Michele G. Sullivan

TORONTO – Childhood obsessive-compulsive disorder often responds very well to an intense course of cognitive-behavioral therapy with an emphasis on exposure and response prevention.

Unfortunately, up to 5 million patients in the United States and Canada are not receiving complete treatment for their OCD, because few clinicians are trained in this kind of therapeutic approach, Eric A. Storch, Ph.D., said at the joint annual meeting of the American Academy of Child and Adolescent Psychiatry and the Canadian Academy of Child and Adolescent Psychiatry.

“There's definitely a lack of training in this area,” said Dr. Storch of the University of Florida, Gainesville. “Some therapists are also reluctant to even try it. But to the question, 'Does CBT work for OCD?' the answer is a resounding yes.”

Three randomized controlled trials have shown the effectiveness of exposure and response prevention (ERP) techniques, he said. A 1998 trial included 22 children aged 8–18 years who were randomly assigned to ERP or clomipramine for 12 weeks. Those on ERP showed an average improvement of almost 60%, compared with a 33% improvement for those in the medication arm (J. Am. Acad. Child Adolesc. Psychiatry 1998;37:1022–9).

One of the 2004 studies randomized 77 children aged 7–17 years to individual or group cognitive-behavioral family-based therapy or a 4–6 week wait list. The children in both therapy groups improved similarly, with symptom reductions of more than 60%, while symptoms increased slightly in the wait-list group (J. Am. Acad. Child Adolesc. Psychiatry 2004;43:46–62). A study of 48 patients aged 8–19 years old by several of the same researchers also found that treatment gains were maintained; 70% of subjects in individual therapy and 84% in group therapy were diagnosis free at a follow-up of 12–18 months (J. Am. Acad. Child Adolesc. Psychiatry 2005;44:1005–14).

The Pediatric OCD Treatment Study, also published in 2004, randomized 112 children aged 7–17 years to CBT alone, sertraline alone, combined CBT and sertraline, or placebo for 12 weeks. Rates of remission were 54% in the combination group, 39% in the CBT group, and 21% in the sertraline only group (JAMA 2004;292:1969–76).

Dr. Storch is now conducting his own trial. It includes 31 children aged 7–17 years, who were randomized to intensive CBT (14 sessions in 3 weeks) or 14 weekly CBT sessions. Preliminary findings indicate a greater improvement in the intensive CBT group (94%) than inthe weekly group (67%).

Up to 80% of OCD has a childhood onset, Dr. Storch said. Without treatment, these children face a life of disruptive thoughts and behaviors. “It doesn't remit,” he said. “There is tremendous impairment: Grades drop, kids get picked on, and the family is affected.”

In OCD, a neutral object becomes associated with increasing anxiety, he said. The patient develops rituals to decrease his anxiety level. “The rituals start small, but they grow exponentially because the patient becomes tolerant to them. In order to maintain the same reduction in stress, the rituals have to become more complex.”

Exposure and response prevention therapy aims to decrease the anxiety associated with the thought by exposing patients to whatever provokes the associated ritual, while asking them to refrain from engaging in the ritual. “Not doing so causes the anxiety to gradually and naturally decrease,” Dr. Storch said.

Each ritual must be extinguished completely before moving on to the next. It's best to start out with the smallest one and then tackle the more difficult ones, he said. “We'll say, for example, 'Don't check the faucet when you go out, but you can still do all your other things.' The key, however, is you can't progress until this one thing is mastered.”

Although actually refraining from the ritual is most effective, patients can also practice refraining in their imaginations. “Duration and frequency are important. If you can expose them for long periods frequently, you will have better results.”

Cognitive restructuring is another component of the treatment, Dr. Storch said.

“OCD arises from inaccurate beliefs about stimuli. The aim is to teach the patient to identify and correct anxiety-provoking thoughts that motivate compulsive behaviors–to help them identify the thought and then appraise it accurately,” he explained. Common cognitive errors are doubt (“I can't remember if I locked my door”); fusion of thought and action (“If I think about something, it must mean I want to do it”); catastrophic thinking (“I'll get sick and die if I go near sick people without washing up”); and responsibility (“If my mom gets cancer, it will be my fault”).

Dr. Storch addresses these cognitive errors by asking patients to keep a thought record. The document consists of recording the action, the thought that came with it, the accompanying anxiety or fear level, and the resulting ritual.

He then asks the patient to “talk back to the OCD” by writing logical thoughts that could counteract the illogical assumptions. “The talk back section might include thoughts about the actual evidence of getting sick from using a public bathroom, for instance, or an observation that friends use public restrooms and don't contract diseases from them and facts about how diseases are transmitted.”

Families should be included in the therapeutic process for optimum reinforcement, he said. “We want to teach parents to implement everything we do 24 hours a day, 7 days a week.”

TORONTO – Childhood obsessive-compulsive disorder often responds very well to an intense course of cognitive-behavioral therapy with an emphasis on exposure and response prevention.

Unfortunately, up to 5 million patients in the United States and Canada are not receiving complete treatment for their OCD, because few clinicians are trained in this kind of therapeutic approach, Eric A. Storch, Ph.D., said at the joint annual meeting of the American Academy of Child and Adolescent Psychiatry and the Canadian Academy of Child and Adolescent Psychiatry.

“There's definitely a lack of training in this area,” said Dr. Storch of the University of Florida, Gainesville. “Some therapists are also reluctant to even try it. But to the question, 'Does CBT work for OCD?' the answer is a resounding yes.”

Three randomized controlled trials have shown the effectiveness of exposure and response prevention (ERP) techniques, he said. A 1998 trial included 22 children aged 8–18 years who were randomly assigned to ERP or clomipramine for 12 weeks. Those on ERP showed an average improvement of almost 60%, compared with a 33% improvement for those in the medication arm (J. Am. Acad. Child Adolesc. Psychiatry 1998;37:1022–9).

One of the 2004 studies randomized 77 children aged 7–17 years to individual or group cognitive-behavioral family-based therapy or a 4–6 week wait list. The children in both therapy groups improved similarly, with symptom reductions of more than 60%, while symptoms increased slightly in the wait-list group (J. Am. Acad. Child Adolesc. Psychiatry 2004;43:46–62). A study of 48 patients aged 8–19 years old by several of the same researchers also found that treatment gains were maintained; 70% of subjects in individual therapy and 84% in group therapy were diagnosis free at a follow-up of 12–18 months (J. Am. Acad. Child Adolesc. Psychiatry 2005;44:1005–14).

The Pediatric OCD Treatment Study, also published in 2004, randomized 112 children aged 7–17 years to CBT alone, sertraline alone, combined CBT and sertraline, or placebo for 12 weeks. Rates of remission were 54% in the combination group, 39% in the CBT group, and 21% in the sertraline only group (JAMA 2004;292:1969–76).

Dr. Storch is now conducting his own trial. It includes 31 children aged 7–17 years, who were randomized to intensive CBT (14 sessions in 3 weeks) or 14 weekly CBT sessions. Preliminary findings indicate a greater improvement in the intensive CBT group (94%) than inthe weekly group (67%).

Up to 80% of OCD has a childhood onset, Dr. Storch said. Without treatment, these children face a life of disruptive thoughts and behaviors. “It doesn't remit,” he said. “There is tremendous impairment: Grades drop, kids get picked on, and the family is affected.”

In OCD, a neutral object becomes associated with increasing anxiety, he said. The patient develops rituals to decrease his anxiety level. “The rituals start small, but they grow exponentially because the patient becomes tolerant to them. In order to maintain the same reduction in stress, the rituals have to become more complex.”

Exposure and response prevention therapy aims to decrease the anxiety associated with the thought by exposing patients to whatever provokes the associated ritual, while asking them to refrain from engaging in the ritual. “Not doing so causes the anxiety to gradually and naturally decrease,” Dr. Storch said.

Each ritual must be extinguished completely before moving on to the next. It's best to start out with the smallest one and then tackle the more difficult ones, he said. “We'll say, for example, 'Don't check the faucet when you go out, but you can still do all your other things.' The key, however, is you can't progress until this one thing is mastered.”

Although actually refraining from the ritual is most effective, patients can also practice refraining in their imaginations. “Duration and frequency are important. If you can expose them for long periods frequently, you will have better results.”

Cognitive restructuring is another component of the treatment, Dr. Storch said.

“OCD arises from inaccurate beliefs about stimuli. The aim is to teach the patient to identify and correct anxiety-provoking thoughts that motivate compulsive behaviors–to help them identify the thought and then appraise it accurately,” he explained. Common cognitive errors are doubt (“I can't remember if I locked my door”); fusion of thought and action (“If I think about something, it must mean I want to do it”); catastrophic thinking (“I'll get sick and die if I go near sick people without washing up”); and responsibility (“If my mom gets cancer, it will be my fault”).

Dr. Storch addresses these cognitive errors by asking patients to keep a thought record. The document consists of recording the action, the thought that came with it, the accompanying anxiety or fear level, and the resulting ritual.

He then asks the patient to “talk back to the OCD” by writing logical thoughts that could counteract the illogical assumptions. “The talk back section might include thoughts about the actual evidence of getting sick from using a public bathroom, for instance, or an observation that friends use public restrooms and don't contract diseases from them and facts about how diseases are transmitted.”

Families should be included in the therapeutic process for optimum reinforcement, he said. “We want to teach parents to implement everything we do 24 hours a day, 7 days a week.”

TORONTO – Childhood obsessive-compulsive disorder often responds very well to an intense course of cognitive-behavioral therapy with an emphasis on exposure and response prevention.

Unfortunately, up to 5 million patients in the United States and Canada are not receiving complete treatment for their OCD, because few clinicians are trained in this kind of therapeutic approach, Eric A. Storch, Ph.D., said at the joint annual meeting of the American Academy of Child and Adolescent Psychiatry and the Canadian Academy of Child and Adolescent Psychiatry.

“There's definitely a lack of training in this area,” said Dr. Storch of the University of Florida, Gainesville. “Some therapists are also reluctant to even try it. But to the question, 'Does CBT work for OCD?' the answer is a resounding yes.”

Three randomized controlled trials have shown the effectiveness of exposure and response prevention (ERP) techniques, he said. A 1998 trial included 22 children aged 8–18 years who were randomly assigned to ERP or clomipramine for 12 weeks. Those on ERP showed an average improvement of almost 60%, compared with a 33% improvement for those in the medication arm (J. Am. Acad. Child Adolesc. Psychiatry 1998;37:1022–9).

One of the 2004 studies randomized 77 children aged 7–17 years to individual or group cognitive-behavioral family-based therapy or a 4–6 week wait list. The children in both therapy groups improved similarly, with symptom reductions of more than 60%, while symptoms increased slightly in the wait-list group (J. Am. Acad. Child Adolesc. Psychiatry 2004;43:46–62). A study of 48 patients aged 8–19 years old by several of the same researchers also found that treatment gains were maintained; 70% of subjects in individual therapy and 84% in group therapy were diagnosis free at a follow-up of 12–18 months (J. Am. Acad. Child Adolesc. Psychiatry 2005;44:1005–14).

The Pediatric OCD Treatment Study, also published in 2004, randomized 112 children aged 7–17 years to CBT alone, sertraline alone, combined CBT and sertraline, or placebo for 12 weeks. Rates of remission were 54% in the combination group, 39% in the CBT group, and 21% in the sertraline only group (JAMA 2004;292:1969–76).

Dr. Storch is now conducting his own trial. It includes 31 children aged 7–17 years, who were randomized to intensive CBT (14 sessions in 3 weeks) or 14 weekly CBT sessions. Preliminary findings indicate a greater improvement in the intensive CBT group (94%) than inthe weekly group (67%).

Up to 80% of OCD has a childhood onset, Dr. Storch said. Without treatment, these children face a life of disruptive thoughts and behaviors. “It doesn't remit,” he said. “There is tremendous impairment: Grades drop, kids get picked on, and the family is affected.”

In OCD, a neutral object becomes associated with increasing anxiety, he said. The patient develops rituals to decrease his anxiety level. “The rituals start small, but they grow exponentially because the patient becomes tolerant to them. In order to maintain the same reduction in stress, the rituals have to become more complex.”

Exposure and response prevention therapy aims to decrease the anxiety associated with the thought by exposing patients to whatever provokes the associated ritual, while asking them to refrain from engaging in the ritual. “Not doing so causes the anxiety to gradually and naturally decrease,” Dr. Storch said.

Each ritual must be extinguished completely before moving on to the next. It's best to start out with the smallest one and then tackle the more difficult ones, he said. “We'll say, for example, 'Don't check the faucet when you go out, but you can still do all your other things.' The key, however, is you can't progress until this one thing is mastered.”

Although actually refraining from the ritual is most effective, patients can also practice refraining in their imaginations. “Duration and frequency are important. If you can expose them for long periods frequently, you will have better results.”

Cognitive restructuring is another component of the treatment, Dr. Storch said.

“OCD arises from inaccurate beliefs about stimuli. The aim is to teach the patient to identify and correct anxiety-provoking thoughts that motivate compulsive behaviors–to help them identify the thought and then appraise it accurately,” he explained. Common cognitive errors are doubt (“I can't remember if I locked my door”); fusion of thought and action (“If I think about something, it must mean I want to do it”); catastrophic thinking (“I'll get sick and die if I go near sick people without washing up”); and responsibility (“If my mom gets cancer, it will be my fault”).

