Mental Health

Last summer, back when people traveled, I had the pleasure of being in Amsterdam for Pride Week. With a half-million tourists, it was a colorful and costumed display of LGBTQ pride, and both the streets and canals had celebrations with food, drinks, music, and displays beyond anything I could describe.

It was all not that long ago that the American Psychiatric Association classified homosexuality as a psychiatric disorder. Now we have Pride celebrations, and I don’t think twice about mentioning my brother-in-law’s husband, or a female colleague’s wife, nor am I shocked when I hear that the children of my friends are in the process of gender transition. Obviously, the idea that people express both their gender and their sexuality in diverse ways is not accepted by everyone, but we’ve come a long way toward acceptance of people who were once stigmatized and pathologized. I’ll also point out that this shift occurred despite the fact that the gay community was affected by AIDS.

There are many other differences – and illnesses – that our society has come to either accept or sympathize with more graciously over time, and yet both mental illness and substance abuse disorders remain stigmatized and punished. To put it bluntly, we have done a terrible job of making these conditions acceptable illnesses to have, even though we have done a reasonably good job of offering effective treatments. Cancer no longer carries the stigma it once did, even though cancer is a leading cause of death, and the treatments are painful, toxic, and may include the loss of body parts and hair. But if you become ill with cancer, your friends bring casseroles (or perhaps rotisserie chickens), and if you’re hospitalized with bipolar disorder or check into a drug treatment center, you’re more likely to be the recipient of judgment and even scorn.

We have to fix this. We talk about the need to destigmatize mental illness and substance use disorders, and to make these illnesses more on par with other diseases. Maybe that is the wrong call: These disorders sometimes cause people to behave in disruptive, dangerous, and illegal ways that we don’t often see with other illnesses. Frankly psychotic people may be seen as “other,” they may smell bad, they may behave in bizarre ways, and they may be frightening. Their rare acts of violence have been publicized so much that “He’s mentally ill” is accepted by the public as a full explanation for why someone would commit a mass shooting. Depression can cause people to be irritable and unpleasant, and our society equates a lack of motivation with laziness. While people may have sympathy for the suicidal thoughts and feelings of others, completed suicide leaves behind devastated survivors. People with substance use problems may become belligerent or commit crimes to support their addictions. In 2018, over 10,500 people were killed by drivers who were impaired by alcohol. I’m not sure how we destigmatize these conditions, but commercials, billboards, and educational programs aren’t doing it.
 

Fears around treatment

Perhaps our efforts need to go toward destigmatizing treatment. It is shocking to me how resistant people are to getting help, or having others know they are getting help, when treatment often renders them free from the psychological agony or misbehaviors caused by their condition.

Since I work in an outpatient setting, I see people who have made it beyond the barrier of seeking help. Almost all of my patients are willing to try medications – there is self-selection among those who chose to see a psychiatrist as opposed to another type of psychotherapist. I also believe that direct-to-consumer advertising has helped normalize the use of psychotropic medications.

When it comes to getting a higher level of care, however, the conversations are so much harder. Many of my patients insist they will never be admitted to a psychiatric unit, and when I ask depressed people if they are having suicidal thoughts, some tell me they are afraid to let me know they are for fear I might hospitalize them. This fear of hospitalization is present in people who have never been in a hospital and have only media depictions or their imaginations to go by, but I also see this with patients who have previously been hospitalized and have emerged from their inpatient stays feeling much better. While we know that any type of hospitalization involves a loss of control, unpleasant moments, and sometimes painful procedures, I have never heard anyone say that, if they were to have a second heart attack, they would refuse an admission to the cardiac care unit.

Discussions about treatment for substance use are even more difficult. People with addictions often don’t want to abstain from the substance they are using, and this is an enormous hurdle. Beyond that, they don’t like the labels that come with acknowledging a problem – words like “junkie,” “addict,” “drunk,” and “alcoholic” are hard to escape.

People fear hospitalization for many reasons: They fear losing control, they don’t recognize that they have a problem, or they rationalize their psychosis or substance use as normal. Most of all, they fear what others will think of them and what repercussions this will have for their futures. Patients would rather continue in a state of agony and dysfunction when inpatient treatment would make them better faster. This is nothing short of tragic.

What can we do? The answer is “a lot.” We need to work harder to make the hospital experience a pleasant one for patients. Inpatient units need to be clean, safe places where patients are treated with kindness, dignity, and respect and activities are appropriate, interesting, and promote healing.

