patented to house and export my patient instructions. Using a standardized methodology to provide educational information through video, preprinted sheets, emails, and other methods allows you to educate your patients at their pace and in the media with which they are most comfortable. To have this flexibility, the educational information must be developed prior to the patient visit. Categorizing the education information by phenotype makes this possible.

What the informational material should contain

Educational information should include important information about the phenotype, the do’s and don’ts for the phenotype, an exact skin care regimen containing clear steps that include product names including brand names, prescription medications, the order in which the products should be applied, and clear instructions on how to use the products.

The patient should be informed about what to do if anticipated adverse events occur, such as redness and peeling from retinoids or dryness from benzoyl peroxide. The same is true about injectable biologic medications for psoriasis. The patients need information on where to inject the product, how often, how to clean the skin beforehand, and what to put on the skin after the injections. It is always important with any skin issue for the patient to know when to contact the office. The American Academy of Dermatology and other organizations offer educational brochures for patients, but they cannot be customized. Patients prefer a customized approach to educational material. They don’t want to read information that does not apply to them. I have found that dividing patients into 16 distinct Baumann Skin Types helps target the right information to the corresponding skin phenotypes.

Summary

Patients need education and guidance to be compliant and improve their outcomes. Your staff needs to be a part of the education process, but taking the time to train your staff and educate your patients is always an issue. Developing a standardized methodology will help overcome these hurdles and solve this problem. The methodology should provide directed education and clear communication with written instructions delivered in the media of the patient’s choice. Doing this will yield better compliance and outcomes.

If you have any questions, suggestions or ideas of how to solve these issues, please share them with me at DrB@skintypesolutions.com.

 

Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.

References

1. JAMA Dermatol. 2015 Jun;151(6):623-6.

2. J Am Acad Dermatol. 2004 Aug;51(2):212-6.

3. J Am Acad Dermatol. 2007 Jul;57(1):81-3.

4. Dermatol Clin. 2008 Jul;26(3):359-73.

5. Baumann L. Cosmetics and skin care in dermatology. In: Wolff K, ed. Fitzpatrick’s Dermatology in General Medicine, 7th ed. New York, NY: McGraw-Hill; 2008:2357-2364.

6. Baumann L. The Baumann skin typing system. In: Farage MA, Miller KW, Maibach HI, eds. Textbook of Aging Skin. Berling, Germany: Springer-Verlag; 2010:929-944.

7. Journal of Cosmetics, Dermatological Sciences and Applications. 2016;6(1):34-40.

 

Social media is now a part of everyday life. From Twitter, with its 140 character limit, to Facebook to Linkedin, there is a world of possibilities for communicating with friends, family, colleagues, and others online. Communication is good, but electronic media is a minefield for medical professionals who do not think carefully before they post.

The stories in the news about health care professionals who have posted obviously inflammatory material online, perhaps in a fit of rage, and have had their careers impacted or ended are just the tip of the iceberg. HIPAA violations have received a good deal of attention, with a well-known example being the doctor who was accused of posting a selfie with Joan Rivers, who was unconscious on the operating table. These examples, however, represent obvious violations of HIPAA and are infractions that most physicians would readily identify. Other examples may not be as obvious.

If a professional posts information on social media about a patient, he or she is not insulated simply because the patient’s name was not included. Suppose a professional creates a post on social media about a procedure or interesting presentation that day, and a family member or friend of the patient sees that post and knows that the patient was seeing that doctor that day and connects the dots. This could constitute a HIPAA violation.

We know of one case where a nurse on the staff of a physicians’ office posted on Facebook that work was grueling that day because he felt under the weather with suspected flu. This may seem, at first, to be an innocuous communication. And that’s all it was, until, the son of an immunosuppressed man who had an appointment at that doctor’s office was flabbergasted to hear from a mutual friend that one of the nurses in the office was at work despite having the flu. He demanded to speak with the office manager and made sure that his father was not seen by that nurse. It may seem like an unlikely coincidence, but, in medical-legal circles, unlikely events occur all the time.

Often, we think that maximizing our privacy setting will ensure that unwanted people will not see what is posted. That is not always the case. With social media, we should assume that nothing is truly private. For example, on Facebook you can opt to allow only your friends to view what you post. However, if your friend comments on one of your posts, that friend’s friends may then be able to view the post. Your “friend” could, also, allow anybody to see what you have posted on Facebook. In a recent case, an administrative assistant happened to be friends on Facebook with an expert from the other side and was able to find compromising information that was used in that expert’s cross-examination at trial. Our social networks are often quite large, and it is not unusual to have hundreds of “friends.” These people typically include acquaintances of whom we have only casual knowledge. It is impossible to know how private information can be interpreted by people we do not know well or how that information may be used.

Many people who use social media will check in or post when they are out with friends or colleagues blowing off steam. For example, you might post something on social media about a holiday party you are attending. But, consider what happens if, at work the next day, something goes wrong, your care is called into question, and a lawsuit ensues. Your post may be innocent, but it now falls into the hands of the patient’s attorney. When you are having your deposition taken, the lawyer pulls your social media post out of a stack of papers and grills you about where you were, what you were doing, how late you stayed out, whether you were drinking, how much, and so on. Maybe you explain to him that you were only at the holiday party for an hour and did not have a single drink. That attorney, however, is not required to take your word for it and can ask you who you were with. All of a sudden, your friends and colleagues are being served with subpoenas for their depositions and being examined about what you did that night. Possibly, the lawyer is sending a subpoena for your credit card receipt and the restaurant’s billing records to determine what you ordered that night.

You should never rely on the false assumption that even “private” messages sent directly to other people will truly remain private. One of us was recently involved in a case where this worked to our advantage. A 30-year-old woman claimed that her family doctor never recommended that she see a gastroenterologist. A friend of the patient testified in a deposition that the two of them had discussed her medical care in private messages on Facebook. After the court ordered that the patient turn over her private Facebook messages, we learned that she told her friend that the doctor had indeed made the recommendation for her to see that specialist.

This cautionary tale doesn’t just apply to social media. Keep in mind that, if you are involved in litigation, attorneys can subpoena the records from your cellular phone provider. All cell phone text message are archived by the cellular provider and can be retrieved under subpoena. You may innocently be blowing off steam to a spouse or friend about a difficult patient or bad outcome but later have those text messages used against you in litigation.

The various social media platforms can be great tools for all kinds of professionals to share interesting information and further their professional development. However, everybody, especially the medical professional, needs to think before they post or send a message. We must also remember that, once information is out in cyberspace, it remains there and can never be truly erased. In other words, you can never unring the proverbial bell. It is important to think about the potential impact of that communication before posting and electronically communicating. Only communicate something that you would be comfortable defending in court.

 

Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Mr. Shear is an associate attorney in the health care department at Marshall Dennehey Warner Coleman & Goggin in Pittsburgh. He represents physicians, medical professionals, and hospitals in medical malpractice actions.

 

Social media is now a part of everyday life. From Twitter, with its 140 character limit, to Facebook to Linkedin, there is a world of possibilities for communicating with friends, family, colleagues, and others online. Communication is good, but electronic media is a minefield for medical professionals who do not think carefully before they post.

The stories in the news about health care professionals who have posted obviously inflammatory material online, perhaps in a fit of rage, and have had their careers impacted or ended are just the tip of the iceberg. HIPAA violations have received a good deal of attention, with a well-known example being the doctor who was accused of posting a selfie with Joan Rivers, who was unconscious on the operating table. These examples, however, represent obvious violations of HIPAA and are infractions that most physicians would readily identify. Other examples may not be as obvious.

If a professional posts information on social media about a patient, he or she is not insulated simply because the patient’s name was not included. Suppose a professional creates a post on social media about a procedure or interesting presentation that day, and a family member or friend of the patient sees that post and knows that the patient was seeing that doctor that day and connects the dots. This could constitute a HIPAA violation.

We know of one case where a nurse on the staff of a physicians’ office posted on Facebook that work was grueling that day because he felt under the weather with suspected flu. This may seem, at first, to be an innocuous communication. And that’s all it was, until, the son of an immunosuppressed man who had an appointment at that doctor’s office was flabbergasted to hear from a mutual friend that one of the nurses in the office was at work despite having the flu. He demanded to speak with the office manager and made sure that his father was not seen by that nurse. It may seem like an unlikely coincidence, but, in medical-legal circles, unlikely events occur all the time.

Often, we think that maximizing our privacy setting will ensure that unwanted people will not see what is posted. That is not always the case. With social media, we should assume that nothing is truly private. For example, on Facebook you can opt to allow only your friends to view what you post. However, if your friend comments on one of your posts, that friend’s friends may then be able to view the post. Your “friend” could, also, allow anybody to see what you have posted on Facebook. In a recent case, an administrative assistant happened to be friends on Facebook with an expert from the other side and was able to find compromising information that was used in that expert’s cross-examination at trial. Our social networks are often quite large, and it is not unusual to have hundreds of “friends.” These people typically include acquaintances of whom we have only casual knowledge. It is impossible to know how private information can be interpreted by people we do not know well or how that information may be used.

Many people who use social media will check in or post when they are out with friends or colleagues blowing off steam. For example, you might post something on social media about a holiday party you are attending. But, consider what happens if, at work the next day, something goes wrong, your care is called into question, and a lawsuit ensues. Your post may be innocent, but it now falls into the hands of the patient’s attorney. When you are having your deposition taken, the lawyer pulls your social media post out of a stack of papers and grills you about where you were, what you were doing, how late you stayed out, whether you were drinking, how much, and so on. Maybe you explain to him that you were only at the holiday party for an hour and did not have a single drink. That attorney, however, is not required to take your word for it and can ask you who you were with. All of a sudden, your friends and colleagues are being served with subpoenas for their depositions and being examined about what you did that night. Possibly, the lawyer is sending a subpoena for your credit card receipt and the restaurant’s billing records to determine what you ordered that night.

You should never rely on the false assumption that even “private” messages sent directly to other people will truly remain private. One of us was recently involved in a case where this worked to our advantage. A 30-year-old woman claimed that her family doctor never recommended that she see a gastroenterologist. A friend of the patient testified in a deposition that the two of them had discussed her medical care in private messages on Facebook. After the court ordered that the patient turn over her private Facebook messages, we learned that she told her friend that the doctor had indeed made the recommendation for her to see that specialist.

This cautionary tale doesn’t just apply to social media. Keep in mind that, if you are involved in litigation, attorneys can subpoena the records from your cellular phone provider. All cell phone text message are archived by the cellular provider and can be retrieved under subpoena. You may innocently be blowing off steam to a spouse or friend about a difficult patient or bad outcome but later have those text messages used against you in litigation.

The various social media platforms can be great tools for all kinds of professionals to share interesting information and further their professional development. However, everybody, especially the medical professional, needs to think before they post or send a message. We must also remember that, once information is out in cyberspace, it remains there and can never be truly erased. In other words, you can never unring the proverbial bell. It is important to think about the potential impact of that communication before posting and electronically communicating. Only communicate something that you would be comfortable defending in court.

 

Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Mr. Shear is an associate attorney in the health care department at Marshall Dennehey Warner Coleman & Goggin in Pittsburgh. He represents physicians, medical professionals, and hospitals in medical malpractice actions.

 

Social media is now a part of everyday life. From Twitter, with its 140 character limit, to Facebook to Linkedin, there is a world of possibilities for communicating with friends, family, colleagues, and others online. Communication is good, but electronic media is a minefield for medical professionals who do not think carefully before they post.

The stories in the news about health care professionals who have posted obviously inflammatory material online, perhaps in a fit of rage, and have had their careers impacted or ended are just the tip of the iceberg. HIPAA violations have received a good deal of attention, with a well-known example being the doctor who was accused of posting a selfie with Joan Rivers, who was unconscious on the operating table. These examples, however, represent obvious violations of HIPAA and are infractions that most physicians would readily identify. Other examples may not be as obvious.

If a professional posts information on social media about a patient, he or she is not insulated simply because the patient’s name was not included. Suppose a professional creates a post on social media about a procedure or interesting presentation that day, and a family member or friend of the patient sees that post and knows that the patient was seeing that doctor that day and connects the dots. This could constitute a HIPAA violation.