Dr. Storch addresses these cognitive errors by asking patients to keep a thought record. The document consists of recording the action, the thought that came with it, the accompanying anxiety or fear level, and the resulting ritual.

He then asks the patient to “talk back to the OCD” by writing logical thoughts that could counteract the illogical assumptions. “The talk back section might include thoughts about the actual evidence of getting sick from using a public bathroom, for instance, or an observation that friends use public restrooms and don't contract diseases from them and facts about how diseases are transmitted.”

Families should be included in the therapeutic process for optimum reinforcement, he said. “We want to teach parents to implement everything we do 24 hours a day, 7 days a week.”

CAMBRIDGE, MD. — Gastric bypass surgery can improve liver pathology in patients who have been diagnosed with nonalcoholic fatty liver disease or nonalcoholic steatohepatitis, Kris V. Kowdley, M.D., said at a hepatobiliary update sponsored by Johns Hopkins University.

Some researchers have expressed concerns that the dramatic and rapid weight loss associated with gastric bypass surgery could actually exacerbate nonalcoholic fatty liver disease (NAFLD), but that “clearly is not the case,” said Dr. Kowdley of the University of Washington, Seattle.

Two recent studies support the beneficial effect of gastroplasty on this spectrum of liver pathology. A 2004 study included 23 patients with nonalcoholic steatohepatitis (NASH) and 12 with simple steatosis. Liver biopsies were obtained from all patients about 2 years after surgery.

There were major improvements in lobular steatosis, necroinflammatory changes, and fibrosis; only four patients still fulfilled the criteria for NASH. Improvements were most pronounced in those with metabolic syndrome (Hepatology 2004;39:1647–54).

A 2005 study examined the results of gastric bypass in 16 patients whose mean presurgery weight was 334 pounds. A follow-up liver biopsy was performed about 1 year later. Steatosis had improved in 15 patients, with resolution in 13.

Of 15 patients who had inflammation at baseline, 12 showed improvement, and 12 of 14 showed less ballooning. Six of 14 patients with perisinusoidal fibrosis and 6 of 13 with portal fibrosis showed improvement. No patient had worsening of steatosis, inflammation, ballooning, or fibrosis (Obes. Res. 2005;13:1180–6).

NAFLD is part of a histopathologic spectrum of liver injury that ranges from simple steatosis to necroinflammatory changes that may progress to cirrhosis. NASH is associated with increased risk of hepatocellular cancer and liver-related death.

The etiology of these disorders is poorly understood but is thought to be a “two-hit” process beginning with fat accumulation in the liver, most often in the presence of obesity, insulin resistance, or type 2 diabetes. “The 'second hit' is presumed to be any number of processes that contribute to oxidative injury in the liver,” Dr. Kowdley said, and could include oxidative stress that interferes with mitochondrial function.

Most patients with NAFLD are asymptomatic; their disease is discovered when screening tests identify abnormal liver function. Many are obese; studies suggest that about 30% of patients who undergo gastric bypass have the disease. But the pattern of fat deposition is perhaps more important than the patient's weight, Dr. Kowdley said; NAFLD is highly associated with truncal obesity.

On ultrasound, the fatty liver typically appears diffusely hyperechoic in relation to the spleen and kidneys. Computed tomography and magnetic resonance imaging may show focal fat deposits. However, a liver biopsy is the most sensitive and specific means of diagnosis and can differentiate simple steatohepatitis from more advanced stages of the disease in which fibrosis may be present.

There are no approved pharmacologic therapies for NAFLD. Several drugs are under investigation, including metformin and thiazolidinediones.

“Weight loss is one highly recommended method of dealing with NAFLD,” Dr. Kowdley said. “Even a modest amount of weight loss, say 20 pounds, significantly decreases the fasting insulin level and improves liver enzymes, and those improvements are maintained as long as weight loss is maintained.”

All patients with NAFLD should be counseled to lose weight through a combination of diet and exercise. Those with a body mass index (BMI) greater than 30 kg/m

Weight loss surgery should be considered if the patient has a BMI of 40, or greater than 35 with liver disease risk factors.

CAMBRIDGE, MD. — Gastric bypass surgery can improve liver pathology in patients who have been diagnosed with nonalcoholic fatty liver disease or nonalcoholic steatohepatitis, Kris V. Kowdley, M.D., said at a hepatobiliary update sponsored by Johns Hopkins University.

Some researchers have expressed concerns that the dramatic and rapid weight loss associated with gastric bypass surgery could actually exacerbate nonalcoholic fatty liver disease (NAFLD), but that “clearly is not the case,” said Dr. Kowdley of the University of Washington, Seattle.

Two recent studies support the beneficial effect of gastroplasty on this spectrum of liver pathology. A 2004 study included 23 patients with nonalcoholic steatohepatitis (NASH) and 12 with simple steatosis. Liver biopsies were obtained from all patients about 2 years after surgery.

There were major improvements in lobular steatosis, necroinflammatory changes, and fibrosis; only four patients still fulfilled the criteria for NASH. Improvements were most pronounced in those with metabolic syndrome (Hepatology 2004;39:1647–54).

A 2005 study examined the results of gastric bypass in 16 patients whose mean presurgery weight was 334 pounds. A follow-up liver biopsy was performed about 1 year later. Steatosis had improved in 15 patients, with resolution in 13.

Of 15 patients who had inflammation at baseline, 12 showed improvement, and 12 of 14 showed less ballooning. Six of 14 patients with perisinusoidal fibrosis and 6 of 13 with portal fibrosis showed improvement. No patient had worsening of steatosis, inflammation, ballooning, or fibrosis (Obes. Res. 2005;13:1180–6).

NAFLD is part of a histopathologic spectrum of liver injury that ranges from simple steatosis to necroinflammatory changes that may progress to cirrhosis. NASH is associated with increased risk of hepatocellular cancer and liver-related death.

The etiology of these disorders is poorly understood but is thought to be a “two-hit” process beginning with fat accumulation in the liver, most often in the presence of obesity, insulin resistance, or type 2 diabetes. “The 'second hit' is presumed to be any number of processes that contribute to oxidative injury in the liver,” Dr. Kowdley said, and could include oxidative stress that interferes with mitochondrial function.

Most patients with NAFLD are asymptomatic; their disease is discovered when screening tests identify abnormal liver function. Many are obese; studies suggest that about 30% of patients who undergo gastric bypass have the disease. But the pattern of fat deposition is perhaps more important than the patient's weight, Dr. Kowdley said; NAFLD is highly associated with truncal obesity.

On ultrasound, the fatty liver typically appears diffusely hyperechoic in relation to the spleen and kidneys. Computed tomography and magnetic resonance imaging may show focal fat deposits. However, a liver biopsy is the most sensitive and specific means of diagnosis and can differentiate simple steatohepatitis from more advanced stages of the disease in which fibrosis may be present.

There are no approved pharmacologic therapies for NAFLD. Several drugs are under investigation, including metformin and thiazolidinediones.

“Weight loss is one highly recommended method of dealing with NAFLD,” Dr. Kowdley said. “Even a modest amount of weight loss, say 20 pounds, significantly decreases the fasting insulin level and improves liver enzymes, and those improvements are maintained as long as weight loss is maintained.”

All patients with NAFLD should be counseled to lose weight through a combination of diet and exercise. Those with a body mass index (BMI) greater than 30 kg/m

Weight loss surgery should be considered if the patient has a BMI of 40, or greater than 35 with liver disease risk factors.

CAMBRIDGE, MD. — Gastric bypass surgery can improve liver pathology in patients who have been diagnosed with nonalcoholic fatty liver disease or nonalcoholic steatohepatitis, Kris V. Kowdley, M.D., said at a hepatobiliary update sponsored by Johns Hopkins University.

Some researchers have expressed concerns that the dramatic and rapid weight loss associated with gastric bypass surgery could actually exacerbate nonalcoholic fatty liver disease (NAFLD), but that “clearly is not the case,” said Dr. Kowdley of the University of Washington, Seattle.

Two recent studies support the beneficial effect of gastroplasty on this spectrum of liver pathology. A 2004 study included 23 patients with nonalcoholic steatohepatitis (NASH) and 12 with simple steatosis. Liver biopsies were obtained from all patients about 2 years after surgery.

There were major improvements in lobular steatosis, necroinflammatory changes, and fibrosis; only four patients still fulfilled the criteria for NASH. Improvements were most pronounced in those with metabolic syndrome (Hepatology 2004;39:1647–54).

A 2005 study examined the results of gastric bypass in 16 patients whose mean presurgery weight was 334 pounds. A follow-up liver biopsy was performed about 1 year later. Steatosis had improved in 15 patients, with resolution in 13.

Of 15 patients who had inflammation at baseline, 12 showed improvement, and 12 of 14 showed less ballooning. Six of 14 patients with perisinusoidal fibrosis and 6 of 13 with portal fibrosis showed improvement. No patient had worsening of steatosis, inflammation, ballooning, or fibrosis (Obes. Res. 2005;13:1180–6).

NAFLD is part of a histopathologic spectrum of liver injury that ranges from simple steatosis to necroinflammatory changes that may progress to cirrhosis. NASH is associated with increased risk of hepatocellular cancer and liver-related death.

The etiology of these disorders is poorly understood but is thought to be a “two-hit” process beginning with fat accumulation in the liver, most often in the presence of obesity, insulin resistance, or type 2 diabetes. “The 'second hit' is presumed to be any number of processes that contribute to oxidative injury in the liver,” Dr. Kowdley said, and could include oxidative stress that interferes with mitochondrial function.

Most patients with NAFLD are asymptomatic; their disease is discovered when screening tests identify abnormal liver function. Many are obese; studies suggest that about 30% of patients who undergo gastric bypass have the disease. But the pattern of fat deposition is perhaps more important than the patient's weight, Dr. Kowdley said; NAFLD is highly associated with truncal obesity.

On ultrasound, the fatty liver typically appears diffusely hyperechoic in relation to the spleen and kidneys. Computed tomography and magnetic resonance imaging may show focal fat deposits. However, a liver biopsy is the most sensitive and specific means of diagnosis and can differentiate simple steatohepatitis from more advanced stages of the disease in which fibrosis may be present.

There are no approved pharmacologic therapies for NAFLD. Several drugs are under investigation, including metformin and thiazolidinediones.

“Weight loss is one highly recommended method of dealing with NAFLD,” Dr. Kowdley said. “Even a modest amount of weight loss, say 20 pounds, significantly decreases the fasting insulin level and improves liver enzymes, and those improvements are maintained as long as weight loss is maintained.”

All patients with NAFLD should be counseled to lose weight through a combination of diet and exercise. Those with a body mass index (BMI) greater than 30 kg/m

Weight loss surgery should be considered if the patient has a BMI of 40, or greater than 35 with liver disease risk factors.

TORONTO — A pilot program aimed at building resiliency and coping skills in teenage girls appears to decrease symptoms of depression and increase self-esteem in those at risk for major depressive disorder.

Researchers also hope that skills taught in the Resourceful Adolescents Project (RAP) will have a positive impact on other psychological problems the teens might face, such as eating disorders, substance abuse, and rule violations, Vicky Veitch Wolfe, Ph.D., said at the joint annual meeting of the American Academy of Child and Adolescent Psychiatry and the Canadian Academy of Child and Adolescent Psychiatry.

“We see a sharp increase in mental health problems in adolescents,” said Dr. Wolfe of the Children's Hospital of the University of Western Ontario, London. “Up to 10% of high school girls develop depression, and 24% of girls report at least one episode of depression during their adolescence. This program is designed to help girls transition between middle school and high school, where we start to see the increase in depression.”

RAP, first developed in Australia and New Zealand, is administered as part of a school's health curriculum. In Dr. Wolfe's pilot project, the program consisted of 10 70-minute sessions taught by a RAP psychologist and other mental health professionals.

Classroom topics included recognizing and regulating bodily stress; correcting negative self-talk; building personal strengths, problem solving, and conflict resolution skills; developing a strong social support network; using humor as a coping mechanism; and effective goal setting.

In addition to classroom activities and discussion, the students used a specially designed workbook and received regular homework assignments. Those activities were graded.

The program was instituted in 12 schools in one Ontario county; 807 ninth-grade girls were enrolled, with half receiving the intervention program and half receiving their normal health education class. Dr. Wolfe presented an analysis of the program's effects on 110 girls who were considered at high risk of depression.

At baseline, the girls had an average score of 22 on the Children's Depression Index (CDI). On the Harter's Self-Perception Profile for Children (SPPC), the average baseline score was about 11 for self, 14.5 for friends, 14 for job, and 9 for appearance.

After the program, the intervention group had significantly decreased their total CDI scores from baseline (22–16.5) as well as their individual scores on mood (5.6–4.0), anhedonia (6.7–4.9), and negative self-esteem (4.5–3.1).

Total CDI scores decreased to a lesser extent in the control group (22–20.5), as did scores for mood (5.5–4.9), anhedonia (6.7–6.1), and negative self-esteem (4.3–4.1).

On the SPPC scale, the intervention group made significant improvements in all areas: self (10.5–12.7), friends (14.3–15.4), job (13.8–15.5), and appearance (8.9–10.6). No significant changes were found in the control group.

A mechanism of change score identified the social domain as the area of greatest change, Dr. Wolfe said. “We saw improved coping and improved interpersonal relationships, particularly with parents,” she said.

Dr. Wolfe cautioned against overinterpretation of her results. “It's relatively small sample for a prevention program, and we would like to examine other indices of change—parent report, for example.” She will also be conducting longer-term analyses of the effects in the entire group, with follow-up at 6, 12, and 18 months.