Maria, a Maryland attorney, told me about her experience with inpatient treatment. “I experienced my hospitalization as jailing and acutely felt the loss of liberty, especially in the ER, where I was confined to something I recognized from my time visiting incarcerated and detained people as a holding cell, complete with a uniformed guard. I was scared to engage in any kind of meaningful self-advocacy around leaving out of fear for my license to practice law and of lengthening my time as an inpatient. As a result, I found myself concentrating on getting out, and not on getting well. With the benefit of hindsight, I can say now that my hospitalization was a lost opportunity, and the coercive elements were barriers to accessing the treatment that I needed, both at the time and in the years following the hospitalization.”

We have too many policies in place where infractions are met with force, seclusion, and sometimes restraint, and we need to be more flexible with these policies. If a psychiatric unit requires lab work prior to admission and the patient refuses, should force be used in the emergency department if there is nothing to indicate that the patient’s health is in imminent danger? And if the hospital has a policy that all psychiatric patients must disrobe to be examined for preexisting scars or contraband – this is an admission standard for some hospitals, but not others – and the patient refuses, what then? Typically, inpatients are not allowed access to their cell phones or the Internet (for many good reasons), but patients find this very upsetting; might it make sense to allow periods where they can use devices with supervision? Hospitals often forbid smoking, and people with psychiatric disorders may smoke – while it is a wonderful health ideal, is it reasonable to forbid smoking for the course of a hospitalization? Rigid adherence to policies does not always serve our patients well, and it sometimes creates dangerous situations for everyone.

We must work to get questions about psychiatric and substance use disorders removed from any job- or licensure-related forms. There is no reason to believe that people answer these forms truthfully or that including these questions protects the public in any way. What we do know is that people don’t seek help because they, like Maria, are afraid of the consequences of getting care. It doesn’t matter if a surgeon’s abilities are limited because he has episodes of hypoglycemia or past episodes of mania, and the only question on licensing forms should be about current conditions that impair the ability to work. Every district branch of the American Psychiatric Association should be actively speaking with their state professional licensing boards about the harm these questions do.

We need better treatments that have fewer side effects, and we need to acknowledge that, while getting help is the right thing to do, not everyone finds the right treatment with the first attempt and not everyone gets better. Our party line to those who feel suicidal has been “Get Help,” often with a phone number for the National Suicide Prevention Lifeline. While this is an important resource to have readily available, many of the people who die of suicide are already in active treatment. Our party line needs to change to “Get Help, and if it isn’t working, Get Different Help.” We want to be careful that our messaging does not foster a sense of hopelessness in those who have sought care and still suffer.

It’s good to talk about the potential benefits of treatment, but we don’t have enough beds and we don’t have enough mental health clinicians. There are states where psychiatric patients who have committed no crime are held in jail cells while they wait for beds to open – that we allow this is nothing short of a disgrace. The sickest patients with treatment-resistant conditions need access to the best care, and that access should not be limited by finances or networks. And while I’m here: We need our mental health professionals to spend their time working with patients, not computer screens, check boxes, and prior authorization protocols.

Finally, we need to work with the media to show positive and accurate depictions of psychiatric treatment as something that helps. We are still undoing the harm of Nurse Ratched and the depiction of electroconvulsive therapy in the 1975 film “One Flew Over the Cuckoo’s Nest,” and the current focus on mental illness and violence does nothing to help people feel comfortable seeking care.

I’ll end with one more thought from Maria: “Mental health professionals need to talk about hospitalization up front, no matter how uncomfortable, and encourage patients to think about hospitalization as a treatment option on a continuum before it is needed, so they are not approaching hospitalization as an abstract concept, often with a lot of fear and stigma attached to it, but rather as an option that they might explore in a fact-based way.”
 

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, both in Baltimore. She reported having nothing to disclose.

Last summer, back when people traveled, I had the pleasure of being in Amsterdam for Pride Week. With a half-million tourists, it was a colorful and costumed display of LGBTQ pride, and both the streets and canals had celebrations with food, drinks, music, and displays beyond anything I could describe.

It was all not that long ago that the American Psychiatric Association classified homosexuality as a psychiatric disorder. Now we have Pride celebrations, and I don’t think twice about mentioning my brother-in-law’s husband, or a female colleague’s wife, nor am I shocked when I hear that the children of my friends are in the process of gender transition. Obviously, the idea that people express both their gender and their sexuality in diverse ways is not accepted by everyone, but we’ve come a long way toward acceptance of people who were once stigmatized and pathologized. I’ll also point out that this shift occurred despite the fact that the gay community was affected by AIDS.