We know of one case where a nurse on the staff of a physicians’ office posted on Facebook that work was grueling that day because he felt under the weather with suspected flu. This may seem, at first, to be an innocuous communication. And that’s all it was, until, the son of an immunosuppressed man who had an appointment at that doctor’s office was flabbergasted to hear from a mutual friend that one of the nurses in the office was at work despite having the flu. He demanded to speak with the office manager and made sure that his father was not seen by that nurse. It may seem like an unlikely coincidence, but, in medical-legal circles, unlikely events occur all the time.

Often, we think that maximizing our privacy setting will ensure that unwanted people will not see what is posted. That is not always the case. With social media, we should assume that nothing is truly private. For example, on Facebook you can opt to allow only your friends to view what you post. However, if your friend comments on one of your posts, that friend’s friends may then be able to view the post. Your “friend” could, also, allow anybody to see what you have posted on Facebook. In a recent case, an administrative assistant happened to be friends on Facebook with an expert from the other side and was able to find compromising information that was used in that expert’s cross-examination at trial. Our social networks are often quite large, and it is not unusual to have hundreds of “friends.” These people typically include acquaintances of whom we have only casual knowledge. It is impossible to know how private information can be interpreted by people we do not know well or how that information may be used.

Many people who use social media will check in or post when they are out with friends or colleagues blowing off steam. For example, you might post something on social media about a holiday party you are attending. But, consider what happens if, at work the next day, something goes wrong, your care is called into question, and a lawsuit ensues. Your post may be innocent, but it now falls into the hands of the patient’s attorney. When you are having your deposition taken, the lawyer pulls your social media post out of a stack of papers and grills you about where you were, what you were doing, how late you stayed out, whether you were drinking, how much, and so on. Maybe you explain to him that you were only at the holiday party for an hour and did not have a single drink. That attorney, however, is not required to take your word for it and can ask you who you were with. All of a sudden, your friends and colleagues are being served with subpoenas for their depositions and being examined about what you did that night. Possibly, the lawyer is sending a subpoena for your credit card receipt and the restaurant’s billing records to determine what you ordered that night.

You should never rely on the false assumption that even “private” messages sent directly to other people will truly remain private. One of us was recently involved in a case where this worked to our advantage. A 30-year-old woman claimed that her family doctor never recommended that she see a gastroenterologist. A friend of the patient testified in a deposition that the two of them had discussed her medical care in private messages on Facebook. After the court ordered that the patient turn over her private Facebook messages, we learned that she told her friend that the doctor had indeed made the recommendation for her to see that specialist.

This cautionary tale doesn’t just apply to social media. Keep in mind that, if you are involved in litigation, attorneys can subpoena the records from your cellular phone provider. All cell phone text message are archived by the cellular provider and can be retrieved under subpoena. You may innocently be blowing off steam to a spouse or friend about a difficult patient or bad outcome but later have those text messages used against you in litigation.

The various social media platforms can be great tools for all kinds of professionals to share interesting information and further their professional development. However, everybody, especially the medical professional, needs to think before they post or send a message. We must also remember that, once information is out in cyberspace, it remains there and can never be truly erased. In other words, you can never unring the proverbial bell. It is important to think about the potential impact of that communication before posting and electronically communicating. Only communicate something that you would be comfortable defending in court.

 

Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Mr. Shear is an associate attorney in the health care department at Marshall Dennehey Warner Coleman & Goggin in Pittsburgh. He represents physicians, medical professionals, and hospitals in medical malpractice actions.

 

How many times do you come out of the exam room after seeing a patient in follow-up and heave a sigh because the parents did not give their child the medicine as you prescribed it?

Without adherence to the medication plan, a lot of suboptimal outcomes can and do occur. A urinary tract infection may come back partially treated, requiring a more extensive work-up. A strep infection may spread to family members. Inflammatory bowel disease may require bowel resection. Asthma may simmer with long-term inflammation and pulmonary compromise as well as concurrent activity limitations. Often children with asthma are given less than 50% of prescribed controller medicines. In one pediatric study, medication adherence was not even asked about in 66% of cases. In adults, 20%-30% of prescriptions are never filled.

As physicians, we are carefully schooled in making complex diagnoses, sorting out and prioritizing the laboratory work-up, and memorizing the latest and most effective treatment regimens. What is rarely taught, however, is how to conduct the conversation needed to optimize subsequent adherence to the medication plan.

Problem-solving counseling is an evidence-based method to improve medication adherence. This is a semistructured form of cognitive-behavioral intervention designed to engage the responsible person (parent or child) in shared decision making about whether and how to take medication, and which one to take. After all, for good or for bad, it is really their choice!

The problem-solving counseling model consists of five steps:

1. Problem definition. This step involves developing a clear and specific definition of the problem. Educating families about a medical condition has to start with asking what they already know. This often includes sagas of bad outcomes in relatives. Ask: Who do you know with asthma? How was it for them? The family needs to know symptoms, simple pathophysiology (such as inflammation you can’t see or feel), course, and prognosis. They also need to know where their child’s condition falls on the continuum. And they need to understand the essential prevention aspect of controllers in what appears to be an asymptomatic child. Failure to communicate this is a common reason for nonadherence in asthma.

2. Generation of alternatives. This involves brainstorming to identify multiple and creative solutions. This step will reveal past experiences as well as things the family learned on the Internet that may be true and relevant, or true but irrelevant, or false. Ask: What have you heard about treatments for asthma? What do you think would be best for your child? Generic handouts with a sampling of medicines, advantages and disadvantages, side effects, and costs of the main choices have been shown to be helpful guides that enhance adherence through empowering the family in their choice and reassuring family members that you have been thorough. It can be a balancing act to describe possible side effects without scaring the family into shutting down and being unable to make any choice at all. However, failure to discuss common effects they may notice – such as a racing heart from rescue medications – but that you think of as trivial, may also lead to nonadherence. A way to communicate about perceived side effects and manage them has to be part of an effective plan. Planning a phone or email check-in can make a big difference.

3. Decision making. This step involves evaluating all the solutions to identify the most effective and feasible option. Once the family understands the problem and the alternatives, it is crucial for you, as the physician, to not only ask their preference but be ready to suggest what you think would be best. While not wanting to be patronized, families want your opinion. I like to have family members close their eyes and visualize carrying out the selected routine. This is a good hypnotic technique for future remembering, but you also may discover important facts by this simple exercise, such as that the child gets up alone for school, making morning dosing unreliable. Shared decision making is not a way to abdicate your expert opinion, just to incorporate family preferences and factors.

4. Solution implementation. This step involves carrying out the plan. There is no substitute for a real life trial! There may be surprising issues: Autistic children may be afraid of a nebulizer machine. Sensitive children may refuse the flavor of some inhalers.

5. Solution verification. Evaluate the effectiveness of the solution and modify the plan as necessary. Follow-up contact is crucial, especially at the start of a new chronic medication plan. When families know that the plan can be changed if things do not go well or they change their minds, they will be less fearful of giving it a try and more honest about barriers they perceive or encounter rather than simply showing up at the next visit with the child’s condition out of control.

 

Although using problem-solving counseling may sound complicated, it is intended to be focused and brief, and has been shown to be feasibly done in the clinic by primary care providers, without lengthening the visit. CHADIS even has teleprompter text specific to parent-reported barriers to help you.

Even when family members understand and agrees to a medication plan during the visit, there are a variety of reasons they may not adhere to it. They may forget to give the medicine, be unable to afford it once prescribed, experience unpleasant side effects, encounter resistance from the child, or get unanticipated push back from family members. All of these issues can be addressed if you know that they happen. You just have to ask! Recommending smartphone reminders or reminder apps (such as Medisafe), using GoodRx to find cheaper sources, suggesting candy as a chaser, recommending behavior strategies for feisty kids, and providing written materials (or a phone call) for reluctant relatives are strategies you can prepare in advance to have in your quiver and are well worth your time.

If it weren’t enough to address adherence to optimize outcomes, asthma management and control will likely be a Clinical Quality Measure, determining how we will be paid starting this year. Now you have a tool to do it!
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.

 

How many times do you come out of the exam room after seeing a patient in follow-up and heave a sigh because the parents did not give their child the medicine as you prescribed it?

Without adherence to the medication plan, a lot of suboptimal outcomes can and do occur. A urinary tract infection may come back partially treated, requiring a more extensive work-up. A strep infection may spread to family members. Inflammatory bowel disease may require bowel resection. Asthma may simmer with long-term inflammation and pulmonary compromise as well as concurrent activity limitations. Often children with asthma are given less than 50% of prescribed controller medicines. In one pediatric study, medication adherence was not even asked about in 66% of cases. In adults, 20%-30% of prescriptions are never filled.

As physicians, we are carefully schooled in making complex diagnoses, sorting out and prioritizing the laboratory work-up, and memorizing the latest and most effective treatment regimens. What is rarely taught, however, is how to conduct the conversation needed to optimize subsequent adherence to the medication plan.

Problem-solving counseling is an evidence-based method to improve medication adherence. This is a semistructured form of cognitive-behavioral intervention designed to engage the responsible person (parent or child) in shared decision making about whether and how to take medication, and which one to take. After all, for good or for bad, it is really their choice!

The problem-solving counseling model consists of five steps:

1. Problem definition. This step involves developing a clear and specific definition of the problem. Educating families about a medical condition has to start with asking what they already know. This often includes sagas of bad outcomes in relatives. Ask: Who do you know with asthma? How was it for them? The family needs to know symptoms, simple pathophysiology (such as inflammation you can’t see or feel), course, and prognosis. They also need to know where their child’s condition falls on the continuum. And they need to understand the essential prevention aspect of controllers in what appears to be an asymptomatic child. Failure to communicate this is a common reason for nonadherence in asthma.

2. Generation of alternatives. This involves brainstorming to identify multiple and creative solutions. This step will reveal past experiences as well as things the family learned on the Internet that may be true and relevant, or true but irrelevant, or false. Ask: What have you heard about treatments for asthma? What do you think would be best for your child? Generic handouts with a sampling of medicines, advantages and disadvantages, side effects, and costs of the main choices have been shown to be helpful guides that enhance adherence through empowering the family in their choice and reassuring family members that you have been thorough. It can be a balancing act to describe possible side effects without scaring the family into shutting down and being unable to make any choice at all. However, failure to discuss common effects they may notice – such as a racing heart from rescue medications – but that you think of as trivial, may also lead to nonadherence. A way to communicate about perceived side effects and manage them has to be part of an effective plan. Planning a phone or email check-in can make a big difference.

3. Decision making. This step involves evaluating all the solutions to identify the most effective and feasible option. Once the family understands the problem and the alternatives, it is crucial for you, as the physician, to not only ask their preference but be ready to suggest what you think would be best. While not wanting to be patronized, families want your opinion. I like to have family members close their eyes and visualize carrying out the selected routine. This is a good hypnotic technique for future remembering, but you also may discover important facts by this simple exercise, such as that the child gets up alone for school, making morning dosing unreliable. Shared decision making is not a way to abdicate your expert opinion, just to incorporate family preferences and factors.

4. Solution implementation. This step involves carrying out the plan. There is no substitute for a real life trial! There may be surprising issues: Autistic children may be afraid of a nebulizer machine. Sensitive children may refuse the flavor of some inhalers.

5. Solution verification. Evaluate the effectiveness of the solution and modify the plan as necessary. Follow-up contact is crucial, especially at the start of a new chronic medication plan. When families know that the plan can be changed if things do not go well or they change their minds, they will be less fearful of giving it a try and more honest about barriers they perceive or encounter rather than simply showing up at the next visit with the child’s condition out of control.

 

Although using problem-solving counseling may sound complicated, it is intended to be focused and brief, and has been shown to be feasibly done in the clinic by primary care providers, without lengthening the visit. CHADIS even has teleprompter text specific to parent-reported barriers to help you.

Even when family members understand and agrees to a medication plan during the visit, there are a variety of reasons they may not adhere to it. They may forget to give the medicine, be unable to afford it once prescribed, experience unpleasant side effects, encounter resistance from the child, or get unanticipated push back from family members. All of these issues can be addressed if you know that they happen. You just have to ask! Recommending smartphone reminders or reminder apps (such as Medisafe), using GoodRx to find cheaper sources, suggesting candy as a chaser, recommending behavior strategies for feisty kids, and providing written materials (or a phone call) for reluctant relatives are strategies you can prepare in advance to have in your quiver and are well worth your time.