TORONTO — A pilot program aimed at building resiliency and coping skills in teenage girls appears to decrease symptoms of depression and increase self-esteem in those at risk for major depressive disorder.

Researchers also hope that skills taught in the Resourceful Adolescents Project (RAP) will have a positive impact on other psychological problems the teens might face, such as eating disorders, substance abuse, and rule violations, Vicky Veitch Wolfe, Ph.D., said at the joint annual meeting of the American Academy of Child and Adolescent Psychiatry and the Canadian Academy of Child and Adolescent Psychiatry.

“We see a sharp increase in mental health problems in adolescents,” said Dr. Wolfe of the Children's Hospital of the University of Western Ontario, London. “Up to 10% of high school girls develop depression, and 24% of girls report at least one episode of depression during their adolescence. This program is designed to help girls transition between middle school and high school, where we start to see the increase in depression.”

RAP, first developed in Australia and New Zealand, is administered as part of a school's health curriculum. In Dr. Wolfe's pilot project, the program consisted of 10 70-minute sessions taught by a RAP psychologist and other mental health professionals.

Classroom topics included recognizing and regulating bodily stress; correcting negative self-talk; building personal strengths, problem solving, and conflict resolution skills; developing a strong social support network; using humor as a coping mechanism; and effective goal setting.

In addition to classroom activities and discussion, the students used a specially designed workbook and received regular homework assignments. Those activities were graded.

The program was instituted in 12 schools in one Ontario county; 807 ninth-grade girls were enrolled, with half receiving the intervention program and half receiving their normal health education class. Dr. Wolfe presented an analysis of the program's effects on 110 girls who were considered at high risk of depression.

At baseline, the girls had an average score of 22 on the Children's Depression Index (CDI). On the Harter's Self-Perception Profile for Children (SPPC), the average baseline score was about 11 for self, 14.5 for friends, 14 for job, and 9 for appearance.

After the program, the intervention group had significantly decreased their total CDI scores from baseline (22–16.5) as well as their individual scores on mood (5.6–4.0), anhedonia (6.7–4.9), and negative self-esteem (4.5–3.1).

Total CDI scores decreased to a lesser extent in the control group (22–20.5), as did scores for mood (5.5–4.9), anhedonia (6.7–6.1), and negative self-esteem (4.3–4.1).

On the SPPC scale, the intervention group made significant improvements in all areas: self (10.5–12.7), friends (14.3–15.4), job (13.8–15.5), and appearance (8.9–10.6). No significant changes were found in the control group.

A mechanism of change score identified the social domain as the area of greatest change, Dr. Wolfe said. “We saw improved coping and improved interpersonal relationships, particularly with parents,” she said.

Dr. Wolfe cautioned against overinterpretation of her results. “It's relatively small sample for a prevention program, and we would like to examine other indices of change—parent report, for example.” She will also be conducting longer-term analyses of the effects in the entire group, with follow-up at 6, 12, and 18 months.

TORONTO — A pilot program aimed at building resiliency and coping skills in teenage girls appears to decrease symptoms of depression and increase self-esteem in those at risk for major depressive disorder.

Researchers also hope that skills taught in the Resourceful Adolescents Project (RAP) will have a positive impact on other psychological problems the teens might face, such as eating disorders, substance abuse, and rule violations, Vicky Veitch Wolfe, Ph.D., said at the joint annual meeting of the American Academy of Child and Adolescent Psychiatry and the Canadian Academy of Child and Adolescent Psychiatry.

“We see a sharp increase in mental health problems in adolescents,” said Dr. Wolfe of the Children's Hospital of the University of Western Ontario, London. “Up to 10% of high school girls develop depression, and 24% of girls report at least one episode of depression during their adolescence. This program is designed to help girls transition between middle school and high school, where we start to see the increase in depression.”

RAP, first developed in Australia and New Zealand, is administered as part of a school's health curriculum. In Dr. Wolfe's pilot project, the program consisted of 10 70-minute sessions taught by a RAP psychologist and other mental health professionals.

Classroom topics included recognizing and regulating bodily stress; correcting negative self-talk; building personal strengths, problem solving, and conflict resolution skills; developing a strong social support network; using humor as a coping mechanism; and effective goal setting.

In addition to classroom activities and discussion, the students used a specially designed workbook and received regular homework assignments. Those activities were graded.

The program was instituted in 12 schools in one Ontario county; 807 ninth-grade girls were enrolled, with half receiving the intervention program and half receiving their normal health education class. Dr. Wolfe presented an analysis of the program's effects on 110 girls who were considered at high risk of depression.

At baseline, the girls had an average score of 22 on the Children's Depression Index (CDI). On the Harter's Self-Perception Profile for Children (SPPC), the average baseline score was about 11 for self, 14.5 for friends, 14 for job, and 9 for appearance.

After the program, the intervention group had significantly decreased their total CDI scores from baseline (22–16.5) as well as their individual scores on mood (5.6–4.0), anhedonia (6.7–4.9), and negative self-esteem (4.5–3.1).

Total CDI scores decreased to a lesser extent in the control group (22–20.5), as did scores for mood (5.5–4.9), anhedonia (6.7–6.1), and negative self-esteem (4.3–4.1).

On the SPPC scale, the intervention group made significant improvements in all areas: self (10.5–12.7), friends (14.3–15.4), job (13.8–15.5), and appearance (8.9–10.6). No significant changes were found in the control group.

A mechanism of change score identified the social domain as the area of greatest change, Dr. Wolfe said. “We saw improved coping and improved interpersonal relationships, particularly with parents,” she said.

Dr. Wolfe cautioned against overinterpretation of her results. “It's relatively small sample for a prevention program, and we would like to examine other indices of change—parent report, for example.” She will also be conducting longer-term analyses of the effects in the entire group, with follow-up at 6, 12, and 18 months.

TORONTO — Few suicide attempts occurred during the Treatment for Adolescents with Depression Study (TADS), but suicide-related events were more common in both fluoxetine arms than in the placebo arm, Graham J. Emslie, M.D., reported at the joint annual meeting of the American Academy of Child and Adolescent Psychiatry and the Canadian Academy of Child and Adolescent Psychiatry.

But Dr. Emslie said this should be tempered with another of the study's conclusions. Almost 30% of the adolescents had suicidal ideation at the study's outset; at 12 weeks of treatment, suicidal behavior had improved in about 86% of the fluoxetine arms, compared with 77% of those in a cognitive-behavioral therapy-only arm.

“If you talk to the press, you would assume people are dying in the [United States] from these medicines, but in fact they are well tolerated,” said Dr. Emslie, chief of the University of Texas Southwestern's division of child and adolescent psychiatry. “About 83% of those on fluoxetine and the same percentage on the combination of cognitive-behavioral therapy and fluoxetine completed the treatment period—and that says a lot.”

TADS included 439 patients aged 12–17 years with major depressive disorder. They were randomized to either 12 weeks of fluoxetine alone, cognitive-behavioral therapy (CBT), CBT with fluoxetine, or to placebo.

Combination therapy was superior to either fluoxetine or CBT alone in reducing symptoms of depression, and fluoxetine alone was superior to CBT alone.

Suicide-related events occurred in nine patients in the fluoxetine-only arm, five in the combination therapy arm, five in the CBT-only arm, and two in the placebo arm. There were five suicide attempts during the study: two in the combination arm, two in the fluoxetine arm, one in the CBT-only arm, and none in the placebo arm.

New suicidal ideation was most common in the fluoxetine-only arm (three cases). There were no new cases in the combination therapy arm, one in the CBT-only arm, and two in the placebo arm.

Suicidal ideation worsened in 13% of those in the fluoxetine arm, 15% of those in the CBT-only arm, 7% of those in the placebo arm, and 5% of those in the combination therapy arm.

“There were few attempts, but there was some increase in ideation,” Dr. Emslie said. He noted that TADS was a flexible-dose study and that the addition of CBT to fluoxetine was associated with lower doses of the drug. “CBT appears to decrease the amount of drug that they need, and keeping the dose lower for longer appears to be a good idea.”

Physical adverse events were more common in the fluoxetine arms, compared with placebo. Insomnia occurred in 4% of those taking fluoxetine and 1% of those in the placebo group. Rates were similar for vomiting (3% vs. 1%), upper abdominal pain (3% vs. 2%), and sedation (2% vs. 0%).

Those taking fluoxetine also reported more psychiatric symptoms than those on placebo. Mania occurred in 2% of the fluoxetine groups, 1% of the placebo group, and none of the CBT-only group. Irritability occurred in 3% of the fluoxetine groups, 1% of the placebo group, and none of the CBT group. Agitation occurred in 1.5% of the fluoxetine groups, 2% of the placebo group, and none of the CBT group. Anxiety occurred in 1% of the fluoxetine groups, none of the placebo group, and 1% of the CBT group. The total psychiatric event rate was 11% for fluoxetine, 5.5% for combination therapy, 4.5% for placebo, and 1% for CBT.

However, Dr. Emslie noted, “There's no evidence that the drug was doing this. These symptoms vary.”

TORONTO — Few suicide attempts occurred during the Treatment for Adolescents with Depression Study (TADS), but suicide-related events were more common in both fluoxetine arms than in the placebo arm, Graham J. Emslie, M.D., reported at the joint annual meeting of the American Academy of Child and Adolescent Psychiatry and the Canadian Academy of Child and Adolescent Psychiatry.

But Dr. Emslie said this should be tempered with another of the study's conclusions. Almost 30% of the adolescents had suicidal ideation at the study's outset; at 12 weeks of treatment, suicidal behavior had improved in about 86% of the fluoxetine arms, compared with 77% of those in a cognitive-behavioral therapy-only arm.

“If you talk to the press, you would assume people are dying in the [United States] from these medicines, but in fact they are well tolerated,” said Dr. Emslie, chief of the University of Texas Southwestern's division of child and adolescent psychiatry. “About 83% of those on fluoxetine and the same percentage on the combination of cognitive-behavioral therapy and fluoxetine completed the treatment period—and that says a lot.”

TADS included 439 patients aged 12–17 years with major depressive disorder. They were randomized to either 12 weeks of fluoxetine alone, cognitive-behavioral therapy (CBT), CBT with fluoxetine, or to placebo.

Combination therapy was superior to either fluoxetine or CBT alone in reducing symptoms of depression, and fluoxetine alone was superior to CBT alone.

Suicide-related events occurred in nine patients in the fluoxetine-only arm, five in the combination therapy arm, five in the CBT-only arm, and two in the placebo arm. There were five suicide attempts during the study: two in the combination arm, two in the fluoxetine arm, one in the CBT-only arm, and none in the placebo arm.

New suicidal ideation was most common in the fluoxetine-only arm (three cases). There were no new cases in the combination therapy arm, one in the CBT-only arm, and two in the placebo arm.

Suicidal ideation worsened in 13% of those in the fluoxetine arm, 15% of those in the CBT-only arm, 7% of those in the placebo arm, and 5% of those in the combination therapy arm.

“There were few attempts, but there was some increase in ideation,” Dr. Emslie said. He noted that TADS was a flexible-dose study and that the addition of CBT to fluoxetine was associated with lower doses of the drug. “CBT appears to decrease the amount of drug that they need, and keeping the dose lower for longer appears to be a good idea.”

Physical adverse events were more common in the fluoxetine arms, compared with placebo. Insomnia occurred in 4% of those taking fluoxetine and 1% of those in the placebo group. Rates were similar for vomiting (3% vs. 1%), upper abdominal pain (3% vs. 2%), and sedation (2% vs. 0%).

Those taking fluoxetine also reported more psychiatric symptoms than those on placebo. Mania occurred in 2% of the fluoxetine groups, 1% of the placebo group, and none of the CBT-only group. Irritability occurred in 3% of the fluoxetine groups, 1% of the placebo group, and none of the CBT group. Agitation occurred in 1.5% of the fluoxetine groups, 2% of the placebo group, and none of the CBT group. Anxiety occurred in 1% of the fluoxetine groups, none of the placebo group, and 1% of the CBT group. The total psychiatric event rate was 11% for fluoxetine, 5.5% for combination therapy, 4.5% for placebo, and 1% for CBT.

However, Dr. Emslie noted, “There's no evidence that the drug was doing this. These symptoms vary.”

TORONTO — Few suicide attempts occurred during the Treatment for Adolescents with Depression Study (TADS), but suicide-related events were more common in both fluoxetine arms than in the placebo arm, Graham J. Emslie, M.D., reported at the joint annual meeting of the American Academy of Child and Adolescent Psychiatry and the Canadian Academy of Child and Adolescent Psychiatry.

But Dr. Emslie said this should be tempered with another of the study's conclusions. Almost 30% of the adolescents had suicidal ideation at the study's outset; at 12 weeks of treatment, suicidal behavior had improved in about 86% of the fluoxetine arms, compared with 77% of those in a cognitive-behavioral therapy-only arm.

“If you talk to the press, you would assume people are dying in the [United States] from these medicines, but in fact they are well tolerated,” said Dr. Emslie, chief of the University of Texas Southwestern's division of child and adolescent psychiatry. “About 83% of those on fluoxetine and the same percentage on the combination of cognitive-behavioral therapy and fluoxetine completed the treatment period—and that says a lot.”

TADS included 439 patients aged 12–17 years with major depressive disorder. They were randomized to either 12 weeks of fluoxetine alone, cognitive-behavioral therapy (CBT), CBT with fluoxetine, or to placebo.