There are many other differences – and illnesses – that our society has come to either accept or sympathize with more graciously over time, and yet both mental illness and substance abuse disorders remain stigmatized and punished. To put it bluntly, we have done a terrible job of making these conditions acceptable illnesses to have, even though we have done a reasonably good job of offering effective treatments. Cancer no longer carries the stigma it once did, even though cancer is a leading cause of death, and the treatments are painful, toxic, and may include the loss of body parts and hair. But if you become ill with cancer, your friends bring casseroles (or perhaps rotisserie chickens), and if you’re hospitalized with bipolar disorder or check into a drug treatment center, you’re more likely to be the recipient of judgment and even scorn.

We have to fix this. We talk about the need to destigmatize mental illness and substance use disorders, and to make these illnesses more on par with other diseases. Maybe that is the wrong call: These disorders sometimes cause people to behave in disruptive, dangerous, and illegal ways that we don’t often see with other illnesses. Frankly psychotic people may be seen as “other,” they may smell bad, they may behave in bizarre ways, and they may be frightening. Their rare acts of violence have been publicized so much that “He’s mentally ill” is accepted by the public as a full explanation for why someone would commit a mass shooting. Depression can cause people to be irritable and unpleasant, and our society equates a lack of motivation with laziness. While people may have sympathy for the suicidal thoughts and feelings of others, completed suicide leaves behind devastated survivors. People with substance use problems may become belligerent or commit crimes to support their addictions. In 2018, over 10,500 people were killed by drivers who were impaired by alcohol. I’m not sure how we destigmatize these conditions, but commercials, billboards, and educational programs aren’t doing it.
 

Fears around treatment

Perhaps our efforts need to go toward destigmatizing treatment. It is shocking to me how resistant people are to getting help, or having others know they are getting help, when treatment often renders them free from the psychological agony or misbehaviors caused by their condition.

Since I work in an outpatient setting, I see people who have made it beyond the barrier of seeking help. Almost all of my patients are willing to try medications – there is self-selection among those who chose to see a psychiatrist as opposed to another type of psychotherapist. I also believe that direct-to-consumer advertising has helped normalize the use of psychotropic medications.

When it comes to getting a higher level of care, however, the conversations are so much harder. Many of my patients insist they will never be admitted to a psychiatric unit, and when I ask depressed people if they are having suicidal thoughts, some tell me they are afraid to let me know they are for fear I might hospitalize them. This fear of hospitalization is present in people who have never been in a hospital and have only media depictions or their imaginations to go by, but I also see this with patients who have previously been hospitalized and have emerged from their inpatient stays feeling much better. While we know that any type of hospitalization involves a loss of control, unpleasant moments, and sometimes painful procedures, I have never heard anyone say that, if they were to have a second heart attack, they would refuse an admission to the cardiac care unit.

Discussions about treatment for substance use are even more difficult. People with addictions often don’t want to abstain from the substance they are using, and this is an enormous hurdle. Beyond that, they don’t like the labels that come with acknowledging a problem – words like “junkie,” “addict,” “drunk,” and “alcoholic” are hard to escape.

People fear hospitalization for many reasons: They fear losing control, they don’t recognize that they have a problem, or they rationalize their psychosis or substance use as normal. Most of all, they fear what others will think of them and what repercussions this will have for their futures. Patients would rather continue in a state of agony and dysfunction when inpatient treatment would make them better faster. This is nothing short of tragic.

What can we do? The answer is “a lot.” We need to work harder to make the hospital experience a pleasant one for patients. Inpatient units need to be clean, safe places where patients are treated with kindness, dignity, and respect and activities are appropriate, interesting, and promote healing.

Maria, a Maryland attorney, told me about her experience with inpatient treatment. “I experienced my hospitalization as jailing and acutely felt the loss of liberty, especially in the ER, where I was confined to something I recognized from my time visiting incarcerated and detained people as a holding cell, complete with a uniformed guard. I was scared to engage in any kind of meaningful self-advocacy around leaving out of fear for my license to practice law and of lengthening my time as an inpatient. As a result, I found myself concentrating on getting out, and not on getting well. With the benefit of hindsight, I can say now that my hospitalization was a lost opportunity, and the coercive elements were barriers to accessing the treatment that I needed, both at the time and in the years following the hospitalization.”