If it weren’t enough to address adherence to optimize outcomes, asthma management and control will likely be a Clinical Quality Measure, determining how we will be paid starting this year. Now you have a tool to do it!
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.

 

How many times do you come out of the exam room after seeing a patient in follow-up and heave a sigh because the parents did not give their child the medicine as you prescribed it?

Without adherence to the medication plan, a lot of suboptimal outcomes can and do occur. A urinary tract infection may come back partially treated, requiring a more extensive work-up. A strep infection may spread to family members. Inflammatory bowel disease may require bowel resection. Asthma may simmer with long-term inflammation and pulmonary compromise as well as concurrent activity limitations. Often children with asthma are given less than 50% of prescribed controller medicines. In one pediatric study, medication adherence was not even asked about in 66% of cases. In adults, 20%-30% of prescriptions are never filled.

As physicians, we are carefully schooled in making complex diagnoses, sorting out and prioritizing the laboratory work-up, and memorizing the latest and most effective treatment regimens. What is rarely taught, however, is how to conduct the conversation needed to optimize subsequent adherence to the medication plan.

Problem-solving counseling is an evidence-based method to improve medication adherence. This is a semistructured form of cognitive-behavioral intervention designed to engage the responsible person (parent or child) in shared decision making about whether and how to take medication, and which one to take. After all, for good or for bad, it is really their choice!

The problem-solving counseling model consists of five steps:

1. Problem definition. This step involves developing a clear and specific definition of the problem. Educating families about a medical condition has to start with asking what they already know. This often includes sagas of bad outcomes in relatives. Ask: Who do you know with asthma? How was it for them? The family needs to know symptoms, simple pathophysiology (such as inflammation you can’t see or feel), course, and prognosis. They also need to know where their child’s condition falls on the continuum. And they need to understand the essential prevention aspect of controllers in what appears to be an asymptomatic child. Failure to communicate this is a common reason for nonadherence in asthma.

2. Generation of alternatives. This involves brainstorming to identify multiple and creative solutions. This step will reveal past experiences as well as things the family learned on the Internet that may be true and relevant, or true but irrelevant, or false. Ask: What have you heard about treatments for asthma? What do you think would be best for your child? Generic handouts with a sampling of medicines, advantages and disadvantages, side effects, and costs of the main choices have been shown to be helpful guides that enhance adherence through empowering the family in their choice and reassuring family members that you have been thorough. It can be a balancing act to describe possible side effects without scaring the family into shutting down and being unable to make any choice at all. However, failure to discuss common effects they may notice – such as a racing heart from rescue medications – but that you think of as trivial, may also lead to nonadherence. A way to communicate about perceived side effects and manage them has to be part of an effective plan. Planning a phone or email check-in can make a big difference.

3. Decision making. This step involves evaluating all the solutions to identify the most effective and feasible option. Once the family understands the problem and the alternatives, it is crucial for you, as the physician, to not only ask their preference but be ready to suggest what you think would be best. While not wanting to be patronized, families want your opinion. I like to have family members close their eyes and visualize carrying out the selected routine. This is a good hypnotic technique for future remembering, but you also may discover important facts by this simple exercise, such as that the child gets up alone for school, making morning dosing unreliable. Shared decision making is not a way to abdicate your expert opinion, just to incorporate family preferences and factors.

4. Solution implementation. This step involves carrying out the plan. There is no substitute for a real life trial! There may be surprising issues: Autistic children may be afraid of a nebulizer machine. Sensitive children may refuse the flavor of some inhalers.

5. Solution verification. Evaluate the effectiveness of the solution and modify the plan as necessary. Follow-up contact is crucial, especially at the start of a new chronic medication plan. When families know that the plan can be changed if things do not go well or they change their minds, they will be less fearful of giving it a try and more honest about barriers they perceive or encounter rather than simply showing up at the next visit with the child’s condition out of control.

 

Although using problem-solving counseling may sound complicated, it is intended to be focused and brief, and has been shown to be feasibly done in the clinic by primary care providers, without lengthening the visit. CHADIS even has teleprompter text specific to parent-reported barriers to help you.

Even when family members understand and agrees to a medication plan during the visit, there are a variety of reasons they may not adhere to it. They may forget to give the medicine, be unable to afford it once prescribed, experience unpleasant side effects, encounter resistance from the child, or get unanticipated push back from family members. All of these issues can be addressed if you know that they happen. You just have to ask! Recommending smartphone reminders or reminder apps (such as Medisafe), using GoodRx to find cheaper sources, suggesting candy as a chaser, recommending behavior strategies for feisty kids, and providing written materials (or a phone call) for reluctant relatives are strategies you can prepare in advance to have in your quiver and are well worth your time.

If it weren’t enough to address adherence to optimize outcomes, asthma management and control will likely be a Clinical Quality Measure, determining how we will be paid starting this year. Now you have a tool to do it!
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.

Traveler’s diarrhea (TD) is the most common illness in people traveling from resource-advantaged countries to resource-limited regions of the globe. Approximately 50% of these types of travelers will contract diarrhea.

I knew of a group of infectious disease experts traveling to India together – presumably well-versed in how to avoid such things – and one-half of the group developed it.

I have many patients sending me electronic messages asking me for their standard 3-day ciprofloxacin prescriptions, “just in case.” I am guilty of having provided this, along with warnings that we could make matters worse by giving them Clostridium difficile colitis. Antibiotics may also increase the risk for post-TD irritable bowel syndrome, which can occur in up to 15% of patients.

Mild TD is defined as passage of one or two unformed stools in 24 hours without nausea, vomiting, abdominal pain, fever, or blood in stools. What is the evidence for the effectiveness of antibiotics, compared with other interventions such as loperamide, for mild TD?

Tinja Lääveri, MD, of the University of Helsinki, and colleagues conducted a systematic review on the efficacy and safety of loperamide for TD (Travel Med Infect Dis. 2016 Jul-Aug;14[4]:299-312). Fifteen articles were retrieved.

Loperamide was observed to be noninferior to antibiotics for the treatment of TD. In one study, loperamide was observed to be superior to bismuth, which is commonly recommended to prevent TD. Adverse events with loperamide occurred predominantly among patients with bloody diarrhea.

The authors remind us that loperamide is different from antimotility agents such as diphenoxylate with atropine, as loperamide has an antisecretory effect at lower doses and decreases motility only at higher doses.

If you subscribe to the idea that diarrhea helps rid the body of toxins, be reminded that secretory diarrhea is exploited by the organism to spread the infestation to as many humans as possible.

The recommended regimen for loperamide is a 4-mg loading dose, followed by 2 mg after every episode of diarrhea. Tell your patients not to use loperamide if they are having fever or bloody diarrhea, or if you suspect they could have C. difficile colitis (that is, recent antibiotics or other risk factors).

Happy travels.
 

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. Dr. Ebbert has no relevant financial disclosures about this article.

Traveler’s diarrhea (TD) is the most common illness in people traveling from resource-advantaged countries to resource-limited regions of the globe. Approximately 50% of these types of travelers will contract diarrhea.

I knew of a group of infectious disease experts traveling to India together – presumably well-versed in how to avoid such things – and one-half of the group developed it.

I have many patients sending me electronic messages asking me for their standard 3-day ciprofloxacin prescriptions, “just in case.” I am guilty of having provided this, along with warnings that we could make matters worse by giving them Clostridium difficile colitis. Antibiotics may also increase the risk for post-TD irritable bowel syndrome, which can occur in up to 15% of patients.

Mild TD is defined as passage of one or two unformed stools in 24 hours without nausea, vomiting, abdominal pain, fever, or blood in stools. What is the evidence for the effectiveness of antibiotics, compared with other interventions such as loperamide, for mild TD?

Tinja Lääveri, MD, of the University of Helsinki, and colleagues conducted a systematic review on the efficacy and safety of loperamide for TD (Travel Med Infect Dis. 2016 Jul-Aug;14[4]:299-312). Fifteen articles were retrieved.

Loperamide was observed to be noninferior to antibiotics for the treatment of TD. In one study, loperamide was observed to be superior to bismuth, which is commonly recommended to prevent TD. Adverse events with loperamide occurred predominantly among patients with bloody diarrhea.

The authors remind us that loperamide is different from antimotility agents such as diphenoxylate with atropine, as loperamide has an antisecretory effect at lower doses and decreases motility only at higher doses.

If you subscribe to the idea that diarrhea helps rid the body of toxins, be reminded that secretory diarrhea is exploited by the organism to spread the infestation to as many humans as possible.

The recommended regimen for loperamide is a 4-mg loading dose, followed by 2 mg after every episode of diarrhea. Tell your patients not to use loperamide if they are having fever or bloody diarrhea, or if you suspect they could have C. difficile colitis (that is, recent antibiotics or other risk factors).

Happy travels.
 

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. Dr. Ebbert has no relevant financial disclosures about this article.

Traveler’s diarrhea (TD) is the most common illness in people traveling from resource-advantaged countries to resource-limited regions of the globe. Approximately 50% of these types of travelers will contract diarrhea.

I knew of a group of infectious disease experts traveling to India together – presumably well-versed in how to avoid such things – and one-half of the group developed it.

I have many patients sending me electronic messages asking me for their standard 3-day ciprofloxacin prescriptions, “just in case.” I am guilty of having provided this, along with warnings that we could make matters worse by giving them Clostridium difficile colitis. Antibiotics may also increase the risk for post-TD irritable bowel syndrome, which can occur in up to 15% of patients.

Mild TD is defined as passage of one or two unformed stools in 24 hours without nausea, vomiting, abdominal pain, fever, or blood in stools. What is the evidence for the effectiveness of antibiotics, compared with other interventions such as loperamide, for mild TD?

Tinja Lääveri, MD, of the University of Helsinki, and colleagues conducted a systematic review on the efficacy and safety of loperamide for TD (Travel Med Infect Dis. 2016 Jul-Aug;14[4]:299-312). Fifteen articles were retrieved.

Loperamide was observed to be noninferior to antibiotics for the treatment of TD. In one study, loperamide was observed to be superior to bismuth, which is commonly recommended to prevent TD. Adverse events with loperamide occurred predominantly among patients with bloody diarrhea.

The authors remind us that loperamide is different from antimotility agents such as diphenoxylate with atropine, as loperamide has an antisecretory effect at lower doses and decreases motility only at higher doses.

If you subscribe to the idea that diarrhea helps rid the body of toxins, be reminded that secretory diarrhea is exploited by the organism to spread the infestation to as many humans as possible.

The recommended regimen for loperamide is a 4-mg loading dose, followed by 2 mg after every episode of diarrhea. Tell your patients not to use loperamide if they are having fever or bloody diarrhea, or if you suspect they could have C. difficile colitis (that is, recent antibiotics or other risk factors).

Happy travels.
 

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. Dr. Ebbert has no relevant financial disclosures about this article.

 

There are several things you should know about necessary vaccinations, and sometimes potential supply problems, if your families will be traveling internationally.

Yellow fever and vaccine supply

Yellow fever is caused by a Flavivirus transmitted by the bite of an infected mosquito. It occurs in sub-Saharan Africa and in tropical areas in South America. Multiple factors determine a traveler’s risk for acquisition, including destination, season, duration of potential exposure, activities, and the local transmission rate. The majority of those infected are asymptomatic or have minimal clinical symptoms. The incubation period is 3-6 days, which is then followed by an influenza-like illness. Approximately 15% of infected individuals develop more serious symptoms including jaundice, hemorrhagic symptoms, shock, and, ultimately, multiorgan system failure with a fatality rate of 90%. There is no specific treatment.

Prevention is avoidance of mosquito bites and receipt of yellow fever vaccine (YF-Vax). It is a relatively safe vaccine and indicated for use in persons at least 9 months of age. There are a few situations in which it can be administered to patients as young as 6 months. The vaccine becomes valid 10 days after administration, and it must be documented on an International Certificate of Vaccination or Prophylaxis card (Yellow Card).