Combination therapy was superior to either fluoxetine or CBT alone in reducing symptoms of depression, and fluoxetine alone was superior to CBT alone.

Suicide-related events occurred in nine patients in the fluoxetine-only arm, five in the combination therapy arm, five in the CBT-only arm, and two in the placebo arm. There were five suicide attempts during the study: two in the combination arm, two in the fluoxetine arm, one in the CBT-only arm, and none in the placebo arm.

New suicidal ideation was most common in the fluoxetine-only arm (three cases). There were no new cases in the combination therapy arm, one in the CBT-only arm, and two in the placebo arm.

Suicidal ideation worsened in 13% of those in the fluoxetine arm, 15% of those in the CBT-only arm, 7% of those in the placebo arm, and 5% of those in the combination therapy arm.

“There were few attempts, but there was some increase in ideation,” Dr. Emslie said. He noted that TADS was a flexible-dose study and that the addition of CBT to fluoxetine was associated with lower doses of the drug. “CBT appears to decrease the amount of drug that they need, and keeping the dose lower for longer appears to be a good idea.”

Physical adverse events were more common in the fluoxetine arms, compared with placebo. Insomnia occurred in 4% of those taking fluoxetine and 1% of those in the placebo group. Rates were similar for vomiting (3% vs. 1%), upper abdominal pain (3% vs. 2%), and sedation (2% vs. 0%).

Those taking fluoxetine also reported more psychiatric symptoms than those on placebo. Mania occurred in 2% of the fluoxetine groups, 1% of the placebo group, and none of the CBT-only group. Irritability occurred in 3% of the fluoxetine groups, 1% of the placebo group, and none of the CBT group. Agitation occurred in 1.5% of the fluoxetine groups, 2% of the placebo group, and none of the CBT group. Anxiety occurred in 1% of the fluoxetine groups, none of the placebo group, and 1% of the CBT group. The total psychiatric event rate was 11% for fluoxetine, 5.5% for combination therapy, 4.5% for placebo, and 1% for CBT.

However, Dr. Emslie noted, “There's no evidence that the drug was doing this. These symptoms vary.”

A new coma assessment scale provides greater neurologic detail than the Glasgow system and has the potential to become the most effective means of evaluating unresponsive patients, according to researchers who developed it at the Mayo Clinic.

“The challenge over the years has been to produce a new scale that remains simple but still is comprehensive,” said Eelco Wijdicks, M.D., who developed the Full Outline of Unresponsiveness (FOUR) Coma scale.

“Prior attempts to do this have been unsuccessful, largely because they had a more comprehensive scale that lost clarity and simplicity. This scale is very simple to use and greatly appreciated by nursing staff,” Dr. Wijdicks said.

Graham M. Teasdale, M.B., inventor of the 30-year-old Glasgow scale, said the new system is more complicated to use and doesn't test as well among neurology nurses.

“The Glasgow Coma Scale was developed to fill the need for a practical method to assess impairment of consciousness in all types of patients with acute brain insult, in all places, by all kinds of staff, at all times, often minute by minute,” Dr. Teasdale, professor emeritus of neurosurgery at the University of Glasgow, Scotland, said in an interview. The FOUR scale is applicable to a smaller proportion of patients and appears to be more complicated, requiring extra training to effectively implement, he said.

Dr. Wijdicks said that neurologists have long complained that the Glasgow Coma Scale (GCS) was an imperfect tool for assessing consciousness. “The major reason is that the GCS doesn't include brain stem reflexes and respiration patterns, which reflect the severity of coma,” Dr. Wijdicks, a neurologist at the Mayo Clinic, Rochester, Minn., said in an interview.

“Also, the eye component doesn't involve voluntary eye movements and so can't recognize visual tracking and a locked-in syndrome.” Finally, he said, the GCS verbal assessment is a moot point for intubated patients.

The FOUR scale assesses voluntary and involuntary eye response; voluntary and involuntary motor response; respiration patterns; and brainstem response as measured by pupil and corneal reflexes. When using the FOUR system, evaluators assign a score of 0–4 in each category. A score of 4 represents normal functioning, while a score of 0 indicates nonfunctioning and should alert the physician to consider a brain death evaluation. (See box.)

The eye component detects both locked-in syndrome, characterized by complete paralysis of voluntary muscles except for those that control eye movement, and vegetative state. The motor category assesses for the presence of myoclonus status, a poor prognostic sign after cardiac resuscitation. It combines decorticate and withdrawal responses, a difference Dr. Wijdicks said is often difficult to differentiate.

Breathing patterns are graded, because Cheyne-Stokes respiration and irregular breathing can represent bihemispheric or lower brainstem dysfunction.

A recently published validation study of FOUR included 120 neurointensive care unit patients, the largest validation study ever on coma scales, evaluated by pairs of neurointensivists (neurologists trained in critical care), neurologic nurses, and residents in different combinations. All raters were given the same training on using the system: 20 minutes' instruction using videos, a single page of written instructions, and the opportunity to practice by grading a few patients (Ann. Neurol. 2005; 58: 585–93).

Average patient age was 59 years, and their brain injuries were of mixed etiology, including hemorrhagic or ischemic stroke (24%), traumatic head injury (21%), brain tumor (11%), and other neurologic illness (13%).

Physician rater pairs scored the best, with good to excellent agreement. Nurse pairs had fair to moderate agreement. Nurse agreement was highest on the respiration and motor components and lowest on the eye and brainstem components. The agreement of the nurses with residents and neurointensivists was good to excellent.

The lower nurse agreement could be one of the biggest drawbacks to the FOUR system, said Donald W. Marion, M.D., a fellow at the Brain Trauma Foundation in New York City. “The fact is, when Dr. Teasdale devised the Glasgow score, the original intention was to develop a score easily used by nurses,” Dr. Marion said. “They were concerned that nurses be able to accurately report to the next shift and to physicians the status of the patient.”

Reliability among less highly trained personnel is a key indicator of a tool's simplicity and ease of use, Dr. Marion pointed out. “If no one other than a specialist can use it, that's a problem.”

Dr. Teasdale agrees. “The study uses too restricted a range of staff–all were in a specialized tertiary critical care unit,” he said. “What about the 'average' emergency room or hospital?”

The FOUR scale does succeed in getting around some of the biggest problems with GCS, including the issue of intubation, which negates the verbal assessment. But FOUR probably won't be any more useful than GCS for traumatic brain injury patients, many of whom are sedated by the time they are assessed at a trauma center, Dr. Marion said.

Nevertheless, “there are some real pluses with it–most importantly, looking for pupil changes and corneal responses. That's a real important improvement over the Glasgow score.” The FOUR scale may be a good supplement to the GCS in some specific areas, but probably won't supplant it, Dr. Teasdale said. “It must and will remain as a basic universal language. However, one of its benefits is its flexibility so it can be adapted, which is the essence of what Dr. Wijdicks has done, as have others in the past.”

Scoring the Full Outline Of Unresponsiveness

EYE RESPONSE

4 = Eyelids open, tracking or blinking to command.

3 = Eyelids open but not tracking.

2 = Eyelids closed but open to loud voice.

1 = Eyelids closed but open to pain.

0 = Eyelids remain closed to pain.

MOTOR RESPONSE

4 = Thumbs up, fist, or peace sign.

3 = Localizing to pain.

2 = Flexion response to pain.

1 = Extension response.

0 = No response to pain, or general myoclonus status.

BRAIN STEM REFLEXES

4 = Pupil and corneal reflexes present.

3 = One pupil wide and fixed.

2 = Pupil or corneal reflexes absent.

1 = Pupil and corneal reflexes absent.

0 = Pupil, corneal, and cough reflexes absent.

RESPIRATION

4 = Not intubated, regular breathing pattern.

3 = Not intubated, Cheyne-Stokes breathing pattern.

2 = Not intubated, irregular breathing.

1 = Breathes above ventilator rate.

0 = Breathes at ventilator rate or with apnea.

Source: Dr. Wijdicks

To receive a copy of the FOUR pocket instructional card, e-mail Dr. Wijdicks at

wijde@mayo.edu

A new coma assessment scale provides greater neurologic detail than the Glasgow system and has the potential to become the most effective means of evaluating unresponsive patients, according to researchers who developed it at the Mayo Clinic.

“The challenge over the years has been to produce a new scale that remains simple but still is comprehensive,” said Eelco Wijdicks, M.D., who developed the Full Outline of Unresponsiveness (FOUR) Coma scale.

“Prior attempts to do this have been unsuccessful, largely because they had a more comprehensive scale that lost clarity and simplicity. This scale is very simple to use and greatly appreciated by nursing staff,” Dr. Wijdicks said.

Graham M. Teasdale, M.B., inventor of the 30-year-old Glasgow scale, said the new system is more complicated to use and doesn't test as well among neurology nurses.

“The Glasgow Coma Scale was developed to fill the need for a practical method to assess impairment of consciousness in all types of patients with acute brain insult, in all places, by all kinds of staff, at all times, often minute by minute,” Dr. Teasdale, professor emeritus of neurosurgery at the University of Glasgow, Scotland, said in an interview. The FOUR scale is applicable to a smaller proportion of patients and appears to be more complicated, requiring extra training to effectively implement, he said.

Dr. Wijdicks said that neurologists have long complained that the Glasgow Coma Scale (GCS) was an imperfect tool for assessing consciousness. “The major reason is that the GCS doesn't include brain stem reflexes and respiration patterns, which reflect the severity of coma,” Dr. Wijdicks, a neurologist at the Mayo Clinic, Rochester, Minn., said in an interview.

“Also, the eye component doesn't involve voluntary eye movements and so can't recognize visual tracking and a locked-in syndrome.” Finally, he said, the GCS verbal assessment is a moot point for intubated patients.

The FOUR scale assesses voluntary and involuntary eye response; voluntary and involuntary motor response; respiration patterns; and brainstem response as measured by pupil and corneal reflexes. When using the FOUR system, evaluators assign a score of 0–4 in each category. A score of 4 represents normal functioning, while a score of 0 indicates nonfunctioning and should alert the physician to consider a brain death evaluation. (See box.)

The eye component detects both locked-in syndrome, characterized by complete paralysis of voluntary muscles except for those that control eye movement, and vegetative state. The motor category assesses for the presence of myoclonus status, a poor prognostic sign after cardiac resuscitation. It combines decorticate and withdrawal responses, a difference Dr. Wijdicks said is often difficult to differentiate.

Breathing patterns are graded, because Cheyne-Stokes respiration and irregular breathing can represent bihemispheric or lower brainstem dysfunction.

A recently published validation study of FOUR included 120 neurointensive care unit patients, the largest validation study ever on coma scales, evaluated by pairs of neurointensivists (neurologists trained in critical care), neurologic nurses, and residents in different combinations. All raters were given the same training on using the system: 20 minutes' instruction using videos, a single page of written instructions, and the opportunity to practice by grading a few patients (Ann. Neurol. 2005; 58: 585–93).

Average patient age was 59 years, and their brain injuries were of mixed etiology, including hemorrhagic or ischemic stroke (24%), traumatic head injury (21%), brain tumor (11%), and other neurologic illness (13%).

Physician rater pairs scored the best, with good to excellent agreement. Nurse pairs had fair to moderate agreement. Nurse agreement was highest on the respiration and motor components and lowest on the eye and brainstem components. The agreement of the nurses with residents and neurointensivists was good to excellent.

The lower nurse agreement could be one of the biggest drawbacks to the FOUR system, said Donald W. Marion, M.D., a fellow at the Brain Trauma Foundation in New York City. “The fact is, when Dr. Teasdale devised the Glasgow score, the original intention was to develop a score easily used by nurses,” Dr. Marion said. “They were concerned that nurses be able to accurately report to the next shift and to physicians the status of the patient.”

Reliability among less highly trained personnel is a key indicator of a tool's simplicity and ease of use, Dr. Marion pointed out. “If no one other than a specialist can use it, that's a problem.”

Dr. Teasdale agrees. “The study uses too restricted a range of staff–all were in a specialized tertiary critical care unit,” he said. “What about the 'average' emergency room or hospital?”

The FOUR scale does succeed in getting around some of the biggest problems with GCS, including the issue of intubation, which negates the verbal assessment. But FOUR probably won't be any more useful than GCS for traumatic brain injury patients, many of whom are sedated by the time they are assessed at a trauma center, Dr. Marion said.

Nevertheless, “there are some real pluses with it–most importantly, looking for pupil changes and corneal responses. That's a real important improvement over the Glasgow score.” The FOUR scale may be a good supplement to the GCS in some specific areas, but probably won't supplant it, Dr. Teasdale said. “It must and will remain as a basic universal language. However, one of its benefits is its flexibility so it can be adapted, which is the essence of what Dr. Wijdicks has done, as have others in the past.”

Scoring the Full Outline Of Unresponsiveness

EYE RESPONSE

4 = Eyelids open, tracking or blinking to command.

3 = Eyelids open but not tracking.

2 = Eyelids closed but open to loud voice.

1 = Eyelids closed but open to pain.

0 = Eyelids remain closed to pain.

MOTOR RESPONSE

4 = Thumbs up, fist, or peace sign.

3 = Localizing to pain.

2 = Flexion response to pain.

1 = Extension response.

0 = No response to pain, or general myoclonus status.

BRAIN STEM REFLEXES

4 = Pupil and corneal reflexes present.

3 = One pupil wide and fixed.