We have too many policies in place where infractions are met with force, seclusion, and sometimes restraint, and we need to be more flexible with these policies. If a psychiatric unit requires lab work prior to admission and the patient refuses, should force be used in the emergency department if there is nothing to indicate that the patient’s health is in imminent danger? And if the hospital has a policy that all psychiatric patients must disrobe to be examined for preexisting scars or contraband – this is an admission standard for some hospitals, but not others – and the patient refuses, what then? Typically, inpatients are not allowed access to their cell phones or the Internet (for many good reasons), but patients find this very upsetting; might it make sense to allow periods where they can use devices with supervision? Hospitals often forbid smoking, and people with psychiatric disorders may smoke – while it is a wonderful health ideal, is it reasonable to forbid smoking for the course of a hospitalization? Rigid adherence to policies does not always serve our patients well, and it sometimes creates dangerous situations for everyone.

We must work to get questions about psychiatric and substance use disorders removed from any job- or licensure-related forms. There is no reason to believe that people answer these forms truthfully or that including these questions protects the public in any way. What we do know is that people don’t seek help because they, like Maria, are afraid of the consequences of getting care. It doesn’t matter if a surgeon’s abilities are limited because he has episodes of hypoglycemia or past episodes of mania, and the only question on licensing forms should be about current conditions that impair the ability to work. Every district branch of the American Psychiatric Association should be actively speaking with their state professional licensing boards about the harm these questions do.

We need better treatments that have fewer side effects, and we need to acknowledge that, while getting help is the right thing to do, not everyone finds the right treatment with the first attempt and not everyone gets better. Our party line to those who feel suicidal has been “Get Help,” often with a phone number for the National Suicide Prevention Lifeline. While this is an important resource to have readily available, many of the people who die of suicide are already in active treatment. Our party line needs to change to “Get Help, and if it isn’t working, Get Different Help.” We want to be careful that our messaging does not foster a sense of hopelessness in those who have sought care and still suffer.

It’s good to talk about the potential benefits of treatment, but we don’t have enough beds and we don’t have enough mental health clinicians. There are states where psychiatric patients who have committed no crime are held in jail cells while they wait for beds to open – that we allow this is nothing short of a disgrace. The sickest patients with treatment-resistant conditions need access to the best care, and that access should not be limited by finances or networks. And while I’m here: We need our mental health professionals to spend their time working with patients, not computer screens, check boxes, and prior authorization protocols.

Finally, we need to work with the media to show positive and accurate depictions of psychiatric treatment as something that helps. We are still undoing the harm of Nurse Ratched and the depiction of electroconvulsive therapy in the 1975 film “One Flew Over the Cuckoo’s Nest,” and the current focus on mental illness and violence does nothing to help people feel comfortable seeking care.

I’ll end with one more thought from Maria: “Mental health professionals need to talk about hospitalization up front, no matter how uncomfortable, and encourage patients to think about hospitalization as a treatment option on a continuum before it is needed, so they are not approaching hospitalization as an abstract concept, often with a lot of fear and stigma attached to it, but rather as an option that they might explore in a fact-based way.”
 

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, both in Baltimore. She reported having nothing to disclose.

Last summer, back when people traveled, I had the pleasure of being in Amsterdam for Pride Week. With a half-million tourists, it was a colorful and costumed display of LGBTQ pride, and both the streets and canals had celebrations with food, drinks, music, and displays beyond anything I could describe.

It was all not that long ago that the American Psychiatric Association classified homosexuality as a psychiatric disorder. Now we have Pride celebrations, and I don’t think twice about mentioning my brother-in-law’s husband, or a female colleague’s wife, nor am I shocked when I hear that the children of my friends are in the process of gender transition. Obviously, the idea that people express both their gender and their sexuality in diverse ways is not accepted by everyone, but we’ve come a long way toward acceptance of people who were once stigmatized and pathologized. I’ll also point out that this shift occurred despite the fact that the gay community was affected by AIDS.

There are many other differences – and illnesses – that our society has come to either accept or sympathize with more graciously over time, and yet both mental illness and substance abuse disorders remain stigmatized and punished. To put it bluntly, we have done a terrible job of making these conditions acceptable illnesses to have, even though we have done a reasonably good job of offering effective treatments. Cancer no longer carries the stigma it once did, even though cancer is a leading cause of death, and the treatments are painful, toxic, and may include the loss of body parts and hair. But if you become ill with cancer, your friends bring casseroles (or perhaps rotisserie chickens), and if you’re hospitalized with bipolar disorder or check into a drug treatment center, you’re more likely to be the recipient of judgment and even scorn.