Previously, vaccine boosters were required every 10 years. However, the duration of immunity was extensively reviewed by the World Health Organization and effective July 11, 2016, boosters are no longer required. A single dose of vaccine is now valid for the lifetime of the individual. This includes those persons vaccinated prior to July 11, 2016. Since it is a live vaccine, administration is contraindicated in certain individuals. Exemption letters are provided for those who have a medical contraindication.

Caution is advised in persons receiving their initial dose of YF-VAX who are older than 60 years of age because they have an increased risk of serious side effects. This is not a concern for the pediatrician. The vaccine can only be administered at state approved facilities. It is one vaccine that is not only recommended, but may be required for entry into certain countries. Go to www.cdc.gov/yellowfever for a complete list.

Sanofi Pasteur is the only U.S. manufacturer of YF-VAX. Production has ceased until mid-2018, when a new manufacturing facility will open. Current supplies are anticipated to be depleted by mid-2017, and orders have been limited to 5 doses per month. Sanofi Pasteur, in conjunction with the Food and Drug Administration, will make Stamaril – a yellow fever vaccine manufactured by the company in France and licensed in over 70 countries – available to U.S. travelers through an Expanded Access Investigational New Drug Application. Details on how and when this program will be operational are forthcoming. What is known is that, nationwide, there will be a limited number of sites administering Stamaril. Once finalized, a list of locations will be posted on the CDC Yellow Fever site.

How does this affect your patients? If travel to a yellow fever risk area is anticipated, they should not delay in seeking pretravel advice and immunizations until the last minute. Individual clinic inventories will not be stable. Postponing a trip or changing destinations is preferred if the vaccine is not available. Yellow fever exemption letters are only provided for those persons who have a medical contraindication to receive YF-VAX.
 

Zika, dengue, and chikungunya

These three Flaviviruses all are transmitted by mosquitoes and can present with fever, rash, and headache. Their distribution is overlapping in several parts of the world. Most infected people are asymptomatic. If symptoms develop, they usually are self-limited. Disease prevention is by mosquito avoidance. There are no preventive vaccines.

Zika virus is the only one associated with a congenital syndrome. It is characterized by brain abnormalities with or without microcephaly, neural tube defects, and ocular abnormalities.

Guidelines for the evaluation and management of Zika virus–exposed infants were initially published in January, 2016, with the most recent update published in August 2016 (MMWR Morb Mortal Wkly Rep. 2016 Aug 26;65[33]:870-8).

Preliminary data from the U.S. Zika pregnancy registry of 442 completed pregnancies between Jan. 15 to Sept. 22, 2016, identified birth defects in 26 fetuses/ infants (6%). There were 21 infants with birth defects among 395 live births and 5 fetuses with birth defects among 47 pregnancy losses. Birth defects were reported for 16 of 271 (6%) asymptomatic and 10 of 167 (6%) symptomatic women. There were no birth defects in infants when exposure occurred after the first trimester. Of the 26 affected infants, 4 had microcephaly and no neuroimaging and 3 (12%) had no fetal or infant testing. Approximately 41% (82/442) of infants did not have Zika virus testing (JAMA. 2017 Jan 3;317[1]:59-68).

It is unclear why testing was not performed. One concern is that the pediatrician may not have been aware of the maternal Zika virus exposure or test results. It may behoove us to begin asking questions about parental international travel to provide optimal management for our patients. We also should be familiar with the current guidelines for evaluating any potentially exposed infants, which include postnatal neuroimaging, Zika virus testing, a comprehensive newborn examination including neurologic exam, and a standard newborn hearing screen prior to hospital discharge.

Regardless of maternal Zika virus test results, infants with any clinical findings suggestive of congenital Zika virus syndrome and possible maternal exposure based on epidemiologic link also should be tested. Zika virus travel alerts and the most up to date information can be found on the Centers for Disease Control and Prevention website (www. cdc.gov/Zika).

CDC/Molly Kurnit, M.P.H.

 

Measles

Although endemic measles was eliminated in the United States in 2000, it is still common in many countries in Europe, Africa, and the Pacific. Most cases in the United States occur in unvaccinated individuals, with 78 cases reported in 2016. As of March 25, 2017, 28 cases have been reported. At least 10 countries – including Belgium, France, Italy, Germany, Portugal, and Thailand – have reported outbreaks of measles since April 2017. As reminder, all children aged 6-11 months should receive one dose of MMR and those 12 months or older should receive two doses of MMR at least 28 days apart if international travel is planned. Adults born after 1956 also should have received two doses of MMR prior to international travel.

Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She reported having no relevant financial disclosures.

 

There are several things you should know about necessary vaccinations, and sometimes potential supply problems, if your families will be traveling internationally.

Yellow fever and vaccine supply

Yellow fever is caused by a Flavivirus transmitted by the bite of an infected mosquito. It occurs in sub-Saharan Africa and in tropical areas in South America. Multiple factors determine a traveler’s risk for acquisition, including destination, season, duration of potential exposure, activities, and the local transmission rate. The majority of those infected are asymptomatic or have minimal clinical symptoms. The incubation period is 3-6 days, which is then followed by an influenza-like illness. Approximately 15% of infected individuals develop more serious symptoms including jaundice, hemorrhagic symptoms, shock, and, ultimately, multiorgan system failure with a fatality rate of 90%. There is no specific treatment.

Prevention is avoidance of mosquito bites and receipt of yellow fever vaccine (YF-Vax). It is a relatively safe vaccine and indicated for use in persons at least 9 months of age. There are a few situations in which it can be administered to patients as young as 6 months. The vaccine becomes valid 10 days after administration, and it must be documented on an International Certificate of Vaccination or Prophylaxis card (Yellow Card).

Previously, vaccine boosters were required every 10 years. However, the duration of immunity was extensively reviewed by the World Health Organization and effective July 11, 2016, boosters are no longer required. A single dose of vaccine is now valid for the lifetime of the individual. This includes those persons vaccinated prior to July 11, 2016. Since it is a live vaccine, administration is contraindicated in certain individuals. Exemption letters are provided for those who have a medical contraindication.

Caution is advised in persons receiving their initial dose of YF-VAX who are older than 60 years of age because they have an increased risk of serious side effects. This is not a concern for the pediatrician. The vaccine can only be administered at state approved facilities. It is one vaccine that is not only recommended, but may be required for entry into certain countries. Go to www.cdc.gov/yellowfever for a complete list.

Sanofi Pasteur is the only U.S. manufacturer of YF-VAX. Production has ceased until mid-2018, when a new manufacturing facility will open. Current supplies are anticipated to be depleted by mid-2017, and orders have been limited to 5 doses per month. Sanofi Pasteur, in conjunction with the Food and Drug Administration, will make Stamaril – a yellow fever vaccine manufactured by the company in France and licensed in over 70 countries – available to U.S. travelers through an Expanded Access Investigational New Drug Application. Details on how and when this program will be operational are forthcoming. What is known is that, nationwide, there will be a limited number of sites administering Stamaril. Once finalized, a list of locations will be posted on the CDC Yellow Fever site.

How does this affect your patients? If travel to a yellow fever risk area is anticipated, they should not delay in seeking pretravel advice and immunizations until the last minute. Individual clinic inventories will not be stable. Postponing a trip or changing destinations is preferred if the vaccine is not available. Yellow fever exemption letters are only provided for those persons who have a medical contraindication to receive YF-VAX.
 

Zika, dengue, and chikungunya

These three Flaviviruses all are transmitted by mosquitoes and can present with fever, rash, and headache. Their distribution is overlapping in several parts of the world. Most infected people are asymptomatic. If symptoms develop, they usually are self-limited. Disease prevention is by mosquito avoidance. There are no preventive vaccines.

Zika virus is the only one associated with a congenital syndrome. It is characterized by brain abnormalities with or without microcephaly, neural tube defects, and ocular abnormalities.

Guidelines for the evaluation and management of Zika virus–exposed infants were initially published in January, 2016, with the most recent update published in August 2016 (MMWR Morb Mortal Wkly Rep. 2016 Aug 26;65[33]:870-8).

Preliminary data from the U.S. Zika pregnancy registry of 442 completed pregnancies between Jan. 15 to Sept. 22, 2016, identified birth defects in 26 fetuses/ infants (6%). There were 21 infants with birth defects among 395 live births and 5 fetuses with birth defects among 47 pregnancy losses. Birth defects were reported for 16 of 271 (6%) asymptomatic and 10 of 167 (6%) symptomatic women. There were no birth defects in infants when exposure occurred after the first trimester. Of the 26 affected infants, 4 had microcephaly and no neuroimaging and 3 (12%) had no fetal or infant testing. Approximately 41% (82/442) of infants did not have Zika virus testing (JAMA. 2017 Jan 3;317[1]:59-68).

It is unclear why testing was not performed. One concern is that the pediatrician may not have been aware of the maternal Zika virus exposure or test results. It may behoove us to begin asking questions about parental international travel to provide optimal management for our patients. We also should be familiar with the current guidelines for evaluating any potentially exposed infants, which include postnatal neuroimaging, Zika virus testing, a comprehensive newborn examination including neurologic exam, and a standard newborn hearing screen prior to hospital discharge.

Regardless of maternal Zika virus test results, infants with any clinical findings suggestive of congenital Zika virus syndrome and possible maternal exposure based on epidemiologic link also should be tested. Zika virus travel alerts and the most up to date information can be found on the Centers for Disease Control and Prevention website (www. cdc.gov/Zika).

CDC/Molly Kurnit, M.P.H.

 

Measles

Although endemic measles was eliminated in the United States in 2000, it is still common in many countries in Europe, Africa, and the Pacific. Most cases in the United States occur in unvaccinated individuals, with 78 cases reported in 2016. As of March 25, 2017, 28 cases have been reported. At least 10 countries – including Belgium, France, Italy, Germany, Portugal, and Thailand – have reported outbreaks of measles since April 2017. As reminder, all children aged 6-11 months should receive one dose of MMR and those 12 months or older should receive two doses of MMR at least 28 days apart if international travel is planned. Adults born after 1956 also should have received two doses of MMR prior to international travel.

Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She reported having no relevant financial disclosures.

 

There are several things you should know about necessary vaccinations, and sometimes potential supply problems, if your families will be traveling internationally.

Yellow fever and vaccine supply

Yellow fever is caused by a Flavivirus transmitted by the bite of an infected mosquito. It occurs in sub-Saharan Africa and in tropical areas in South America. Multiple factors determine a traveler’s risk for acquisition, including destination, season, duration of potential exposure, activities, and the local transmission rate. The majority of those infected are asymptomatic or have minimal clinical symptoms. The incubation period is 3-6 days, which is then followed by an influenza-like illness. Approximately 15% of infected individuals develop more serious symptoms including jaundice, hemorrhagic symptoms, shock, and, ultimately, multiorgan system failure with a fatality rate of 90%. There is no specific treatment.

Prevention is avoidance of mosquito bites and receipt of yellow fever vaccine (YF-Vax). It is a relatively safe vaccine and indicated for use in persons at least 9 months of age. There are a few situations in which it can be administered to patients as young as 6 months. The vaccine becomes valid 10 days after administration, and it must be documented on an International Certificate of Vaccination or Prophylaxis card (Yellow Card).

Previously, vaccine boosters were required every 10 years. However, the duration of immunity was extensively reviewed by the World Health Organization and effective July 11, 2016, boosters are no longer required. A single dose of vaccine is now valid for the lifetime of the individual. This includes those persons vaccinated prior to July 11, 2016. Since it is a live vaccine, administration is contraindicated in certain individuals. Exemption letters are provided for those who have a medical contraindication.

Caution is advised in persons receiving their initial dose of YF-VAX who are older than 60 years of age because they have an increased risk of serious side effects. This is not a concern for the pediatrician. The vaccine can only be administered at state approved facilities. It is one vaccine that is not only recommended, but may be required for entry into certain countries. Go to www.cdc.gov/yellowfever for a complete list.