2 = Pupil or corneal reflexes absent.

1 = Pupil and corneal reflexes absent.

0 = Pupil, corneal, and cough reflexes absent.

RESPIRATION

4 = Not intubated, regular breathing pattern.

3 = Not intubated, Cheyne-Stokes breathing pattern.

2 = Not intubated, irregular breathing.

1 = Breathes above ventilator rate.

0 = Breathes at ventilator rate or with apnea.

Source: Dr. Wijdicks

To receive a copy of the FOUR pocket instructional card, e-mail Dr. Wijdicks at

wijde@mayo.edu

A new coma assessment scale provides greater neurologic detail than the Glasgow system and has the potential to become the most effective means of evaluating unresponsive patients, according to researchers who developed it at the Mayo Clinic.

“The challenge over the years has been to produce a new scale that remains simple but still is comprehensive,” said Eelco Wijdicks, M.D., who developed the Full Outline of Unresponsiveness (FOUR) Coma scale.

“Prior attempts to do this have been unsuccessful, largely because they had a more comprehensive scale that lost clarity and simplicity. This scale is very simple to use and greatly appreciated by nursing staff,” Dr. Wijdicks said.

Graham M. Teasdale, M.B., inventor of the 30-year-old Glasgow scale, said the new system is more complicated to use and doesn't test as well among neurology nurses.

“The Glasgow Coma Scale was developed to fill the need for a practical method to assess impairment of consciousness in all types of patients with acute brain insult, in all places, by all kinds of staff, at all times, often minute by minute,” Dr. Teasdale, professor emeritus of neurosurgery at the University of Glasgow, Scotland, said in an interview. The FOUR scale is applicable to a smaller proportion of patients and appears to be more complicated, requiring extra training to effectively implement, he said.

Dr. Wijdicks said that neurologists have long complained that the Glasgow Coma Scale (GCS) was an imperfect tool for assessing consciousness. “The major reason is that the GCS doesn't include brain stem reflexes and respiration patterns, which reflect the severity of coma,” Dr. Wijdicks, a neurologist at the Mayo Clinic, Rochester, Minn., said in an interview.

“Also, the eye component doesn't involve voluntary eye movements and so can't recognize visual tracking and a locked-in syndrome.” Finally, he said, the GCS verbal assessment is a moot point for intubated patients.

The FOUR scale assesses voluntary and involuntary eye response; voluntary and involuntary motor response; respiration patterns; and brainstem response as measured by pupil and corneal reflexes. When using the FOUR system, evaluators assign a score of 0–4 in each category. A score of 4 represents normal functioning, while a score of 0 indicates nonfunctioning and should alert the physician to consider a brain death evaluation. (See box.)

The eye component detects both locked-in syndrome, characterized by complete paralysis of voluntary muscles except for those that control eye movement, and vegetative state. The motor category assesses for the presence of myoclonus status, a poor prognostic sign after cardiac resuscitation. It combines decorticate and withdrawal responses, a difference Dr. Wijdicks said is often difficult to differentiate.

Breathing patterns are graded, because Cheyne-Stokes respiration and irregular breathing can represent bihemispheric or lower brainstem dysfunction.

A recently published validation study of FOUR included 120 neurointensive care unit patients, the largest validation study ever on coma scales, evaluated by pairs of neurointensivists (neurologists trained in critical care), neurologic nurses, and residents in different combinations. All raters were given the same training on using the system: 20 minutes' instruction using videos, a single page of written instructions, and the opportunity to practice by grading a few patients (Ann. Neurol. 2005; 58: 585–93).

Average patient age was 59 years, and their brain injuries were of mixed etiology, including hemorrhagic or ischemic stroke (24%), traumatic head injury (21%), brain tumor (11%), and other neurologic illness (13%).

Physician rater pairs scored the best, with good to excellent agreement. Nurse pairs had fair to moderate agreement. Nurse agreement was highest on the respiration and motor components and lowest on the eye and brainstem components. The agreement of the nurses with residents and neurointensivists was good to excellent.

The lower nurse agreement could be one of the biggest drawbacks to the FOUR system, said Donald W. Marion, M.D., a fellow at the Brain Trauma Foundation in New York City. “The fact is, when Dr. Teasdale devised the Glasgow score, the original intention was to develop a score easily used by nurses,” Dr. Marion said. “They were concerned that nurses be able to accurately report to the next shift and to physicians the status of the patient.”

Reliability among less highly trained personnel is a key indicator of a tool's simplicity and ease of use, Dr. Marion pointed out. “If no one other than a specialist can use it, that's a problem.”

Dr. Teasdale agrees. “The study uses too restricted a range of staff–all were in a specialized tertiary critical care unit,” he said. “What about the 'average' emergency room or hospital?”

The FOUR scale does succeed in getting around some of the biggest problems with GCS, including the issue of intubation, which negates the verbal assessment. But FOUR probably won't be any more useful than GCS for traumatic brain injury patients, many of whom are sedated by the time they are assessed at a trauma center, Dr. Marion said.

Nevertheless, “there are some real pluses with it–most importantly, looking for pupil changes and corneal responses. That's a real important improvement over the Glasgow score.” The FOUR scale may be a good supplement to the GCS in some specific areas, but probably won't supplant it, Dr. Teasdale said. “It must and will remain as a basic universal language. However, one of its benefits is its flexibility so it can be adapted, which is the essence of what Dr. Wijdicks has done, as have others in the past.”

Scoring the Full Outline Of Unresponsiveness

EYE RESPONSE

4 = Eyelids open, tracking or blinking to command.

3 = Eyelids open but not tracking.

2 = Eyelids closed but open to loud voice.

1 = Eyelids closed but open to pain.

0 = Eyelids remain closed to pain.

MOTOR RESPONSE

4 = Thumbs up, fist, or peace sign.

3 = Localizing to pain.

2 = Flexion response to pain.

1 = Extension response.

0 = No response to pain, or general myoclonus status.

BRAIN STEM REFLEXES

4 = Pupil and corneal reflexes present.

3 = One pupil wide and fixed.

2 = Pupil or corneal reflexes absent.

1 = Pupil and corneal reflexes absent.

0 = Pupil, corneal, and cough reflexes absent.

RESPIRATION

4 = Not intubated, regular breathing pattern.

3 = Not intubated, Cheyne-Stokes breathing pattern.

2 = Not intubated, irregular breathing.

1 = Breathes above ventilator rate.

0 = Breathes at ventilator rate or with apnea.

Source: Dr. Wijdicks

To receive a copy of the FOUR pocket instructional card, e-mail Dr. Wijdicks at

wijde@mayo.edu

TORONTO – Few suicide attempts occurred during the Treatment for Adolescents with Depression Study (TADS), but suicide-related events were more common in both fluoxetine arms than in the placebo arm, Graham J. Emslie, M.D., reported at the joint annual meeting of the American Academy of Child and Adolescent Psychiatry and the Canadian Academy of Child and Adolescent Psychiatry.

But, Dr. Emslie said this should be tempered with another of the study's conclusions. Almost 30% of the adolescents had suicidal ideation at the study's outset; at 12 weeks of treatment, suicidal behavior had improved in about 86% of the fluoxetine arms, compared with 77% of those in a cognitive-behavioral therapy-only arm.

“If you talk to the press, you would assume people are dying in the [United States] from these medicines, but in fact they are well tolerated,” said Dr. Emslie, chief of the University of Texas Southwestern's division of child and adolescent psychiatry, Dallas. “About 83% of those on fluoxetine and the same percentage on the combination of cognitive-behavioral therapy (CBT) and fluoxetine completed the treatment period–and that says a lot.”

TADS included 439 patients aged 12–17 years with major depressive disorder. Patients were randomized to 12 weeks of fluoxetine alone (10–40 mg/day), cognitive-behavioral therapy (CBT), CBT with fluoxetine (10–40 mg/day), or to placebo.

Combination therapy was superior to either fluoxetine or CBT alone in reducing symptoms of depression, and fluoxetine alone was superior to CBT alone.

Suicide-related events occurred in nine patients in the fluoxetine-only arm, five in the combination therapy arm, five in the CBT-only arm, and two in the placebo arm. There were five suicide attempts: two in the combination arm, two in the fluoxetine arm, one in the CBT-only arm, and none in the placebo arm.

New suicidal ideation was most common in the fluoxetine-only arm (three cases). There were no new cases in the combination therapy arm, one in the CBT-only arm, and two in the placebo arm.

Suicidal ideation worsened in 13% of those in the fluoxetine arm, 15% of those in the CBT-only arm, 7% of those in the placebo arm, and 5% of those in the combination arm. “There were few attempts, but there was some increase in ideation,” Dr. Emslie said. He noted that TADS was a flexible-dose study and that the addition of CBT to fluoxetine was associated with lower doses of the drug. “CBT appears to decrease the amount of drug that they need, and keeping the dose lower for longer appears to be a good idea.”

Physical adverse events were more common in the fluoxetine arms, compared with placebo. Insomnia occurred in 4% of those taking fluoxetine and 1% of those in the placebo group. Rates were similar for vomiting (3% vs. 1%) and upper abdominal pain (3% vs. 2%).

Those taking fluoxetine also reported more psychiatric symptoms than those on placebo. Mania occurred in 2% of the fluoxetine groups, 1% of the placebo group, and none of the CBT-only group. Irritability occurred in 3% of the fluoxetine groups, 1% of the placebo group, and none of the CBT group. The total psychiatric event rate was 11% for fluoxetine, 5.5% for combination therapy, 4.5% for placebo, and 1% for CBT.

However, Dr. Emslie noted, “There's no evidence that the drug was doing this. These symptoms vary. They go up and down with time.”

TORONTO – Few suicide attempts occurred during the Treatment for Adolescents with Depression Study (TADS), but suicide-related events were more common in both fluoxetine arms than in the placebo arm, Graham J. Emslie, M.D., reported at the joint annual meeting of the American Academy of Child and Adolescent Psychiatry and the Canadian Academy of Child and Adolescent Psychiatry.

But, Dr. Emslie said this should be tempered with another of the study's conclusions. Almost 30% of the adolescents had suicidal ideation at the study's outset; at 12 weeks of treatment, suicidal behavior had improved in about 86% of the fluoxetine arms, compared with 77% of those in a cognitive-behavioral therapy-only arm.

“If you talk to the press, you would assume people are dying in the [United States] from these medicines, but in fact they are well tolerated,” said Dr. Emslie, chief of the University of Texas Southwestern's division of child and adolescent psychiatry, Dallas. “About 83% of those on fluoxetine and the same percentage on the combination of cognitive-behavioral therapy (CBT) and fluoxetine completed the treatment period–and that says a lot.”

TADS included 439 patients aged 12–17 years with major depressive disorder. Patients were randomized to 12 weeks of fluoxetine alone (10–40 mg/day), cognitive-behavioral therapy (CBT), CBT with fluoxetine (10–40 mg/day), or to placebo.

Combination therapy was superior to either fluoxetine or CBT alone in reducing symptoms of depression, and fluoxetine alone was superior to CBT alone.

Suicide-related events occurred in nine patients in the fluoxetine-only arm, five in the combination therapy arm, five in the CBT-only arm, and two in the placebo arm. There were five suicide attempts: two in the combination arm, two in the fluoxetine arm, one in the CBT-only arm, and none in the placebo arm.

New suicidal ideation was most common in the fluoxetine-only arm (three cases). There were no new cases in the combination therapy arm, one in the CBT-only arm, and two in the placebo arm.

Suicidal ideation worsened in 13% of those in the fluoxetine arm, 15% of those in the CBT-only arm, 7% of those in the placebo arm, and 5% of those in the combination arm. “There were few attempts, but there was some increase in ideation,” Dr. Emslie said. He noted that TADS was a flexible-dose study and that the addition of CBT to fluoxetine was associated with lower doses of the drug. “CBT appears to decrease the amount of drug that they need, and keeping the dose lower for longer appears to be a good idea.”

Physical adverse events were more common in the fluoxetine arms, compared with placebo. Insomnia occurred in 4% of those taking fluoxetine and 1% of those in the placebo group. Rates were similar for vomiting (3% vs. 1%) and upper abdominal pain (3% vs. 2%).

Those taking fluoxetine also reported more psychiatric symptoms than those on placebo. Mania occurred in 2% of the fluoxetine groups, 1% of the placebo group, and none of the CBT-only group. Irritability occurred in 3% of the fluoxetine groups, 1% of the placebo group, and none of the CBT group. The total psychiatric event rate was 11% for fluoxetine, 5.5% for combination therapy, 4.5% for placebo, and 1% for CBT.

However, Dr. Emslie noted, “There's no evidence that the drug was doing this. These symptoms vary. They go up and down with time.”

TORONTO – Few suicide attempts occurred during the Treatment for Adolescents with Depression Study (TADS), but suicide-related events were more common in both fluoxetine arms than in the placebo arm, Graham J. Emslie, M.D., reported at the joint annual meeting of the American Academy of Child and Adolescent Psychiatry and the Canadian Academy of Child and Adolescent Psychiatry.

But, Dr. Emslie said this should be tempered with another of the study's conclusions. Almost 30% of the adolescents had suicidal ideation at the study's outset; at 12 weeks of treatment, suicidal behavior had improved in about 86% of the fluoxetine arms, compared with 77% of those in a cognitive-behavioral therapy-only arm.