We have to fix this. We talk about the need to destigmatize mental illness and substance use disorders, and to make these illnesses more on par with other diseases. Maybe that is the wrong call: These disorders sometimes cause people to behave in disruptive, dangerous, and illegal ways that we don’t often see with other illnesses. Frankly psychotic people may be seen as “other,” they may smell bad, they may behave in bizarre ways, and they may be frightening. Their rare acts of violence have been publicized so much that “He’s mentally ill” is accepted by the public as a full explanation for why someone would commit a mass shooting. Depression can cause people to be irritable and unpleasant, and our society equates a lack of motivation with laziness. While people may have sympathy for the suicidal thoughts and feelings of others, completed suicide leaves behind devastated survivors. People with substance use problems may become belligerent or commit crimes to support their addictions. In 2018, over 10,500 people were killed by drivers who were impaired by alcohol. I’m not sure how we destigmatize these conditions, but commercials, billboards, and educational programs aren’t doing it.
 

Fears around treatment

Perhaps our efforts need to go toward destigmatizing treatment. It is shocking to me how resistant people are to getting help, or having others know they are getting help, when treatment often renders them free from the psychological agony or misbehaviors caused by their condition.

Since I work in an outpatient setting, I see people who have made it beyond the barrier of seeking help. Almost all of my patients are willing to try medications – there is self-selection among those who chose to see a psychiatrist as opposed to another type of psychotherapist. I also believe that direct-to-consumer advertising has helped normalize the use of psychotropic medications.

When it comes to getting a higher level of care, however, the conversations are so much harder. Many of my patients insist they will never be admitted to a psychiatric unit, and when I ask depressed people if they are having suicidal thoughts, some tell me they are afraid to let me know they are for fear I might hospitalize them. This fear of hospitalization is present in people who have never been in a hospital and have only media depictions or their imaginations to go by, but I also see this with patients who have previously been hospitalized and have emerged from their inpatient stays feeling much better. While we know that any type of hospitalization involves a loss of control, unpleasant moments, and sometimes painful procedures, I have never heard anyone say that, if they were to have a second heart attack, they would refuse an admission to the cardiac care unit.

Discussions about treatment for substance use are even more difficult. People with addictions often don’t want to abstain from the substance they are using, and this is an enormous hurdle. Beyond that, they don’t like the labels that come with acknowledging a problem – words like “junkie,” “addict,” “drunk,” and “alcoholic” are hard to escape.

People fear hospitalization for many reasons: They fear losing control, they don’t recognize that they have a problem, or they rationalize their psychosis or substance use as normal. Most of all, they fear what others will think of them and what repercussions this will have for their futures. Patients would rather continue in a state of agony and dysfunction when inpatient treatment would make them better faster. This is nothing short of tragic.

What can we do? The answer is “a lot.” We need to work harder to make the hospital experience a pleasant one for patients. Inpatient units need to be clean, safe places where patients are treated with kindness, dignity, and respect and activities are appropriate, interesting, and promote healing.

Maria, a Maryland attorney, told me about her experience with inpatient treatment. “I experienced my hospitalization as jailing and acutely felt the loss of liberty, especially in the ER, where I was confined to something I recognized from my time visiting incarcerated and detained people as a holding cell, complete with a uniformed guard. I was scared to engage in any kind of meaningful self-advocacy around leaving out of fear for my license to practice law and of lengthening my time as an inpatient. As a result, I found myself concentrating on getting out, and not on getting well. With the benefit of hindsight, I can say now that my hospitalization was a lost opportunity, and the coercive elements were barriers to accessing the treatment that I needed, both at the time and in the years following the hospitalization.”

We have too many policies in place where infractions are met with force, seclusion, and sometimes restraint, and we need to be more flexible with these policies. If a psychiatric unit requires lab work prior to admission and the patient refuses, should force be used in the emergency department if there is nothing to indicate that the patient’s health is in imminent danger? And if the hospital has a policy that all psychiatric patients must disrobe to be examined for preexisting scars or contraband – this is an admission standard for some hospitals, but not others – and the patient refuses, what then? Typically, inpatients are not allowed access to their cell phones or the Internet (for many good reasons), but patients find this very upsetting; might it make sense to allow periods where they can use devices with supervision? Hospitals often forbid smoking, and people with psychiatric disorders may smoke – while it is a wonderful health ideal, is it reasonable to forbid smoking for the course of a hospitalization? Rigid adherence to policies does not always serve our patients well, and it sometimes creates dangerous situations for everyone.