Sanofi Pasteur is the only U.S. manufacturer of YF-VAX. Production has ceased until mid-2018, when a new manufacturing facility will open. Current supplies are anticipated to be depleted by mid-2017, and orders have been limited to 5 doses per month. Sanofi Pasteur, in conjunction with the Food and Drug Administration, will make Stamaril – a yellow fever vaccine manufactured by the company in France and licensed in over 70 countries – available to U.S. travelers through an Expanded Access Investigational New Drug Application. Details on how and when this program will be operational are forthcoming. What is known is that, nationwide, there will be a limited number of sites administering Stamaril. Once finalized, a list of locations will be posted on the CDC Yellow Fever site.

How does this affect your patients? If travel to a yellow fever risk area is anticipated, they should not delay in seeking pretravel advice and immunizations until the last minute. Individual clinic inventories will not be stable. Postponing a trip or changing destinations is preferred if the vaccine is not available. Yellow fever exemption letters are only provided for those persons who have a medical contraindication to receive YF-VAX.
 

Zika, dengue, and chikungunya

These three Flaviviruses all are transmitted by mosquitoes and can present with fever, rash, and headache. Their distribution is overlapping in several parts of the world. Most infected people are asymptomatic. If symptoms develop, they usually are self-limited. Disease prevention is by mosquito avoidance. There are no preventive vaccines.

Zika virus is the only one associated with a congenital syndrome. It is characterized by brain abnormalities with or without microcephaly, neural tube defects, and ocular abnormalities.

Guidelines for the evaluation and management of Zika virus–exposed infants were initially published in January, 2016, with the most recent update published in August 2016 (MMWR Morb Mortal Wkly Rep. 2016 Aug 26;65[33]:870-8).

Preliminary data from the U.S. Zika pregnancy registry of 442 completed pregnancies between Jan. 15 to Sept. 22, 2016, identified birth defects in 26 fetuses/ infants (6%). There were 21 infants with birth defects among 395 live births and 5 fetuses with birth defects among 47 pregnancy losses. Birth defects were reported for 16 of 271 (6%) asymptomatic and 10 of 167 (6%) symptomatic women. There were no birth defects in infants when exposure occurred after the first trimester. Of the 26 affected infants, 4 had microcephaly and no neuroimaging and 3 (12%) had no fetal or infant testing. Approximately 41% (82/442) of infants did not have Zika virus testing (JAMA. 2017 Jan 3;317[1]:59-68).

It is unclear why testing was not performed. One concern is that the pediatrician may not have been aware of the maternal Zika virus exposure or test results. It may behoove us to begin asking questions about parental international travel to provide optimal management for our patients. We also should be familiar with the current guidelines for evaluating any potentially exposed infants, which include postnatal neuroimaging, Zika virus testing, a comprehensive newborn examination including neurologic exam, and a standard newborn hearing screen prior to hospital discharge.

Regardless of maternal Zika virus test results, infants with any clinical findings suggestive of congenital Zika virus syndrome and possible maternal exposure based on epidemiologic link also should be tested. Zika virus travel alerts and the most up to date information can be found on the Centers for Disease Control and Prevention website (www. cdc.gov/Zika).

CDC/Molly Kurnit, M.P.H.

 

Measles

Although endemic measles was eliminated in the United States in 2000, it is still common in many countries in Europe, Africa, and the Pacific. Most cases in the United States occur in unvaccinated individuals, with 78 cases reported in 2016. As of March 25, 2017, 28 cases have been reported. At least 10 countries – including Belgium, France, Italy, Germany, Portugal, and Thailand – have reported outbreaks of measles since April 2017. As reminder, all children aged 6-11 months should receive one dose of MMR and those 12 months or older should receive two doses of MMR at least 28 days apart if international travel is planned. Adults born after 1956 also should have received two doses of MMR prior to international travel.

Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She reported having no relevant financial disclosures.

Pes planus, or flat feet, is a common concern addressed during well-child visits. Many parents express concern more because of the appearance of the feet than actual symptomatology. But what is within the realm of normal and what is beyond?

Ninety percent of clinic visits for foot problems are for flat feet.¹ Historically, the treatment of flat feet was wearing orthopedic shoes that were unappealing, so parents fear that is the fate of their child. Although the exact incidence rate of flat feet has not been determined, it clearly is quite common. Other contributing factors are joint hypermobility, obesity, and age. All children under the age of 2 years have flat feet because of the fat pad that is present. By the age of 10 years, this fat pad regresses and the normal arch is formed.

Determining the incidence is complicated by the lack of classification of normal versus abnormal. Because flexible flat feet usually are asymptomatic, some authorities have difficulty classifying it as abnormal. Flat feet are classified into three categories; flexible flat feet, flexible flat feet with short Achilles tendon, and rigid flat feet. Flexible flat feet account for two-thirds of diagnosed cases.²

Given that the arch does not fully form until the end of the first decade of life, neither diagnosis nor treatment should be given until after that time. Evaluating for flat feet in the clinic is usually limited to inspection in weight bearing and non-weight bearing. There are more formal procedures using foot prints and x-rays, but practically speaking those are not necessary. It is key to examine the patient while he or she is standing, to see if the arch is present and to gauge the orientation of the talus bone. When the patient is supine, again note if the arch is present and check the degree of dorsiflexion and plantarflexion.

Determine whether the talus bone is straight or in a valgus position, and whether there is a shortened Achilles tendon. This is crucial in predicting whether symptoms will emerge if they haven’t already. Patients with rigid flat feet or flexible flat feet with shortened Achilles tendon usually begin to complain of discomfort with activity in the second or third decade of life. Those symptoms may be limited to pain in the foot near the head of the talus, or can be complaints of knee, hip, or back pain.¹

For the asymptomatic patient, no intervention is needed. Although many clinicians recommend orthotics, studies have shown that after years of wearing orthotics, the feet remain flat. For symptomatic patients with flexible flat feet, there is increased intrinsic muscle activity, which can result in soreness and achiness of the feet. Orthotics can offer some relief, but for patients with shortened Achilles tendons, it potentially can cause more discomfort.² Both OTC and hard custom orthotics have been shown to relieve pain without significant increase in the height of the arch. There is little information to support using one over the other.²

Heel cord stretching is another reasonable intervention to improve any discomfort. It is important to note that the knee must be extended and the subtalar joint must be in the neutral position for the stretch to be effective.

Surgery is reserved for flexible and rigid flat feet that are symptomatic despite conservative treatment. Bone reconstruction and tendon lengthening have shown reduction in symptoms.

In summary, the vast majority of patients with flat feet do not need any intervention. Proper categorization is important to determine if intervention will be needed. The use of orthotics should be reserved for symptomatic patients, but will not alter the height of the arch. Surgery is indicated for those patients with significant symptoms that have not improved with conservative measures. It has been found to be effective if all components of the deformity have been addressed.
 

Dr. Pearce is a pediatrician in Frankfort, Ill. She said she had no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.

References

1. Iran J Pediatr. 2013 Jun;23(3):247-60.

2. J Child Orthop. 2010;4(2):107-21.

Pes planus, or flat feet, is a common concern addressed during well-child visits. Many parents express concern more because of the appearance of the feet than actual symptomatology. But what is within the realm of normal and what is beyond?

Ninety percent of clinic visits for foot problems are for flat feet.¹ Historically, the treatment of flat feet was wearing orthopedic shoes that were unappealing, so parents fear that is the fate of their child. Although the exact incidence rate of flat feet has not been determined, it clearly is quite common. Other contributing factors are joint hypermobility, obesity, and age. All children under the age of 2 years have flat feet because of the fat pad that is present. By the age of 10 years, this fat pad regresses and the normal arch is formed.

Determining the incidence is complicated by the lack of classification of normal versus abnormal. Because flexible flat feet usually are asymptomatic, some authorities have difficulty classifying it as abnormal. Flat feet are classified into three categories; flexible flat feet, flexible flat feet with short Achilles tendon, and rigid flat feet. Flexible flat feet account for two-thirds of diagnosed cases.²

Given that the arch does not fully form until the end of the first decade of life, neither diagnosis nor treatment should be given until after that time. Evaluating for flat feet in the clinic is usually limited to inspection in weight bearing and non-weight bearing. There are more formal procedures using foot prints and x-rays, but practically speaking those are not necessary. It is key to examine the patient while he or she is standing, to see if the arch is present and to gauge the orientation of the talus bone. When the patient is supine, again note if the arch is present and check the degree of dorsiflexion and plantarflexion.

Determine whether the talus bone is straight or in a valgus position, and whether there is a shortened Achilles tendon. This is crucial in predicting whether symptoms will emerge if they haven’t already. Patients with rigid flat feet or flexible flat feet with shortened Achilles tendon usually begin to complain of discomfort with activity in the second or third decade of life. Those symptoms may be limited to pain in the foot near the head of the talus, or can be complaints of knee, hip, or back pain.¹

For the asymptomatic patient, no intervention is needed. Although many clinicians recommend orthotics, studies have shown that after years of wearing orthotics, the feet remain flat. For symptomatic patients with flexible flat feet, there is increased intrinsic muscle activity, which can result in soreness and achiness of the feet. Orthotics can offer some relief, but for patients with shortened Achilles tendons, it potentially can cause more discomfort.² Both OTC and hard custom orthotics have been shown to relieve pain without significant increase in the height of the arch. There is little information to support using one over the other.²

Heel cord stretching is another reasonable intervention to improve any discomfort. It is important to note that the knee must be extended and the subtalar joint must be in the neutral position for the stretch to be effective.

Surgery is reserved for flexible and rigid flat feet that are symptomatic despite conservative treatment. Bone reconstruction and tendon lengthening have shown reduction in symptoms.

In summary, the vast majority of patients with flat feet do not need any intervention. Proper categorization is important to determine if intervention will be needed. The use of orthotics should be reserved for symptomatic patients, but will not alter the height of the arch. Surgery is indicated for those patients with significant symptoms that have not improved with conservative measures. It has been found to be effective if all components of the deformity have been addressed.
 

Dr. Pearce is a pediatrician in Frankfort, Ill. She said she had no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.

References

1. Iran J Pediatr. 2013 Jun;23(3):247-60.

2. J Child Orthop. 2010;4(2):107-21.

Pes planus, or flat feet, is a common concern addressed during well-child visits. Many parents express concern more because of the appearance of the feet than actual symptomatology. But what is within the realm of normal and what is beyond?

Ninety percent of clinic visits for foot problems are for flat feet.¹ Historically, the treatment of flat feet was wearing orthopedic shoes that were unappealing, so parents fear that is the fate of their child. Although the exact incidence rate of flat feet has not been determined, it clearly is quite common. Other contributing factors are joint hypermobility, obesity, and age. All children under the age of 2 years have flat feet because of the fat pad that is present. By the age of 10 years, this fat pad regresses and the normal arch is formed.

Determining the incidence is complicated by the lack of classification of normal versus abnormal. Because flexible flat feet usually are asymptomatic, some authorities have difficulty classifying it as abnormal. Flat feet are classified into three categories; flexible flat feet, flexible flat feet with short Achilles tendon, and rigid flat feet. Flexible flat feet account for two-thirds of diagnosed cases.²

Given that the arch does not fully form until the end of the first decade of life, neither diagnosis nor treatment should be given until after that time. Evaluating for flat feet in the clinic is usually limited to inspection in weight bearing and non-weight bearing. There are more formal procedures using foot prints and x-rays, but practically speaking those are not necessary. It is key to examine the patient while he or she is standing, to see if the arch is present and to gauge the orientation of the talus bone. When the patient is supine, again note if the arch is present and check the degree of dorsiflexion and plantarflexion.

Determine whether the talus bone is straight or in a valgus position, and whether there is a shortened Achilles tendon. This is crucial in predicting whether symptoms will emerge if they haven’t already. Patients with rigid flat feet or flexible flat feet with shortened Achilles tendon usually begin to complain of discomfort with activity in the second or third decade of life. Those symptoms may be limited to pain in the foot near the head of the talus, or can be complaints of knee, hip, or back pain.¹

For the asymptomatic patient, no intervention is needed. Although many clinicians recommend orthotics, studies have shown that after years of wearing orthotics, the feet remain flat. For symptomatic patients with flexible flat feet, there is increased intrinsic muscle activity, which can result in soreness and achiness of the feet. Orthotics can offer some relief, but for patients with shortened Achilles tendons, it potentially can cause more discomfort.² Both OTC and hard custom orthotics have been shown to relieve pain without significant increase in the height of the arch. There is little information to support using one over the other.²

Heel cord stretching is another reasonable intervention to improve any discomfort. It is important to note that the knee must be extended and the subtalar joint must be in the neutral position for the stretch to be effective.