“If you talk to the press, you would assume people are dying in the [United States] from these medicines, but in fact they are well tolerated,” said Dr. Emslie, chief of the University of Texas Southwestern's division of child and adolescent psychiatry, Dallas. “About 83% of those on fluoxetine and the same percentage on the combination of cognitive-behavioral therapy (CBT) and fluoxetine completed the treatment period–and that says a lot.”

TADS included 439 patients aged 12–17 years with major depressive disorder. Patients were randomized to 12 weeks of fluoxetine alone (10–40 mg/day), cognitive-behavioral therapy (CBT), CBT with fluoxetine (10–40 mg/day), or to placebo.

Combination therapy was superior to either fluoxetine or CBT alone in reducing symptoms of depression, and fluoxetine alone was superior to CBT alone.

Suicide-related events occurred in nine patients in the fluoxetine-only arm, five in the combination therapy arm, five in the CBT-only arm, and two in the placebo arm. There were five suicide attempts: two in the combination arm, two in the fluoxetine arm, one in the CBT-only arm, and none in the placebo arm.

New suicidal ideation was most common in the fluoxetine-only arm (three cases). There were no new cases in the combination therapy arm, one in the CBT-only arm, and two in the placebo arm.

Suicidal ideation worsened in 13% of those in the fluoxetine arm, 15% of those in the CBT-only arm, 7% of those in the placebo arm, and 5% of those in the combination arm. “There were few attempts, but there was some increase in ideation,” Dr. Emslie said. He noted that TADS was a flexible-dose study and that the addition of CBT to fluoxetine was associated with lower doses of the drug. “CBT appears to decrease the amount of drug that they need, and keeping the dose lower for longer appears to be a good idea.”

Physical adverse events were more common in the fluoxetine arms, compared with placebo. Insomnia occurred in 4% of those taking fluoxetine and 1% of those in the placebo group. Rates were similar for vomiting (3% vs. 1%) and upper abdominal pain (3% vs. 2%).

Those taking fluoxetine also reported more psychiatric symptoms than those on placebo. Mania occurred in 2% of the fluoxetine groups, 1% of the placebo group, and none of the CBT-only group. Irritability occurred in 3% of the fluoxetine groups, 1% of the placebo group, and none of the CBT group. The total psychiatric event rate was 11% for fluoxetine, 5.5% for combination therapy, 4.5% for placebo, and 1% for CBT.

However, Dr. Emslie noted, “There's no evidence that the drug was doing this. These symptoms vary. They go up and down with time.”

WASHINGTON – During each stage of childhood, adopted children must master a different level in processing their unique life story, Kay Seligsohn, Ph.D., said at the annual meeting of the American Academy of Pediatrics.

“Each stage has its own tasks, its own challenges, and its own red flags,” said Dr. Seligsohn of the Children's Hospital and Harvard Medical School Adoption Program, Boston.

The tasks of the toddler years are to develop a sense of autonomy and self-identity. Adoption during these years can hinder the process. “They are taken from the only home they have known and dropped off in a place where they know no one and may not even speak the language,” Dr. Seligsohn said. “Imagine what that teaches them–that they have no autonomy at all.”

This experience, combined with the limited language and cognitive skills of a toddler, is the root of the attachment delays and behavioral problems these children often experience as they settle into their new family. “Parents should anticipate that they will see extreme 2-year-old behavior.”

But behavior issues, “beyond the normal 'terrible twos,'” should be red flags that the attachment process isn't going well or that the child might have an underlying medical or psychological problem.

“We diagnose a lot of fetal alcohol effects and sensory integration problems at this stage,” Dr. Seligsohn said.

Toddlerhood also is the best time to begin introducing the child's personal adoption story, she said. “The best way is simply to have it become part of the general family fabric, like knowing what town they live in.”

The preschool years are a time of emerging self-awareness for children. They experience an explosion of physical skills and language development. At this stage, children can parrot their adoption story as though it's a bedtime tale, but probably don't really understand much of it, she said.

Adopting a child who is preschool age has both its challenges and its rewards. “They know what a family is and are often looking forward to belonging to one. But they will go through a period of extended grief and loss even if they are going to a better situation.”

The behaviors surrounding grief and loss can be upsetting to adoptive parents, who view adoption as a time of happiness and excitement.

It's important to let parents know that the grieving process is both normal and necessary. “Attachment proceeds slowly because of the grieving, but it moves simultaneously with it,” said Dr. Seligsohn.

It is also during the preschool years that children start to lose their past memories. It can be very beneficial to record those recollections before they are lost, so the child can later hear a complete record of his or her life. If the child isn't fluent in English, hiring an interpreter can be a good investment.

During this time, attentional issues, hyperactivity, fetal alcohol effects, and language delays can emerge. Preschoolers also can suffer from extreme anxiety that manifests as nightmares or monster fears. Older children can become obsessed with worries about separation.

Children in the latency phase are developing their self-esteem and cognitive skills, as well as their sense of logical reciprocity. For many children, this new thought process allows them to understand for the first time the concept of a birth family and, consequently, its loss. “They think, 'If I was adopted, my real mother gave me up.'”

This realization concerning the birth family is always accompanied by grief and sadness, Dr. Seligsohn said. “It might not be extreme–it could be as brief as a few days of feeling blue. But it can be quite problematic.”

Children can begin to idealize their birth family and compare it to their adoptive family–usually to the adoptive family's detriment. These family romance fantasies are “a normal part of the process of understanding that your parents aren't always good, and that you can love them and be angry at them at the same time,” she said.

This issue usually abates toward the end of middle childhood, but for some children it can be connected with the development of oppositional or mood disorders, which would include depression, anxiety, bipolar, and posttraumatic stress disorders.

“There is a higher incidence of these disorders in the adopted population, so it's good to check this out when the parent expresses any concern,” she advised.

Adopted adolescents are struggling to understand their ego and sexual identity. Adoptive parents often aren't much help during this crucial period, Dr. Seligsohn said.

“The [adoptive parents] are horrible at talking about sexuality, especially if there is a history of infertility that led to the adoption. There's also the myth that all people who place kids for adoption are promiscuous teenage moms.”

Unfortunately, she said, adopted teenagers may believe this as well and may engage in high-risk behavior as a subconscious way of identifying with their absent birth parents.

Adolescence is the time when most adopted children begin searching for their birth families. The advent of the Internet has made it much easier to do this and much easier to be secretive about it. It's important to monitor Internet use to forestall secrecy.

Adoptive parents need to understand and support the child's need to discover this very important part of his or her past, Dr Seligsohn said.

WASHINGTON – During each stage of childhood, adopted children must master a different level in processing their unique life story, Kay Seligsohn, Ph.D., said at the annual meeting of the American Academy of Pediatrics.

“Each stage has its own tasks, its own challenges, and its own red flags,” said Dr. Seligsohn of the Children's Hospital and Harvard Medical School Adoption Program, Boston.

The tasks of the toddler years are to develop a sense of autonomy and self-identity. Adoption during these years can hinder the process. “They are taken from the only home they have known and dropped off in a place where they know no one and may not even speak the language,” Dr. Seligsohn said. “Imagine what that teaches them–that they have no autonomy at all.”

This experience, combined with the limited language and cognitive skills of a toddler, is the root of the attachment delays and behavioral problems these children often experience as they settle into their new family. “Parents should anticipate that they will see extreme 2-year-old behavior.”

But behavior issues, “beyond the normal 'terrible twos,'” should be red flags that the attachment process isn't going well or that the child might have an underlying medical or psychological problem.

“We diagnose a lot of fetal alcohol effects and sensory integration problems at this stage,” Dr. Seligsohn said.

Toddlerhood also is the best time to begin introducing the child's personal adoption story, she said. “The best way is simply to have it become part of the general family fabric, like knowing what town they live in.”

The preschool years are a time of emerging self-awareness for children. They experience an explosion of physical skills and language development. At this stage, children can parrot their adoption story as though it's a bedtime tale, but probably don't really understand much of it, she said.

Adopting a child who is preschool age has both its challenges and its rewards. “They know what a family is and are often looking forward to belonging to one. But they will go through a period of extended grief and loss even if they are going to a better situation.”

The behaviors surrounding grief and loss can be upsetting to adoptive parents, who view adoption as a time of happiness and excitement.

It's important to let parents know that the grieving process is both normal and necessary. “Attachment proceeds slowly because of the grieving, but it moves simultaneously with it,” said Dr. Seligsohn.

It is also during the preschool years that children start to lose their past memories. It can be very beneficial to record those recollections before they are lost, so the child can later hear a complete record of his or her life. If the child isn't fluent in English, hiring an interpreter can be a good investment.

During this time, attentional issues, hyperactivity, fetal alcohol effects, and language delays can emerge. Preschoolers also can suffer from extreme anxiety that manifests as nightmares or monster fears. Older children can become obsessed with worries about separation.

Children in the latency phase are developing their self-esteem and cognitive skills, as well as their sense of logical reciprocity. For many children, this new thought process allows them to understand for the first time the concept of a birth family and, consequently, its loss. “They think, 'If I was adopted, my real mother gave me up.'”

This realization concerning the birth family is always accompanied by grief and sadness, Dr. Seligsohn said. “It might not be extreme–it could be as brief as a few days of feeling blue. But it can be quite problematic.”

Children can begin to idealize their birth family and compare it to their adoptive family–usually to the adoptive family's detriment. These family romance fantasies are “a normal part of the process of understanding that your parents aren't always good, and that you can love them and be angry at them at the same time,” she said.

This issue usually abates toward the end of middle childhood, but for some children it can be connected with the development of oppositional or mood disorders, which would include depression, anxiety, bipolar, and posttraumatic stress disorders.

“There is a higher incidence of these disorders in the adopted population, so it's good to check this out when the parent expresses any concern,” she advised.

Adopted adolescents are struggling to understand their ego and sexual identity. Adoptive parents often aren't much help during this crucial period, Dr. Seligsohn said.

“The [adoptive parents] are horrible at talking about sexuality, especially if there is a history of infertility that led to the adoption. There's also the myth that all people who place kids for adoption are promiscuous teenage moms.”

Unfortunately, she said, adopted teenagers may believe this as well and may engage in high-risk behavior as a subconscious way of identifying with their absent birth parents.

Adolescence is the time when most adopted children begin searching for their birth families. The advent of the Internet has made it much easier to do this and much easier to be secretive about it. It's important to monitor Internet use to forestall secrecy.

Adoptive parents need to understand and support the child's need to discover this very important part of his or her past, Dr Seligsohn said.

WASHINGTON – During each stage of childhood, adopted children must master a different level in processing their unique life story, Kay Seligsohn, Ph.D., said at the annual meeting of the American Academy of Pediatrics.

“Each stage has its own tasks, its own challenges, and its own red flags,” said Dr. Seligsohn of the Children's Hospital and Harvard Medical School Adoption Program, Boston.

The tasks of the toddler years are to develop a sense of autonomy and self-identity. Adoption during these years can hinder the process. “They are taken from the only home they have known and dropped off in a place where they know no one and may not even speak the language,” Dr. Seligsohn said. “Imagine what that teaches them–that they have no autonomy at all.”

This experience, combined with the limited language and cognitive skills of a toddler, is the root of the attachment delays and behavioral problems these children often experience as they settle into their new family. “Parents should anticipate that they will see extreme 2-year-old behavior.”

But behavior issues, “beyond the normal 'terrible twos,'” should be red flags that the attachment process isn't going well or that the child might have an underlying medical or psychological problem.

“We diagnose a lot of fetal alcohol effects and sensory integration problems at this stage,” Dr. Seligsohn said.

Toddlerhood also is the best time to begin introducing the child's personal adoption story, she said. “The best way is simply to have it become part of the general family fabric, like knowing what town they live in.”

The preschool years are a time of emerging self-awareness for children. They experience an explosion of physical skills and language development. At this stage, children can parrot their adoption story as though it's a bedtime tale, but probably don't really understand much of it, she said.

Adopting a child who is preschool age has both its challenges and its rewards. “They know what a family is and are often looking forward to belonging to one. But they will go through a period of extended grief and loss even if they are going to a better situation.”

The behaviors surrounding grief and loss can be upsetting to adoptive parents, who view adoption as a time of happiness and excitement.

It's important to let parents know that the grieving process is both normal and necessary. “Attachment proceeds slowly because of the grieving, but it moves simultaneously with it,” said Dr. Seligsohn.

It is also during the preschool years that children start to lose their past memories. It can be very beneficial to record those recollections before they are lost, so the child can later hear a complete record of his or her life. If the child isn't fluent in English, hiring an interpreter can be a good investment.

During this time, attentional issues, hyperactivity, fetal alcohol effects, and language delays can emerge. Preschoolers also can suffer from extreme anxiety that manifests as nightmares or monster fears. Older children can become obsessed with worries about separation.

Children in the latency phase are developing their self-esteem and cognitive skills, as well as their sense of logical reciprocity. For many children, this new thought process allows them to understand for the first time the concept of a birth family and, consequently, its loss. “They think, 'If I was adopted, my real mother gave me up.'”

This realization concerning the birth family is always accompanied by grief and sadness, Dr. Seligsohn said. “It might not be extreme–it could be as brief as a few days of feeling blue. But it can be quite problematic.”

Children can begin to idealize their birth family and compare it to their adoptive family–usually to the adoptive family's detriment. These family romance fantasies are “a normal part of the process of understanding that your parents aren't always good, and that you can love them and be angry at them at the same time,” she said.