We must work to get questions about psychiatric and substance use disorders removed from any job- or licensure-related forms. There is no reason to believe that people answer these forms truthfully or that including these questions protects the public in any way. What we do know is that people don’t seek help because they, like Maria, are afraid of the consequences of getting care. It doesn’t matter if a surgeon’s abilities are limited because he has episodes of hypoglycemia or past episodes of mania, and the only question on licensing forms should be about current conditions that impair the ability to work. Every district branch of the American Psychiatric Association should be actively speaking with their state professional licensing boards about the harm these questions do.

We need better treatments that have fewer side effects, and we need to acknowledge that, while getting help is the right thing to do, not everyone finds the right treatment with the first attempt and not everyone gets better. Our party line to those who feel suicidal has been “Get Help,” often with a phone number for the National Suicide Prevention Lifeline. While this is an important resource to have readily available, many of the people who die of suicide are already in active treatment. Our party line needs to change to “Get Help, and if it isn’t working, Get Different Help.” We want to be careful that our messaging does not foster a sense of hopelessness in those who have sought care and still suffer.

It’s good to talk about the potential benefits of treatment, but we don’t have enough beds and we don’t have enough mental health clinicians. There are states where psychiatric patients who have committed no crime are held in jail cells while they wait for beds to open – that we allow this is nothing short of a disgrace. The sickest patients with treatment-resistant conditions need access to the best care, and that access should not be limited by finances or networks. And while I’m here: We need our mental health professionals to spend their time working with patients, not computer screens, check boxes, and prior authorization protocols.

Finally, we need to work with the media to show positive and accurate depictions of psychiatric treatment as something that helps. We are still undoing the harm of Nurse Ratched and the depiction of electroconvulsive therapy in the 1975 film “One Flew Over the Cuckoo’s Nest,” and the current focus on mental illness and violence does nothing to help people feel comfortable seeking care.

I’ll end with one more thought from Maria: “Mental health professionals need to talk about hospitalization up front, no matter how uncomfortable, and encourage patients to think about hospitalization as a treatment option on a continuum before it is needed, so they are not approaching hospitalization as an abstract concept, often with a lot of fear and stigma attached to it, but rather as an option that they might explore in a fact-based way.”
 

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, both in Baltimore. She reported having nothing to disclose.

Adjunctive pimavanserin brought clinically meaningful improvement in patients with anxious major depressive disorder inadequately responsive to standard antidepressants alone in a post hoc analysis of the CLARITY trial, Bryan Dirks, MD, reported at the virtual congress of the European College of Neuropsychopharmacology.

This is an intriguing observation, because it’s estimated that roughly 50% of individuals with major depressive disorder (MDD) have comorbid anxiety disorders or a high level of anxiety symptoms. Moreover, anxious depression has been associated with increased risk of suicidality, high unemployment, and impaired functioning.

CLARITY was a phase 2, multicenter, randomized, double-blind, placebo-controlled clinical trial whose positive results for the primary outcome have been published (J Clin Psychiatry. 2019 Sep 24;80[6]:19m12928. doi: 10.4088/JCP.19m12928). Because the encouraging findings regarding pimavanserin’s impact on anxious depression came from a post hoc analysis, the results need replication. That’s ongoing in a phase 3 trial of adjunctive pimavanserin versus placebo in patients with MDD, according to Dr. Dirks, director of clinical research at Acadia Pharmaceuticals, San Diego.

The CLARITY post hoc analysis included 104 patients with baseline MDD inadequately responsive to an SSRI or a serotonin norepinephrine reuptake inhibitor and anxious depression as defined by a Hamilton Depression Rating Scale (HAMD-17) anxiety/somatization factor subscale score of 7 or more. Twenty-nine of the patients were randomized to 34 mg of adjunctive oral pimavanserin once daily, and 75 to placebo. At 5 weeks, the HAMD-17 anxiety/somatization factor score in the pimavanserin group had dropped by a mean of 5 points from a baseline of 8.8, a significantly greater effect than the 2.8-point drop in placebo-treated controls.

By week 5, the treatment response rate as defined by at least a 50% reduction in HAMD-17 total score from baseline was 55% with pimavanserin and 22% with placebo. The remission rate as indicated by a HAMD-17 total score below 7 was 24% in the pimavanserin group, compared with 5% with placebo. These results translated into an effect size of 0.78, considered by statisticians to be on the border between medium and large. Those response and remission rates in patients with anxious depression were higher with pimavanserin and lower with placebo than in the overall CLARITY trial.