Surgery is reserved for flexible and rigid flat feet that are symptomatic despite conservative treatment. Bone reconstruction and tendon lengthening have shown reduction in symptoms.

In summary, the vast majority of patients with flat feet do not need any intervention. Proper categorization is important to determine if intervention will be needed. The use of orthotics should be reserved for symptomatic patients, but will not alter the height of the arch. Surgery is indicated for those patients with significant symptoms that have not improved with conservative measures. It has been found to be effective if all components of the deformity have been addressed.
 

Dr. Pearce is a pediatrician in Frankfort, Ill. She said she had no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.

References

1. Iran J Pediatr. 2013 Jun;23(3):247-60.

2. J Child Orthop. 2010;4(2):107-21.

 

Recently North Carolina proposed a bill (House Bill 780) that will ban same-sex marriage in the state, even though the U.S. Supreme Court ruled in 2015 that no states can ban same-sex marriage because doing so violates the 14th Amendment. Although many mainly will argue that H.B. 780 is unconstitutional, this bill also can be detrimental to the health of lesbian, gay, and bisexual (LGB) youth.

In March 2017, JAMA Pediatrics published a study on the association between same-sex marriage laws and the rates of suicide attempts.¹ Using data from the Youth Risk Behavior Surveillance System, they analyzed the relationship between state policies that permitted same-sex marriage and self-report of suicide attempts within the last 12 months. Thirty percent of LGB youth (13% of the survey population) reported a suicide attempt in the past year prior to any state policies that permitted same-sex marriage, compared with about 9% of the general population. After states implemented pro–same-sex marriage policies, LGB youth suicide attempts dropped to about 26% – a 14% relative decline. This was not limited to LGB youth. The general youth suicide rates declined from 8.6% to 8% – a 7% relative decline. Although the change in suicide attempts was small, the authors determined that the likelihood it occurred by chance was very slim, and concluded that policies enabling same-sex marriage may be associated with an improvement in population health, especially for LGB youth.

This was not the first study examining the relationship between policies and the health of LGB youth. Mark Hatzenbuehler, PhD, of Columbia University, New York, and his associates have published multiple studies on this topic. Four years earlier, Hatzenbuehler et al. published a study on the relationship between antibullying policies and suicide among LGB youth. Using data from the Oregon Healthy Teen survey (2006-2008), he found that LGB youth who live in counties where there are fewer districts with antibullying policies are more than twice as likely to attempt suicide, compared with LGB youth who live in counties where more districts had antibullying policies. Furthermore, the type of antibullying policy mattered. If a district’s antibullying policy did not prohibit bullying based on sexual orientation, then it had no impact on the suicide attempt rates of LGB youth in that area.² Similar results were found when the relationship between anti–homophobic bullying policies and LGB suicide attempts was examined in the larger Youth Risk Behavior Surveillance System.³

State and local policies also influence other health outcomes among LGB youth. Hatzenbuehler et al. did another study that examined community-level determinants of tobacco use among LGB youth. Again using the data from the Oregon Healthy Teen Survey, they found that LGB youth living in communities that were more supportive of LGB youth (i.e., communities with a high proportion of same-sex couples living in the area, a high proportion of gay-straight alliances at schools, and LGB-specific antibullying policies) were less likely to smoke cigarettes, compared with LGB youth living in communities that were less supportive.⁴ A similar study in Canada by Konishi et al. found that schools with gay-straight alliances and anti–homophobic bullying policies were less likely to have LGB youth engaging in risky alcohol or illicit drug use.⁵

Why do these policies matter? A common theme among these policies is that they can either cause or alleviate stress for LGB youth. States that restrict same-sex marriages or schools that do not have any gay-straight alliances may signal to LGB youth that they are not valued or welcomed, or at the very worse, are despised. This creates a hostile and stressful environment for LGB youth, which raises the risk for mental health problems, such as depression and anxiety, which in turn, raises the risk for substance use and suicide.⁶ Conversely, the presence of a gay-straight alliance at school or a state that allows same-sex marriage may indicate to LGB youth that they are welcomed, if not just tolerated, and may alleviate this risk. Furthermore, antibullying policies seem to reduce the stress associated with bullying among LGB youth because it may serve as a deterrent to bullying based on sexual orientation. Although passing pro-LGB policies will not solve all the health problems among LGB youth, these policies certainly have an impact.

There might be trepidation among some pediatricians about being vocal on a politically charged policy proposal such as H.B. 780. However, suicide and substance use are major concerns for all physicians – especially pediatricians. Policy makers considering passing laws that can affect their LGB constituents should read these studies to see what kind of influence these proposals can have on the health and well-being of LGB youth. Moreover, health care providers should use their expertise, influence, and standing in their community to support policies that encourage protection for LGB youth and oppose policies that can harm LGB youth. These leaders are responsible for ensuring the health of the people they serve.
 

 

Dr. Montano is clinical instructor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC.

References

1. JAMA Pediatr. 2017. doi: 10.1001/jamapediatrics.2016.4529.

2. J Adolesc Health. 2013:S21-6. doi: 10.1016/j.jadohealth.2012.08.010.

3. Am J Public Health. 2014. doi: 10.2105/AJPH.2013.301508.

4. Arch Pediatr Adolesc Med. 2011. doi: 10.1001/archpediatrics.2011.64.

5. Prev Med. 2013. doi: 10.1016/j.ypmed.2013.06.031.

6. Psychol Bull. 2003. doi: 10.1037/0033-2909.129.5.674.

 

Recently North Carolina proposed a bill (House Bill 780) that will ban same-sex marriage in the state, even though the U.S. Supreme Court ruled in 2015 that no states can ban same-sex marriage because doing so violates the 14th Amendment. Although many mainly will argue that H.B. 780 is unconstitutional, this bill also can be detrimental to the health of lesbian, gay, and bisexual (LGB) youth.

In March 2017, JAMA Pediatrics published a study on the association between same-sex marriage laws and the rates of suicide attempts.¹ Using data from the Youth Risk Behavior Surveillance System, they analyzed the relationship between state policies that permitted same-sex marriage and self-report of suicide attempts within the last 12 months. Thirty percent of LGB youth (13% of the survey population) reported a suicide attempt in the past year prior to any state policies that permitted same-sex marriage, compared with about 9% of the general population. After states implemented pro–same-sex marriage policies, LGB youth suicide attempts dropped to about 26% – a 14% relative decline. This was not limited to LGB youth. The general youth suicide rates declined from 8.6% to 8% – a 7% relative decline. Although the change in suicide attempts was small, the authors determined that the likelihood it occurred by chance was very slim, and concluded that policies enabling same-sex marriage may be associated with an improvement in population health, especially for LGB youth.

This was not the first study examining the relationship between policies and the health of LGB youth. Mark Hatzenbuehler, PhD, of Columbia University, New York, and his associates have published multiple studies on this topic. Four years earlier, Hatzenbuehler et al. published a study on the relationship between antibullying policies and suicide among LGB youth. Using data from the Oregon Healthy Teen survey (2006-2008), he found that LGB youth who live in counties where there are fewer districts with antibullying policies are more than twice as likely to attempt suicide, compared with LGB youth who live in counties where more districts had antibullying policies. Furthermore, the type of antibullying policy mattered. If a district’s antibullying policy did not prohibit bullying based on sexual orientation, then it had no impact on the suicide attempt rates of LGB youth in that area.² Similar results were found when the relationship between anti–homophobic bullying policies and LGB suicide attempts was examined in the larger Youth Risk Behavior Surveillance System.³

State and local policies also influence other health outcomes among LGB youth. Hatzenbuehler et al. did another study that examined community-level determinants of tobacco use among LGB youth. Again using the data from the Oregon Healthy Teen Survey, they found that LGB youth living in communities that were more supportive of LGB youth (i.e., communities with a high proportion of same-sex couples living in the area, a high proportion of gay-straight alliances at schools, and LGB-specific antibullying policies) were less likely to smoke cigarettes, compared with LGB youth living in communities that were less supportive.⁴ A similar study in Canada by Konishi et al. found that schools with gay-straight alliances and anti–homophobic bullying policies were less likely to have LGB youth engaging in risky alcohol or illicit drug use.⁵

Why do these policies matter? A common theme among these policies is that they can either cause or alleviate stress for LGB youth. States that restrict same-sex marriages or schools that do not have any gay-straight alliances may signal to LGB youth that they are not valued or welcomed, or at the very worse, are despised. This creates a hostile and stressful environment for LGB youth, which raises the risk for mental health problems, such as depression and anxiety, which in turn, raises the risk for substance use and suicide.⁶ Conversely, the presence of a gay-straight alliance at school or a state that allows same-sex marriage may indicate to LGB youth that they are welcomed, if not just tolerated, and may alleviate this risk. Furthermore, antibullying policies seem to reduce the stress associated with bullying among LGB youth because it may serve as a deterrent to bullying based on sexual orientation. Although passing pro-LGB policies will not solve all the health problems among LGB youth, these policies certainly have an impact.

There might be trepidation among some pediatricians about being vocal on a politically charged policy proposal such as H.B. 780. However, suicide and substance use are major concerns for all physicians – especially pediatricians. Policy makers considering passing laws that can affect their LGB constituents should read these studies to see what kind of influence these proposals can have on the health and well-being of LGB youth. Moreover, health care providers should use their expertise, influence, and standing in their community to support policies that encourage protection for LGB youth and oppose policies that can harm LGB youth. These leaders are responsible for ensuring the health of the people they serve.
 

 

Dr. Montano is clinical instructor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC.

References

1. JAMA Pediatr. 2017. doi: 10.1001/jamapediatrics.2016.4529.

2. J Adolesc Health. 2013:S21-6. doi: 10.1016/j.jadohealth.2012.08.010.

3. Am J Public Health. 2014. doi: 10.2105/AJPH.2013.301508.

4. Arch Pediatr Adolesc Med. 2011. doi: 10.1001/archpediatrics.2011.64.

5. Prev Med. 2013. doi: 10.1016/j.ypmed.2013.06.031.

6. Psychol Bull. 2003. doi: 10.1037/0033-2909.129.5.674.

 

Recently North Carolina proposed a bill (House Bill 780) that will ban same-sex marriage in the state, even though the U.S. Supreme Court ruled in 2015 that no states can ban same-sex marriage because doing so violates the 14th Amendment. Although many mainly will argue that H.B. 780 is unconstitutional, this bill also can be detrimental to the health of lesbian, gay, and bisexual (LGB) youth.

In March 2017, JAMA Pediatrics published a study on the association between same-sex marriage laws and the rates of suicide attempts.¹ Using data from the Youth Risk Behavior Surveillance System, they analyzed the relationship between state policies that permitted same-sex marriage and self-report of suicide attempts within the last 12 months. Thirty percent of LGB youth (13% of the survey population) reported a suicide attempt in the past year prior to any state policies that permitted same-sex marriage, compared with about 9% of the general population. After states implemented pro–same-sex marriage policies, LGB youth suicide attempts dropped to about 26% – a 14% relative decline. This was not limited to LGB youth. The general youth suicide rates declined from 8.6% to 8% – a 7% relative decline. Although the change in suicide attempts was small, the authors determined that the likelihood it occurred by chance was very slim, and concluded that policies enabling same-sex marriage may be associated with an improvement in population health, especially for LGB youth.