This issue usually abates toward the end of middle childhood, but for some children it can be connected with the development of oppositional or mood disorders, which would include depression, anxiety, bipolar, and posttraumatic stress disorders.

“There is a higher incidence of these disorders in the adopted population, so it's good to check this out when the parent expresses any concern,” she advised.

Adopted adolescents are struggling to understand their ego and sexual identity. Adoptive parents often aren't much help during this crucial period, Dr. Seligsohn said.

“The [adoptive parents] are horrible at talking about sexuality, especially if there is a history of infertility that led to the adoption. There's also the myth that all people who place kids for adoption are promiscuous teenage moms.”

Unfortunately, she said, adopted teenagers may believe this as well and may engage in high-risk behavior as a subconscious way of identifying with their absent birth parents.

Adolescence is the time when most adopted children begin searching for their birth families. The advent of the Internet has made it much easier to do this and much easier to be secretive about it. It's important to monitor Internet use to forestall secrecy.

Adoptive parents need to understand and support the child's need to discover this very important part of his or her past, Dr Seligsohn said.

Parental emotional support of children as young as 1 year of age is associated with lower incidence of externalizing problems later in childhood.

“Our results are suggestive of very early parenting potentially having a long-term impact on the behavioral development of the child,” Carolyn A. McCarty, Ph.D., and her colleagues reported. “Helping parents learn ways to provide emotional support to the child very early on may be a particularly important facet of efforts to promote positive behavior patterns among children” (J. Dev. Behav. Pediatr. 2005;26:267–75).

Dr. McCarty of the University of Washington, Seattle, and her coinvestigators examined the effect of supportive parenting on behavior in 2,940 children aged 7 and 8 years. Data were taken from the National Longitudinal Survey of Youth, Children, and Young Adults (NLSY-Child, years 1994, 1996, 1998, and 2000). About 60% of the children were white; 75% lived in two-parent households at the time of the survey.

Parental emotional support was measured by maternal self-report on the NLSY-Child and by interviewer observation. A supplement of the survey included the 28-item Behavioral Problems Index to characterize child behavior patterns.

While there was no significant association between internalizing problems and parental emotional support, the researchers found a significant negative association between externalizing problems and parent support.

The most significant association occurred between childhood behavior and parental support when the child was 1 to 2 years old. The association between externalizing problems and emotional support at ages 3–4 years and 5–6 years was nonsignificant.

“Children who do not receive warm, responsive, involved parenting in the early years are at risk of more behavioral problems, such as aggression, defiance, and delinquency in subsequent years,” the investigators concluded.

Parental emotional support of children as young as 1 year of age is associated with lower incidence of externalizing problems later in childhood.

“Our results are suggestive of very early parenting potentially having a long-term impact on the behavioral development of the child,” Carolyn A. McCarty, Ph.D., and her colleagues reported. “Helping parents learn ways to provide emotional support to the child very early on may be a particularly important facet of efforts to promote positive behavior patterns among children” (J. Dev. Behav. Pediatr. 2005;26:267–75).

Dr. McCarty of the University of Washington, Seattle, and her coinvestigators examined the effect of supportive parenting on behavior in 2,940 children aged 7 and 8 years. Data were taken from the National Longitudinal Survey of Youth, Children, and Young Adults (NLSY-Child, years 1994, 1996, 1998, and 2000). About 60% of the children were white; 75% lived in two-parent households at the time of the survey.

Parental emotional support was measured by maternal self-report on the NLSY-Child and by interviewer observation. A supplement of the survey included the 28-item Behavioral Problems Index to characterize child behavior patterns.

While there was no significant association between internalizing problems and parental emotional support, the researchers found a significant negative association between externalizing problems and parent support.

The most significant association occurred between childhood behavior and parental support when the child was 1 to 2 years old. The association between externalizing problems and emotional support at ages 3–4 years and 5–6 years was nonsignificant.

“Children who do not receive warm, responsive, involved parenting in the early years are at risk of more behavioral problems, such as aggression, defiance, and delinquency in subsequent years,” the investigators concluded.

Parental emotional support of children as young as 1 year of age is associated with lower incidence of externalizing problems later in childhood.

“Our results are suggestive of very early parenting potentially having a long-term impact on the behavioral development of the child,” Carolyn A. McCarty, Ph.D., and her colleagues reported. “Helping parents learn ways to provide emotional support to the child very early on may be a particularly important facet of efforts to promote positive behavior patterns among children” (J. Dev. Behav. Pediatr. 2005;26:267–75).

Dr. McCarty of the University of Washington, Seattle, and her coinvestigators examined the effect of supportive parenting on behavior in 2,940 children aged 7 and 8 years. Data were taken from the National Longitudinal Survey of Youth, Children, and Young Adults (NLSY-Child, years 1994, 1996, 1998, and 2000). About 60% of the children were white; 75% lived in two-parent households at the time of the survey.

Parental emotional support was measured by maternal self-report on the NLSY-Child and by interviewer observation. A supplement of the survey included the 28-item Behavioral Problems Index to characterize child behavior patterns.

While there was no significant association between internalizing problems and parental emotional support, the researchers found a significant negative association between externalizing problems and parent support.

The most significant association occurred between childhood behavior and parental support when the child was 1 to 2 years old. The association between externalizing problems and emotional support at ages 3–4 years and 5–6 years was nonsignificant.

“Children who do not receive warm, responsive, involved parenting in the early years are at risk of more behavioral problems, such as aggression, defiance, and delinquency in subsequent years,” the investigators concluded.

LOS ANGELES — A miniature roller equipped with dozens of microfine 30-gauge needles that repeatedly puncture the facial epidermis may be a good alternative to laser resurfacing or dermabrasion for some patients.

The Medical Roll-CIT induces collagen formation without destroying the epidermis, Philip Miller, M.D., said at the fall meeting of the American Academy of Facial Plastic and Reconstructive Surgeons. "It's straightforward, simple, and easy to do," said Dr. Miller, a plastic surgeon in New York City. "People are back in public in 2–5 days—and, most importantly, patients are highly satisfied with the results."

Patients prepare for the procedure with daily applications of concentrated vitamins A and C for about 3 weeks. Both the lotion and the roller are made by South Africa-based Environ Skin Care Ltd.

Before the procedure, a nerve block and topical anesthetic are given. The physician rolls the device over the areas to be treated multiple times, in a random pattern, creating hundreds to thousands of tiny puncture wounds. The wounds are about 1.5 mm deep—just deep enough to reach the papillary dermis, Dr. Miller said.

The procedure does cause bleeding; the skin should be covered with damp swabs for absorption. Bleeding stops quickly, and after it does, the vitamin lotion is applied again. Patients are instructed to apply the lotion for 3 weeks. "The needle wounds serve as channels to direct the nutrients to the dermis," Dr. Miller said.

There is no need for postoperative narcotic medication. After healing is complete, there is no photosensitivity, he said.

Dr. Miller has performed the procedure on 11 patients (6 for acne scars and 5 for mild rhytids). Nine patients (82%) said they experienced a 70%–79% improvement from baseline, while two rated their improvement as 50%–59%. There were no pigmentary changes on any treated skin, even Fitzpatrick types V and VI.

Dr. Miller said he has no financial interest in the device.

Micropunctures surround islands of uninvolved epidermis after the procedure. Courtesy Dr. Philip Miller

LOS ANGELES — A miniature roller equipped with dozens of microfine 30-gauge needles that repeatedly puncture the facial epidermis may be a good alternative to laser resurfacing or dermabrasion for some patients.

The Medical Roll-CIT induces collagen formation without destroying the epidermis, Philip Miller, M.D., said at the fall meeting of the American Academy of Facial Plastic and Reconstructive Surgeons. "It's straightforward, simple, and easy to do," said Dr. Miller, a plastic surgeon in New York City. "People are back in public in 2–5 days—and, most importantly, patients are highly satisfied with the results."

Patients prepare for the procedure with daily applications of concentrated vitamins A and C for about 3 weeks. Both the lotion and the roller are made by South Africa-based Environ Skin Care Ltd.

Before the procedure, a nerve block and topical anesthetic are given. The physician rolls the device over the areas to be treated multiple times, in a random pattern, creating hundreds to thousands of tiny puncture wounds. The wounds are about 1.5 mm deep—just deep enough to reach the papillary dermis, Dr. Miller said.

The procedure does cause bleeding; the skin should be covered with damp swabs for absorption. Bleeding stops quickly, and after it does, the vitamin lotion is applied again. Patients are instructed to apply the lotion for 3 weeks. "The needle wounds serve as channels to direct the nutrients to the dermis," Dr. Miller said.

There is no need for postoperative narcotic medication. After healing is complete, there is no photosensitivity, he said.

Dr. Miller has performed the procedure on 11 patients (6 for acne scars and 5 for mild rhytids). Nine patients (82%) said they experienced a 70%–79% improvement from baseline, while two rated their improvement as 50%–59%. There were no pigmentary changes on any treated skin, even Fitzpatrick types V and VI.

Dr. Miller said he has no financial interest in the device.

Micropunctures surround islands of uninvolved epidermis after the procedure. Courtesy Dr. Philip Miller

LOS ANGELES — A miniature roller equipped with dozens of microfine 30-gauge needles that repeatedly puncture the facial epidermis may be a good alternative to laser resurfacing or dermabrasion for some patients.

The Medical Roll-CIT induces collagen formation without destroying the epidermis, Philip Miller, M.D., said at the fall meeting of the American Academy of Facial Plastic and Reconstructive Surgeons. "It's straightforward, simple, and easy to do," said Dr. Miller, a plastic surgeon in New York City. "People are back in public in 2–5 days—and, most importantly, patients are highly satisfied with the results."

Patients prepare for the procedure with daily applications of concentrated vitamins A and C for about 3 weeks. Both the lotion and the roller are made by South Africa-based Environ Skin Care Ltd.

Before the procedure, a nerve block and topical anesthetic are given. The physician rolls the device over the areas to be treated multiple times, in a random pattern, creating hundreds to thousands of tiny puncture wounds. The wounds are about 1.5 mm deep—just deep enough to reach the papillary dermis, Dr. Miller said.

The procedure does cause bleeding; the skin should be covered with damp swabs for absorption. Bleeding stops quickly, and after it does, the vitamin lotion is applied again. Patients are instructed to apply the lotion for 3 weeks. "The needle wounds serve as channels to direct the nutrients to the dermis," Dr. Miller said.

There is no need for postoperative narcotic medication. After healing is complete, there is no photosensitivity, he said.

Dr. Miller has performed the procedure on 11 patients (6 for acne scars and 5 for mild rhytids). Nine patients (82%) said they experienced a 70%–79% improvement from baseline, while two rated their improvement as 50%–59%. There were no pigmentary changes on any treated skin, even Fitzpatrick types V and VI.

Dr. Miller said he has no financial interest in the device.

Micropunctures surround islands of uninvolved epidermis after the procedure. Courtesy Dr. Philip Miller

LOS ANGELES — Non- or minimally ablative facial resurfacing offers patients the results they desire without extended downtime, said several presenters at the annual fall meeting of the American Academy of Facial Plastic and Reconstructive Surgery.

"Most of my patients want nonsurgical treatments with no downtime," said Elizabeth Rostan, M.D., a cosmetic dermatologist in Charlotte, N.C. "In my community, I can't give away a CO₂ laser resurfacing."

Most of Dr. Rostan's fractional resurfacing patients are women who want treatment for photoaging, acne scars, or melasma. "Many of these patients are the ones for whom you might consider intense pulsed light. It would burn off the pigmentary lesions, but it would not give you the same improvement you see in fine wrinkling."

In terms of both efficacy and recovery, fractional resurfacing falls between nonablative and ablative techniques.

"The results we get are better than what we would see with a nonablative technique, but not quite as good as what we would see with an ablative resurfacing," she said. "However, with the fractional resurfacing, patients aren't experiencing the 2 weeks of downtime that they would with a CO₂ laser resurfacing, either."

The device directs its energy along the path of a computer-generated pattern, producing about 2,000 tiny holes (microthermal injury zones) per square centimeter. Because the areas of injury are so tiny, "you are treating about 20% of the skin surface, leaving 80% to renew and heal," Dr. Rostan said.

The laser intensity can be varied for different applications. The 8-J/cm

Patients require a topical anesthetic, which takes about 1 hour to achieve maximum effect. The actual resurfacing procedure lasts about 20 minutes, she said. However, three to five treatments, spaced about a week apart, are usually necessary to achieve the desired result.

Afterward, there is mild erythema and edema. "Patients are usually pink for 2 days, but it can sometimes last as long as 4 days," Dr. Rostan said. "But they can easily cover it with makeup and be back to work the day after the procedure."

Fractional resurfacing is also a good alternative for elderly patients or for those with health issues that might compromise wound healing in an ablative resurfacing, she said. "I've done a healthy 87-year-old, as well as a transplant patient, with no adverse effects."

But she said she would carefully consider patients with scleroderma or rheumatoid problems. "Anyone who you'd have concerns about for laser resurfacing, you would also have to think about for fractional resurfacing."

The in-office erbium laser provides a one-time minimally ablative resurfacing with results similar to a whole course of intense fractional resurfacing, said James Newman, M.D., a facial plastic surgeon from San Mateo, Calif.

"I began using office-based laser treatments in response to patients' wanting a treatment without much downtime or prolonged healing, but who also didn't want to come into the office four or five times to treat a brown spot," he said.