The impact of adjunctive pimavanserin on top of a background SSRI or SNRI was even more pronounced in the subgroup of patients with baseline severe MDD as defined by a HAMD-17 total score of 24 or more plus an anxiety/somatization factor score of 7 or greater. Seventeen such patients were randomized to adjunctive pimavanserin, 36 to placebo. At 5 weeks, the mean HAMD total score had dropped by 17.4 points from a baseline of 27.6 in the pimavanserin group, compared with a 9.3-point reduction in controls.

“Of note, significant differences from placebo were observed as early as week 2 with pimavanserin,” Dr. Dirks said.

Pimavanserin is a novel selective serotonin inverse agonist with a high affinity for 5-HT2A receptors and low affinity for 5-HT2C receptors. At present pimavanserin is Food Drug Administration–approved as Nuplazid only for treatment of hallucinations and delusions associated with Parkinson’s disease psychosis, but because of the drug’s unique mechanism of action it is under study for a variety of other mental disorders. Indeed, pimavanserin is now under FDA review for a possible expanded indication for treatment of dementia-related psychosis. The drug is also under study for schizophrenia as well as for MDD.

The CLARITY trial and this post hoc analysis were sponsored by Acadia Pharmaceuticals.

bjancin@mdedge.com

SOURCE: Dirks B. ECNP 2020. Abstract P 094.

Adjunctive pimavanserin brought clinically meaningful improvement in patients with anxious major depressive disorder inadequately responsive to standard antidepressants alone in a post hoc analysis of the CLARITY trial, Bryan Dirks, MD, reported at the virtual congress of the European College of Neuropsychopharmacology.

This is an intriguing observation, because it’s estimated that roughly 50% of individuals with major depressive disorder (MDD) have comorbid anxiety disorders or a high level of anxiety symptoms. Moreover, anxious depression has been associated with increased risk of suicidality, high unemployment, and impaired functioning.

CLARITY was a phase 2, multicenter, randomized, double-blind, placebo-controlled clinical trial whose positive results for the primary outcome have been published (J Clin Psychiatry. 2019 Sep 24;80[6]:19m12928. doi: 10.4088/JCP.19m12928). Because the encouraging findings regarding pimavanserin’s impact on anxious depression came from a post hoc analysis, the results need replication. That’s ongoing in a phase 3 trial of adjunctive pimavanserin versus placebo in patients with MDD, according to Dr. Dirks, director of clinical research at Acadia Pharmaceuticals, San Diego.

The CLARITY post hoc analysis included 104 patients with baseline MDD inadequately responsive to an SSRI or a serotonin norepinephrine reuptake inhibitor and anxious depression as defined by a Hamilton Depression Rating Scale (HAMD-17) anxiety/somatization factor subscale score of 7 or more. Twenty-nine of the patients were randomized to 34 mg of adjunctive oral pimavanserin once daily, and 75 to placebo. At 5 weeks, the HAMD-17 anxiety/somatization factor score in the pimavanserin group had dropped by a mean of 5 points from a baseline of 8.8, a significantly greater effect than the 2.8-point drop in placebo-treated controls.

By week 5, the treatment response rate as defined by at least a 50% reduction in HAMD-17 total score from baseline was 55% with pimavanserin and 22% with placebo. The remission rate as indicated by a HAMD-17 total score below 7 was 24% in the pimavanserin group, compared with 5% with placebo. These results translated into an effect size of 0.78, considered by statisticians to be on the border between medium and large. Those response and remission rates in patients with anxious depression were higher with pimavanserin and lower with placebo than in the overall CLARITY trial.

The impact of adjunctive pimavanserin on top of a background SSRI or SNRI was even more pronounced in the subgroup of patients with baseline severe MDD as defined by a HAMD-17 total score of 24 or more plus an anxiety/somatization factor score of 7 or greater. Seventeen such patients were randomized to adjunctive pimavanserin, 36 to placebo. At 5 weeks, the mean HAMD total score had dropped by 17.4 points from a baseline of 27.6 in the pimavanserin group, compared with a 9.3-point reduction in controls.

“Of note, significant differences from placebo were observed as early as week 2 with pimavanserin,” Dr. Dirks said.

Pimavanserin is a novel selective serotonin inverse agonist with a high affinity for 5-HT2A receptors and low affinity for 5-HT2C receptors. At present pimavanserin is Food Drug Administration–approved as Nuplazid only for treatment of hallucinations and delusions associated with Parkinson’s disease psychosis, but because of the drug’s unique mechanism of action it is under study for a variety of other mental disorders. Indeed, pimavanserin is now under FDA review for a possible expanded indication for treatment of dementia-related psychosis. The drug is also under study for schizophrenia as well as for MDD.