This was not the first study examining the relationship between policies and the health of LGB youth. Mark Hatzenbuehler, PhD, of Columbia University, New York, and his associates have published multiple studies on this topic. Four years earlier, Hatzenbuehler et al. published a study on the relationship between antibullying policies and suicide among LGB youth. Using data from the Oregon Healthy Teen survey (2006-2008), he found that LGB youth who live in counties where there are fewer districts with antibullying policies are more than twice as likely to attempt suicide, compared with LGB youth who live in counties where more districts had antibullying policies. Furthermore, the type of antibullying policy mattered. If a district’s antibullying policy did not prohibit bullying based on sexual orientation, then it had no impact on the suicide attempt rates of LGB youth in that area.² Similar results were found when the relationship between anti–homophobic bullying policies and LGB suicide attempts was examined in the larger Youth Risk Behavior Surveillance System.³

State and local policies also influence other health outcomes among LGB youth. Hatzenbuehler et al. did another study that examined community-level determinants of tobacco use among LGB youth. Again using the data from the Oregon Healthy Teen Survey, they found that LGB youth living in communities that were more supportive of LGB youth (i.e., communities with a high proportion of same-sex couples living in the area, a high proportion of gay-straight alliances at schools, and LGB-specific antibullying policies) were less likely to smoke cigarettes, compared with LGB youth living in communities that were less supportive.⁴ A similar study in Canada by Konishi et al. found that schools with gay-straight alliances and anti–homophobic bullying policies were less likely to have LGB youth engaging in risky alcohol or illicit drug use.⁵

Why do these policies matter? A common theme among these policies is that they can either cause or alleviate stress for LGB youth. States that restrict same-sex marriages or schools that do not have any gay-straight alliances may signal to LGB youth that they are not valued or welcomed, or at the very worse, are despised. This creates a hostile and stressful environment for LGB youth, which raises the risk for mental health problems, such as depression and anxiety, which in turn, raises the risk for substance use and suicide.⁶ Conversely, the presence of a gay-straight alliance at school or a state that allows same-sex marriage may indicate to LGB youth that they are welcomed, if not just tolerated, and may alleviate this risk. Furthermore, antibullying policies seem to reduce the stress associated with bullying among LGB youth because it may serve as a deterrent to bullying based on sexual orientation. Although passing pro-LGB policies will not solve all the health problems among LGB youth, these policies certainly have an impact.

There might be trepidation among some pediatricians about being vocal on a politically charged policy proposal such as H.B. 780. However, suicide and substance use are major concerns for all physicians – especially pediatricians. Policy makers considering passing laws that can affect their LGB constituents should read these studies to see what kind of influence these proposals can have on the health and well-being of LGB youth. Moreover, health care providers should use their expertise, influence, and standing in their community to support policies that encourage protection for LGB youth and oppose policies that can harm LGB youth. These leaders are responsible for ensuring the health of the people they serve.
 

 

Dr. Montano is clinical instructor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC.

References

1. JAMA Pediatr. 2017. doi: 10.1001/jamapediatrics.2016.4529.

2. J Adolesc Health. 2013:S21-6. doi: 10.1016/j.jadohealth.2012.08.010.

3. Am J Public Health. 2014. doi: 10.2105/AJPH.2013.301508.

4. Arch Pediatr Adolesc Med. 2011. doi: 10.1001/archpediatrics.2011.64.

5. Prev Med. 2013. doi: 10.1016/j.ypmed.2013.06.031.

6. Psychol Bull. 2003. doi: 10.1037/0033-2909.129.5.674.

 

Dating during residency is a job unto itself – one that I didn’t expect to balance alongside my long and frequently odd hours of work. To make matters worse, I happen to be in a field where the examination is almost entirely through conversation, involving probing questions, where maintaining calm and strength is important in the face of patient stories that often tear at my heart. Then, on a date (first or otherwise) I spend more time listening to another person’s stories while trying hard not to interpret the information through the perspective of my profession. To orient my older readers, I primarily date using the Internet and dating applications. There, my profile names me as “Resident.” This title is unassuming and unintimidating. Resident of what, potential suitors wonder, while examining carefully curated pictures of travel to exotic places and of me smiling happily with friends. I swipe right and left, matching with people, chatting digitally at first, and, if there is mutual interest, arranging to meet in person.

I get a different reaction every time I tell a date I’m a psychiatrist. It seems each man has his own expectations of what it means to date a psychiatrist. This column is a shout-out to all the physicians, and especially psychiatrists, who have been single while practicing, required to pretend our work is just like everyone else’s. Because the truth is, our work is different. How can one really describe the goings-on at a psychiatric hospital to a potential partner? Or deal with fatigue that accompanies listening to emotional suffering while at work and then needing the energy to commiserate with the person across the table?

Two personal dating experiences highlight these challenges. Some time ago, I went out with a guy for just 2 weeks. It was nice, but not what I wanted, so I broke it off. His response to me: “I thought you really understood me. You seemed like you wanted to know me. Only a psychiatrist could be so cruel.” I didn’t think I was cruel, and I don’t know how well I understood him – or why he got that impression. Perhaps I do ask more intense questions earlier on in conversation than others might? Indeed, my profession requires accessing deep truths about people’s lives in a short period of time. After a day of hearing these real stories, I don’t want to exchange small talk. I want to know the person I’m sharing a meal with.

The second experience prompted this column – a recent breakup with a man I really felt and thought I could be with. I had begun perusing fellowships in the cities where he wanted to move. Perhaps predictably, my heart was broken. I am grateful to have a specialty that encourages a close connection to my patients. I am privileged to see and consider the motives, desires, fantasies, and fears of my patients. For dating, however, this skill is excessively fine tuned. I sense too subtly when something is going wrong. As a therapist in training, I am learning to hear the manifest content and listen for the latent content. I felt it with this man, despite knowing that he liked me and was serious about our relationship. I sensed the change in his approach to me – the transference, if you will. I suspected the reason was his stated desire to move to the West Coast “eventually.” When he actually revealed his plan to move and end the relationship, however, I cried as someone who has been hurt would cry. His response was: “ It will be okay. ... You’re supereligible. … Don’t cry. ... I’m surprised by all your emotion – especially the way you describe yourself at work.” He expected me to have control over my emotions because of my profession.

Psychiatrists are trained to examine emotions and behaviors, characterize them first as symptoms, then as diagnoses, and finally assess the best way to intervene. The emotions of my patients sometime get tangled with my own. I try to disentangle myself through my own therapy, and filling my life with productive activities and close friends. However, I think as a young, single psychiatrist, I have a space of loneliness that is too easily filled by the pain shared by my patients. I also expect better control over my emotions, but sometimes, my cup is already full, and all it can do is overflow with tears.
 

Dr. Posada is a second-year resident in the psychiatry and behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, health disparities, and psychosomatic medicine.

 

Dating during residency is a job unto itself – one that I didn’t expect to balance alongside my long and frequently odd hours of work. To make matters worse, I happen to be in a field where the examination is almost entirely through conversation, involving probing questions, where maintaining calm and strength is important in the face of patient stories that often tear at my heart. Then, on a date (first or otherwise) I spend more time listening to another person’s stories while trying hard not to interpret the information through the perspective of my profession. To orient my older readers, I primarily date using the Internet and dating applications. There, my profile names me as “Resident.” This title is unassuming and unintimidating. Resident of what, potential suitors wonder, while examining carefully curated pictures of travel to exotic places and of me smiling happily with friends. I swipe right and left, matching with people, chatting digitally at first, and, if there is mutual interest, arranging to meet in person.

I get a different reaction every time I tell a date I’m a psychiatrist. It seems each man has his own expectations of what it means to date a psychiatrist. This column is a shout-out to all the physicians, and especially psychiatrists, who have been single while practicing, required to pretend our work is just like everyone else’s. Because the truth is, our work is different. How can one really describe the goings-on at a psychiatric hospital to a potential partner? Or deal with fatigue that accompanies listening to emotional suffering while at work and then needing the energy to commiserate with the person across the table?

Two personal dating experiences highlight these challenges. Some time ago, I went out with a guy for just 2 weeks. It was nice, but not what I wanted, so I broke it off. His response to me: “I thought you really understood me. You seemed like you wanted to know me. Only a psychiatrist could be so cruel.” I didn’t think I was cruel, and I don’t know how well I understood him – or why he got that impression. Perhaps I do ask more intense questions earlier on in conversation than others might? Indeed, my profession requires accessing deep truths about people’s lives in a short period of time. After a day of hearing these real stories, I don’t want to exchange small talk. I want to know the person I’m sharing a meal with.

The second experience prompted this column – a recent breakup with a man I really felt and thought I could be with. I had begun perusing fellowships in the cities where he wanted to move. Perhaps predictably, my heart was broken. I am grateful to have a specialty that encourages a close connection to my patients. I am privileged to see and consider the motives, desires, fantasies, and fears of my patients. For dating, however, this skill is excessively fine tuned. I sense too subtly when something is going wrong. As a therapist in training, I am learning to hear the manifest content and listen for the latent content. I felt it with this man, despite knowing that he liked me and was serious about our relationship. I sensed the change in his approach to me – the transference, if you will. I suspected the reason was his stated desire to move to the West Coast “eventually.” When he actually revealed his plan to move and end the relationship, however, I cried as someone who has been hurt would cry. His response was: “ It will be okay. ... You’re supereligible. … Don’t cry. ... I’m surprised by all your emotion – especially the way you describe yourself at work.” He expected me to have control over my emotions because of my profession.

Psychiatrists are trained to examine emotions and behaviors, characterize them first as symptoms, then as diagnoses, and finally assess the best way to intervene. The emotions of my patients sometime get tangled with my own. I try to disentangle myself through my own therapy, and filling my life with productive activities and close friends. However, I think as a young, single psychiatrist, I have a space of loneliness that is too easily filled by the pain shared by my patients. I also expect better control over my emotions, but sometimes, my cup is already full, and all it can do is overflow with tears.
 

Dr. Posada is a second-year resident in the psychiatry and behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, health disparities, and psychosomatic medicine.

 

Dating during residency is a job unto itself – one that I didn’t expect to balance alongside my long and frequently odd hours of work. To make matters worse, I happen to be in a field where the examination is almost entirely through conversation, involving probing questions, where maintaining calm and strength is important in the face of patient stories that often tear at my heart. Then, on a date (first or otherwise) I spend more time listening to another person’s stories while trying hard not to interpret the information through the perspective of my profession. To orient my older readers, I primarily date using the Internet and dating applications. There, my profile names me as “Resident.” This title is unassuming and unintimidating. Resident of what, potential suitors wonder, while examining carefully curated pictures of travel to exotic places and of me smiling happily with friends. I swipe right and left, matching with people, chatting digitally at first, and, if there is mutual interest, arranging to meet in person.

I get a different reaction every time I tell a date I’m a psychiatrist. It seems each man has his own expectations of what it means to date a psychiatrist. This column is a shout-out to all the physicians, and especially psychiatrists, who have been single while practicing, required to pretend our work is just like everyone else’s. Because the truth is, our work is different. How can one really describe the goings-on at a psychiatric hospital to a potential partner? Or deal with fatigue that accompanies listening to emotional suffering while at work and then needing the energy to commiserate with the person across the table?

Two personal dating experiences highlight these challenges. Some time ago, I went out with a guy for just 2 weeks. It was nice, but not what I wanted, so I broke it off. His response to me: “I thought you really understood me. You seemed like you wanted to know me. Only a psychiatrist could be so cruel.” I didn’t think I was cruel, and I don’t know how well I understood him – or why he got that impression. Perhaps I do ask more intense questions earlier on in conversation than others might? Indeed, my profession requires accessing deep truths about people’s lives in a short period of time. After a day of hearing these real stories, I don’t want to exchange small talk. I want to know the person I’m sharing a meal with.

The second experience prompted this column – a recent breakup with a man I really felt and thought I could be with. I had begun perusing fellowships in the cities where he wanted to move. Perhaps predictably, my heart was broken. I am grateful to have a specialty that encourages a close connection to my patients. I am privileged to see and consider the motives, desires, fantasies, and fears of my patients. For dating, however, this skill is excessively fine tuned. I sense too subtly when something is going wrong. As a therapist in training, I am learning to hear the manifest content and listen for the latent content. I felt it with this man, despite knowing that he liked me and was serious about our relationship. I sensed the change in his approach to me – the transference, if you will. I suspected the reason was his stated desire to move to the West Coast “eventually.” When he actually revealed his plan to move and end the relationship, however, I cried as someone who has been hurt would cry. His response was: “ It will be okay. ... You’re supereligible. … Don’t cry. ... I’m surprised by all your emotion – especially the way you describe yourself at work.” He expected me to have control over my emotions because of my profession.