The small erbium lasers are also relatively inexpensive (about $30,000), which allows the physician to rapidly recoup the investment and offer patients a modestly priced treatment. "For the removal of brown spots from the face or hands, it would be about $300, and for a perioral regional resurfacing, maybe $1,000 or less," he said.

The small, portable lasers have lower fluences (about 5–7 J/cm

"They also have a pulse duration of about 300 milliseconds, and because they are lower powered, they can't go as fast. The maximum repetition rate is about 2 Hz," Dr. Newman said.

This makes the in-office erbium laser good for localized or regional (perioral or periorbital) resurfacing, but not appropriate for a full-face procedure, he said.

The main indications for this device are solar lentigines, early elastosis of periorbital skin, sebaceous hyperplasia, scar modification, and epidermal keratosis, Dr. Newman said. Downtime is 4–7 days, "similar to what you would expect with intense fractional resurfacing or a medium-depth chemical peel."

"If they can come in and get it over with in one treatment, and then put up with a week at most of healing, patients will be very happy with this," he said.

The plasma resurfacer gives similar results, without the epidermal sloughing that the erbium laser generates, said Edgar Fincher, M.D., a dermatologic surgeon in Los Angeles.

These devices feature a nitrogen canister that pumps the gas into a handpiece, where a radiofrequency generator heats it and delivers it through a nozzle to the skin surface. They can deliver energy ranging from 1 to 4 J/cm

Like a CO₂ or erbium laser, the plasma resurfacer causes an immediate zone of thermal damage, with heat dissipation into the deeper tissues, stimulating fibroblast action.

The difference with the plasma resurfacer, Dr. Fincher said, is that the lower fluences preserve the epidermis until reepithelialization is complete. "It does not vaporize the epidermis, which accelerates wound healing. About 4 days later, you have reepithelialization and necrotic keratinocytes moving up and beginning to slough." By day 10, histology shows a fully reformed stratified epidermis and increased number of active fibroblasts generating collagen, he said.

These devices have received Food and Drug Administration approval for use in single-pass, low-energy repeat treatments and single-pass, high-energy treatment of facial rhytids, and for the treatment of superficial skin lesions.

Dr. Fincher has used a plasma resurfacer for about 2 years, with no incidence of scarring or hypopigmentation. He has seen some transient hyperpigmentation, however, and two patients have had prolonged (4–6 weeks) erythema.

"We tell people that, pretty reliably, they will be back to normal in 10 days," he said.

A full-face treatment can be done in about 15 minutes. Patients who are being treated for dyschromia or photodamage will probably require two or three treatments about 1 month apart. These low-energy treatments are usually performed with a topical anesthetic, although nerve blocks may be necessary for some patients. The high-energy treatments necessary for treating acne scars usually require local anesthetic or IV sedation.

"We still have a CO₂ laser and use it occasionally, but this has replaced it as our workhorse resurfacing device," Dr. Fincher said.

LOS ANGELES — Non- or minimally ablative facial resurfacing offers patients the results they desire without extended downtime, said several presenters at the annual fall meeting of the American Academy of Facial Plastic and Reconstructive Surgery.

"Most of my patients want nonsurgical treatments with no downtime," said Elizabeth Rostan, M.D., a cosmetic dermatologist in Charlotte, N.C. "In my community, I can't give away a CO₂ laser resurfacing."

Most of Dr. Rostan's fractional resurfacing patients are women who want treatment for photoaging, acne scars, or melasma. "Many of these patients are the ones for whom you might consider intense pulsed light. It would burn off the pigmentary lesions, but it would not give you the same improvement you see in fine wrinkling."

In terms of both efficacy and recovery, fractional resurfacing falls between nonablative and ablative techniques.

"The results we get are better than what we would see with a nonablative technique, but not quite as good as what we would see with an ablative resurfacing," she said. "However, with the fractional resurfacing, patients aren't experiencing the 2 weeks of downtime that they would with a CO₂ laser resurfacing, either."

The device directs its energy along the path of a computer-generated pattern, producing about 2,000 tiny holes (microthermal injury zones) per square centimeter. Because the areas of injury are so tiny, "you are treating about 20% of the skin surface, leaving 80% to renew and heal," Dr. Rostan said.

The laser intensity can be varied for different applications. The 8-J/cm

Patients require a topical anesthetic, which takes about 1 hour to achieve maximum effect. The actual resurfacing procedure lasts about 20 minutes, she said. However, three to five treatments, spaced about a week apart, are usually necessary to achieve the desired result.

Afterward, there is mild erythema and edema. "Patients are usually pink for 2 days, but it can sometimes last as long as 4 days," Dr. Rostan said. "But they can easily cover it with makeup and be back to work the day after the procedure."

Fractional resurfacing is also a good alternative for elderly patients or for those with health issues that might compromise wound healing in an ablative resurfacing, she said. "I've done a healthy 87-year-old, as well as a transplant patient, with no adverse effects."

But she said she would carefully consider patients with scleroderma or rheumatoid problems. "Anyone who you'd have concerns about for laser resurfacing, you would also have to think about for fractional resurfacing."

The in-office erbium laser provides a one-time minimally ablative resurfacing with results similar to a whole course of intense fractional resurfacing, said James Newman, M.D., a facial plastic surgeon from San Mateo, Calif.

"I began using office-based laser treatments in response to patients' wanting a treatment without much downtime or prolonged healing, but who also didn't want to come into the office four or five times to treat a brown spot," he said.

The small erbium lasers are also relatively inexpensive (about $30,000), which allows the physician to rapidly recoup the investment and offer patients a modestly priced treatment. "For the removal of brown spots from the face or hands, it would be about $300, and for a perioral regional resurfacing, maybe $1,000 or less," he said.

The small, portable lasers have lower fluences (about 5–7 J/cm

"They also have a pulse duration of about 300 milliseconds, and because they are lower powered, they can't go as fast. The maximum repetition rate is about 2 Hz," Dr. Newman said.

This makes the in-office erbium laser good for localized or regional (perioral or periorbital) resurfacing, but not appropriate for a full-face procedure, he said.

The main indications for this device are solar lentigines, early elastosis of periorbital skin, sebaceous hyperplasia, scar modification, and epidermal keratosis, Dr. Newman said. Downtime is 4–7 days, "similar to what you would expect with intense fractional resurfacing or a medium-depth chemical peel."

"If they can come in and get it over with in one treatment, and then put up with a week at most of healing, patients will be very happy with this," he said.

The plasma resurfacer gives similar results, without the epidermal sloughing that the erbium laser generates, said Edgar Fincher, M.D., a dermatologic surgeon in Los Angeles.

These devices feature a nitrogen canister that pumps the gas into a handpiece, where a radiofrequency generator heats it and delivers it through a nozzle to the skin surface. They can deliver energy ranging from 1 to 4 J/cm

Like a CO₂ or erbium laser, the plasma resurfacer causes an immediate zone of thermal damage, with heat dissipation into the deeper tissues, stimulating fibroblast action.

The difference with the plasma resurfacer, Dr. Fincher said, is that the lower fluences preserve the epidermis until reepithelialization is complete. "It does not vaporize the epidermis, which accelerates wound healing. About 4 days later, you have reepithelialization and necrotic keratinocytes moving up and beginning to slough." By day 10, histology shows a fully reformed stratified epidermis and increased number of active fibroblasts generating collagen, he said.

These devices have received Food and Drug Administration approval for use in single-pass, low-energy repeat treatments and single-pass, high-energy treatment of facial rhytids, and for the treatment of superficial skin lesions.

Dr. Fincher has used a plasma resurfacer for about 2 years, with no incidence of scarring or hypopigmentation. He has seen some transient hyperpigmentation, however, and two patients have had prolonged (4–6 weeks) erythema.

"We tell people that, pretty reliably, they will be back to normal in 10 days," he said.

A full-face treatment can be done in about 15 minutes. Patients who are being treated for dyschromia or photodamage will probably require two or three treatments about 1 month apart. These low-energy treatments are usually performed with a topical anesthetic, although nerve blocks may be necessary for some patients. The high-energy treatments necessary for treating acne scars usually require local anesthetic or IV sedation.

"We still have a CO₂ laser and use it occasionally, but this has replaced it as our workhorse resurfacing device," Dr. Fincher said.

LOS ANGELES — Non- or minimally ablative facial resurfacing offers patients the results they desire without extended downtime, said several presenters at the annual fall meeting of the American Academy of Facial Plastic and Reconstructive Surgery.

"Most of my patients want nonsurgical treatments with no downtime," said Elizabeth Rostan, M.D., a cosmetic dermatologist in Charlotte, N.C. "In my community, I can't give away a CO₂ laser resurfacing."

Most of Dr. Rostan's fractional resurfacing patients are women who want treatment for photoaging, acne scars, or melasma. "Many of these patients are the ones for whom you might consider intense pulsed light. It would burn off the pigmentary lesions, but it would not give you the same improvement you see in fine wrinkling."

In terms of both efficacy and recovery, fractional resurfacing falls between nonablative and ablative techniques.

"The results we get are better than what we would see with a nonablative technique, but not quite as good as what we would see with an ablative resurfacing," she said. "However, with the fractional resurfacing, patients aren't experiencing the 2 weeks of downtime that they would with a CO₂ laser resurfacing, either."

The device directs its energy along the path of a computer-generated pattern, producing about 2,000 tiny holes (microthermal injury zones) per square centimeter. Because the areas of injury are so tiny, "you are treating about 20% of the skin surface, leaving 80% to renew and heal," Dr. Rostan said.

The laser intensity can be varied for different applications. The 8-J/cm

Patients require a topical anesthetic, which takes about 1 hour to achieve maximum effect. The actual resurfacing procedure lasts about 20 minutes, she said. However, three to five treatments, spaced about a week apart, are usually necessary to achieve the desired result.

Afterward, there is mild erythema and edema. "Patients are usually pink for 2 days, but it can sometimes last as long as 4 days," Dr. Rostan said. "But they can easily cover it with makeup and be back to work the day after the procedure."

Fractional resurfacing is also a good alternative for elderly patients or for those with health issues that might compromise wound healing in an ablative resurfacing, she said. "I've done a healthy 87-year-old, as well as a transplant patient, with no adverse effects."

But she said she would carefully consider patients with scleroderma or rheumatoid problems. "Anyone who you'd have concerns about for laser resurfacing, you would also have to think about for fractional resurfacing."

The in-office erbium laser provides a one-time minimally ablative resurfacing with results similar to a whole course of intense fractional resurfacing, said James Newman, M.D., a facial plastic surgeon from San Mateo, Calif.

"I began using office-based laser treatments in response to patients' wanting a treatment without much downtime or prolonged healing, but who also didn't want to come into the office four or five times to treat a brown spot," he said.

The small erbium lasers are also relatively inexpensive (about $30,000), which allows the physician to rapidly recoup the investment and offer patients a modestly priced treatment. "For the removal of brown spots from the face or hands, it would be about $300, and for a perioral regional resurfacing, maybe $1,000 or less," he said.

The small, portable lasers have lower fluences (about 5–7 J/cm

"They also have a pulse duration of about 300 milliseconds, and because they are lower powered, they can't go as fast. The maximum repetition rate is about 2 Hz," Dr. Newman said.

This makes the in-office erbium laser good for localized or regional (perioral or periorbital) resurfacing, but not appropriate for a full-face procedure, he said.

The main indications for this device are solar lentigines, early elastosis of periorbital skin, sebaceous hyperplasia, scar modification, and epidermal keratosis, Dr. Newman said. Downtime is 4–7 days, "similar to what you would expect with intense fractional resurfacing or a medium-depth chemical peel."

"If they can come in and get it over with in one treatment, and then put up with a week at most of healing, patients will be very happy with this," he said.

The plasma resurfacer gives similar results, without the epidermal sloughing that the erbium laser generates, said Edgar Fincher, M.D., a dermatologic surgeon in Los Angeles.

These devices feature a nitrogen canister that pumps the gas into a handpiece, where a radiofrequency generator heats it and delivers it through a nozzle to the skin surface. They can deliver energy ranging from 1 to 4 J/cm

Like a CO₂ or erbium laser, the plasma resurfacer causes an immediate zone of thermal damage, with heat dissipation into the deeper tissues, stimulating fibroblast action.

The difference with the plasma resurfacer, Dr. Fincher said, is that the lower fluences preserve the epidermis until reepithelialization is complete. "It does not vaporize the epidermis, which accelerates wound healing. About 4 days later, you have reepithelialization and necrotic keratinocytes moving up and beginning to slough." By day 10, histology shows a fully reformed stratified epidermis and increased number of active fibroblasts generating collagen, he said.

These devices have received Food and Drug Administration approval for use in single-pass, low-energy repeat treatments and single-pass, high-energy treatment of facial rhytids, and for the treatment of superficial skin lesions.

Dr. Fincher has used a plasma resurfacer for about 2 years, with no incidence of scarring or hypopigmentation. He has seen some transient hyperpigmentation, however, and two patients have had prolonged (4–6 weeks) erythema.

"We tell people that, pretty reliably, they will be back to normal in 10 days," he said.

A full-face treatment can be done in about 15 minutes. Patients who are being treated for dyschromia or photodamage will probably require two or three treatments about 1 month apart. These low-energy treatments are usually performed with a topical anesthetic, although nerve blocks may be necessary for some patients. The high-energy treatments necessary for treating acne scars usually require local anesthetic or IV sedation.

"We still have a CO₂ laser and use it occasionally, but this has replaced it as our workhorse resurfacing device," Dr. Fincher said.