Psychiatrists are trained to examine emotions and behaviors, characterize them first as symptoms, then as diagnoses, and finally assess the best way to intervene. The emotions of my patients sometime get tangled with my own. I try to disentangle myself through my own therapy, and filling my life with productive activities and close friends. However, I think as a young, single psychiatrist, I have a space of loneliness that is too easily filled by the pain shared by my patients. I also expect better control over my emotions, but sometimes, my cup is already full, and all it can do is overflow with tears.
 

Dr. Posada is a second-year resident in the psychiatry and behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, health disparities, and psychosomatic medicine.

 

A 7-year-old boy, Jacob, with a history of ADHD and frequent impulsive behavior, takes a calculator from another child’s desk. About 3 months before, he had come home after taking another child’s action figure. His parents have been working on parent training for ADHD, but don’t know how to respond to this behavior and are very upset at their son.

Discussion

Stealing is an issue of serious concern to parents. To understand how common this is in younger children, researchers need to rely on the reports of parents and teachers, which may be underestimates of the problem because stealing is usually a hidden or covert behavior. Research on older youth can include anonymous self-reports.

In general, it appears that stealing is somewhat common in childhood, but becomes much more common in adolescence. Most studies based on parent and teacher reports show that about 5% of children under 10 years of age steal. Childhood stealing, especially occurring more than once in a 6-month period, is definitely of concern as it is strongly associated with the development of more serious antisocial behaviors over time. When children reach adolescence, stealing becomes much more common with 10%-15% of teens reporting stealing in anonymous self-reports.

Stealing and dishonesty are such disappointing behaviors to adults that it is tempting to resort to harsh punishments, long lectures, or harshly disparaging words. But these kinds of punishments backfire. The goal is an overall positive relationship and a calm consistent response to undesired behaviors. Parents often need support in how to be positive with a child who is frustrating them. Taking 15 minutes a day to do some activity a child likes – playing catch, playing a board game, cooking together, or doing crafts – all while noticing the positive things a child is doing rather than teaching, criticizing, or grilling a child on what happened in school sets a happier tone to the relationship, which is a background for any discipline. Jacob’s parents had already been working on this through their parent training class, but it helped to encourage them to keep doing this.

Because of the covert nature of stealing, it is sometimes hard to know where an item has come from, and children are likely to lie about this, saying that a friend gave it to them or they found it. To avoid this, when working with a child who has been stealing, the expectation should be made clear in advance that it is the child’s responsibility to avoid suspicion by having nothing in his possession that is not known to the adult. It is important to avoid back and forth arguments. The adult’s decision is final. With frequent stealing, it is helpful to make an inventory of the child’s possessions as a baseline.

When it comes to consequences, the important thing is to be sure that they are consistent and predictable. Returning an item to the owner and apologizing are logical. Another excellent type of consequence for behaviors that happen rarely is an extra work chore of about half an hour.

So a parent might say something like, “Jacob, we know that a stealing monster has been getting you, and we want to fight against him. I have made up a list of everything you have right now, and it is going to be your responsibility to make sure you don’t bring home anything else. So that means even if you find something or someone gives you something, you shouldn’t take it. If I find anything that isn’t on the list, you are going to have to return it to the person it belongs to and apologize, and then do an extra work chore for half an hour. A habit can be hard to change, but I know we can do it together. Let’s go play catch.” Then when the child is found with something in his possession, the adult should remain calm, avoid a lecture, and just say something like, “Jacob, this is something that doesn’t belong to you. You need to return it to the person it belongs to, and you have an extra half hour of raking leaves. No TV until the leaves are done.” The parent also should be alert to opportunities to attend to or praise behaviors like the child saving money to spend on things he wants, or asking to borrow things from other family members rather than just taking them.

Stealing can be a tough problem and often goes along with other rule-breaking behavior. If a parent is struggling to stay calm and find the positive, referral to group or individual parent training through programs like the Incredible Years or Triple P can give a parent the chance to learn and practice skills step by step.

As children enter their teen years, stealing becomes much more common, and can be reinforced by peers as well as by the action itself. The same principles of finding positive activities, continuing positive interactions with parents, and predictable and consistent – rather than harsh – consequences continue to apply, but may require additional supports. Larger programs such as Multisystemic Therapy, which works with families, peers, and communities, have been demonstrated to be effective for young people with juvenile delinquency.
 

 

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

Resource

Stealing, in “Children’s needs III: Development, prevention, and intervention,” (Washington: National Association of School Psychologists, 2006, pp. 171-83).

 

A 7-year-old boy, Jacob, with a history of ADHD and frequent impulsive behavior, takes a calculator from another child’s desk. About 3 months before, he had come home after taking another child’s action figure. His parents have been working on parent training for ADHD, but don’t know how to respond to this behavior and are very upset at their son.

Discussion

Stealing is an issue of serious concern to parents. To understand how common this is in younger children, researchers need to rely on the reports of parents and teachers, which may be underestimates of the problem because stealing is usually a hidden or covert behavior. Research on older youth can include anonymous self-reports.

In general, it appears that stealing is somewhat common in childhood, but becomes much more common in adolescence. Most studies based on parent and teacher reports show that about 5% of children under 10 years of age steal. Childhood stealing, especially occurring more than once in a 6-month period, is definitely of concern as it is strongly associated with the development of more serious antisocial behaviors over time. When children reach adolescence, stealing becomes much more common with 10%-15% of teens reporting stealing in anonymous self-reports.

Stealing and dishonesty are such disappointing behaviors to adults that it is tempting to resort to harsh punishments, long lectures, or harshly disparaging words. But these kinds of punishments backfire. The goal is an overall positive relationship and a calm consistent response to undesired behaviors. Parents often need support in how to be positive with a child who is frustrating them. Taking 15 minutes a day to do some activity a child likes – playing catch, playing a board game, cooking together, or doing crafts – all while noticing the positive things a child is doing rather than teaching, criticizing, or grilling a child on what happened in school sets a happier tone to the relationship, which is a background for any discipline. Jacob’s parents had already been working on this through their parent training class, but it helped to encourage them to keep doing this.

Because of the covert nature of stealing, it is sometimes hard to know where an item has come from, and children are likely to lie about this, saying that a friend gave it to them or they found it. To avoid this, when working with a child who has been stealing, the expectation should be made clear in advance that it is the child’s responsibility to avoid suspicion by having nothing in his possession that is not known to the adult. It is important to avoid back and forth arguments. The adult’s decision is final. With frequent stealing, it is helpful to make an inventory of the child’s possessions as a baseline.

When it comes to consequences, the important thing is to be sure that they are consistent and predictable. Returning an item to the owner and apologizing are logical. Another excellent type of consequence for behaviors that happen rarely is an extra work chore of about half an hour.

So a parent might say something like, “Jacob, we know that a stealing monster has been getting you, and we want to fight against him. I have made up a list of everything you have right now, and it is going to be your responsibility to make sure you don’t bring home anything else. So that means even if you find something or someone gives you something, you shouldn’t take it. If I find anything that isn’t on the list, you are going to have to return it to the person it belongs to and apologize, and then do an extra work chore for half an hour. A habit can be hard to change, but I know we can do it together. Let’s go play catch.” Then when the child is found with something in his possession, the adult should remain calm, avoid a lecture, and just say something like, “Jacob, this is something that doesn’t belong to you. You need to return it to the person it belongs to, and you have an extra half hour of raking leaves. No TV until the leaves are done.” The parent also should be alert to opportunities to attend to or praise behaviors like the child saving money to spend on things he wants, or asking to borrow things from other family members rather than just taking them.

Stealing can be a tough problem and often goes along with other rule-breaking behavior. If a parent is struggling to stay calm and find the positive, referral to group or individual parent training through programs like the Incredible Years or Triple P can give a parent the chance to learn and practice skills step by step.

As children enter their teen years, stealing becomes much more common, and can be reinforced by peers as well as by the action itself. The same principles of finding positive activities, continuing positive interactions with parents, and predictable and consistent – rather than harsh – consequences continue to apply, but may require additional supports. Larger programs such as Multisystemic Therapy, which works with families, peers, and communities, have been demonstrated to be effective for young people with juvenile delinquency.
 

 

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

Resource

Stealing, in “Children’s needs III: Development, prevention, and intervention,” (Washington: National Association of School Psychologists, 2006, pp. 171-83).

 

A 7-year-old boy, Jacob, with a history of ADHD and frequent impulsive behavior, takes a calculator from another child’s desk. About 3 months before, he had come home after taking another child’s action figure. His parents have been working on parent training for ADHD, but don’t know how to respond to this behavior and are very upset at their son.

Discussion

Stealing is an issue of serious concern to parents. To understand how common this is in younger children, researchers need to rely on the reports of parents and teachers, which may be underestimates of the problem because stealing is usually a hidden or covert behavior. Research on older youth can include anonymous self-reports.

In general, it appears that stealing is somewhat common in childhood, but becomes much more common in adolescence. Most studies based on parent and teacher reports show that about 5% of children under 10 years of age steal. Childhood stealing, especially occurring more than once in a 6-month period, is definitely of concern as it is strongly associated with the development of more serious antisocial behaviors over time. When children reach adolescence, stealing becomes much more common with 10%-15% of teens reporting stealing in anonymous self-reports.

Stealing and dishonesty are such disappointing behaviors to adults that it is tempting to resort to harsh punishments, long lectures, or harshly disparaging words. But these kinds of punishments backfire. The goal is an overall positive relationship and a calm consistent response to undesired behaviors. Parents often need support in how to be positive with a child who is frustrating them. Taking 15 minutes a day to do some activity a child likes – playing catch, playing a board game, cooking together, or doing crafts – all while noticing the positive things a child is doing rather than teaching, criticizing, or grilling a child on what happened in school sets a happier tone to the relationship, which is a background for any discipline. Jacob’s parents had already been working on this through their parent training class, but it helped to encourage them to keep doing this.

Because of the covert nature of stealing, it is sometimes hard to know where an item has come from, and children are likely to lie about this, saying that a friend gave it to them or they found it. To avoid this, when working with a child who has been stealing, the expectation should be made clear in advance that it is the child’s responsibility to avoid suspicion by having nothing in his possession that is not known to the adult. It is important to avoid back and forth arguments. The adult’s decision is final. With frequent stealing, it is helpful to make an inventory of the child’s possessions as a baseline.

When it comes to consequences, the important thing is to be sure that they are consistent and predictable. Returning an item to the owner and apologizing are logical. Another excellent type of consequence for behaviors that happen rarely is an extra work chore of about half an hour.

So a parent might say something like, “Jacob, we know that a stealing monster has been getting you, and we want to fight against him. I have made up a list of everything you have right now, and it is going to be your responsibility to make sure you don’t bring home anything else. So that means even if you find something or someone gives you something, you shouldn’t take it. If I find anything that isn’t on the list, you are going to have to return it to the person it belongs to and apologize, and then do an extra work chore for half an hour. A habit can be hard to change, but I know we can do it together. Let’s go play catch.” Then when the child is found with something in his possession, the adult should remain calm, avoid a lecture, and just say something like, “Jacob, this is something that doesn’t belong to you. You need to return it to the person it belongs to, and you have an extra half hour of raking leaves. No TV until the leaves are done.” The parent also should be alert to opportunities to attend to or praise behaviors like the child saving money to spend on things he wants, or asking to borrow things from other family members rather than just taking them.

Stealing can be a tough problem and often goes along with other rule-breaking behavior. If a parent is struggling to stay calm and find the positive, referral to group or individual parent training through programs like the Incredible Years or Triple P can give a parent the chance to learn and practice skills step by step.

As children enter their teen years, stealing becomes much more common, and can be reinforced by peers as well as by the action itself. The same principles of finding positive activities, continuing positive interactions with parents, and predictable and consistent – rather than harsh – consequences continue to apply, but may require additional supports. Larger programs such as Multisystemic Therapy, which works with families, peers, and communities, have been demonstrated to be effective for young people with juvenile delinquency.
 

 

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

Resource

Stealing, in “Children’s needs III: Development, prevention, and intervention,” (Washington: National Association of School Psychologists, 2006, pp. 171-83).