The CLARITY trial and this post hoc analysis were sponsored by Acadia Pharmaceuticals.

bjancin@mdedge.com

SOURCE: Dirks B. ECNP 2020. Abstract P 094.

Adjunctive pimavanserin brought clinically meaningful improvement in patients with anxious major depressive disorder inadequately responsive to standard antidepressants alone in a post hoc analysis of the CLARITY trial, Bryan Dirks, MD, reported at the virtual congress of the European College of Neuropsychopharmacology.

This is an intriguing observation, because it’s estimated that roughly 50% of individuals with major depressive disorder (MDD) have comorbid anxiety disorders or a high level of anxiety symptoms. Moreover, anxious depression has been associated with increased risk of suicidality, high unemployment, and impaired functioning.

CLARITY was a phase 2, multicenter, randomized, double-blind, placebo-controlled clinical trial whose positive results for the primary outcome have been published (J Clin Psychiatry. 2019 Sep 24;80[6]:19m12928. doi: 10.4088/JCP.19m12928). Because the encouraging findings regarding pimavanserin’s impact on anxious depression came from a post hoc analysis, the results need replication. That’s ongoing in a phase 3 trial of adjunctive pimavanserin versus placebo in patients with MDD, according to Dr. Dirks, director of clinical research at Acadia Pharmaceuticals, San Diego.

The CLARITY post hoc analysis included 104 patients with baseline MDD inadequately responsive to an SSRI or a serotonin norepinephrine reuptake inhibitor and anxious depression as defined by a Hamilton Depression Rating Scale (HAMD-17) anxiety/somatization factor subscale score of 7 or more. Twenty-nine of the patients were randomized to 34 mg of adjunctive oral pimavanserin once daily, and 75 to placebo. At 5 weeks, the HAMD-17 anxiety/somatization factor score in the pimavanserin group had dropped by a mean of 5 points from a baseline of 8.8, a significantly greater effect than the 2.8-point drop in placebo-treated controls.

By week 5, the treatment response rate as defined by at least a 50% reduction in HAMD-17 total score from baseline was 55% with pimavanserin and 22% with placebo. The remission rate as indicated by a HAMD-17 total score below 7 was 24% in the pimavanserin group, compared with 5% with placebo. These results translated into an effect size of 0.78, considered by statisticians to be on the border between medium and large. Those response and remission rates in patients with anxious depression were higher with pimavanserin and lower with placebo than in the overall CLARITY trial.

The impact of adjunctive pimavanserin on top of a background SSRI or SNRI was even more pronounced in the subgroup of patients with baseline severe MDD as defined by a HAMD-17 total score of 24 or more plus an anxiety/somatization factor score of 7 or greater. Seventeen such patients were randomized to adjunctive pimavanserin, 36 to placebo. At 5 weeks, the mean HAMD total score had dropped by 17.4 points from a baseline of 27.6 in the pimavanserin group, compared with a 9.3-point reduction in controls.

“Of note, significant differences from placebo were observed as early as week 2 with pimavanserin,” Dr. Dirks said.

Pimavanserin is a novel selective serotonin inverse agonist with a high affinity for 5-HT2A receptors and low affinity for 5-HT2C receptors. At present pimavanserin is Food Drug Administration–approved as Nuplazid only for treatment of hallucinations and delusions associated with Parkinson’s disease psychosis, but because of the drug’s unique mechanism of action it is under study for a variety of other mental disorders. Indeed, pimavanserin is now under FDA review for a possible expanded indication for treatment of dementia-related psychosis. The drug is also under study for schizophrenia as well as for MDD.

The CLARITY trial and this post hoc analysis were sponsored by Acadia Pharmaceuticals.

bjancin@mdedge.com

SOURCE: Dirks B. ECNP 2020. Abstract P 094.

As a provider whose passion is helping women after stillbirth or neonatal loss, I get many transfers of women from their previous practice after a loss. Sometimes they transfer because they need a “fresh start,” but often, it is because they were let down by the practice – not by the medical care they received but by the emotional care and support and what was said or not said after the loss of the baby. A 2014 meta-analysis in the British Journal of Obstetrics and Gynaecology found that “Parents regarded contacts with health professionals as their central source of reassurance; but experiences often fell short of expectations.”¹ I decided to conduct a survey via local and national support groups about what “loss parents” felt helpful or not helpful after the loss of a child. I purposely made these quotes the dominant part of this article, as I believe our patients are often our best teachers.

Inappropriate comments providers make

A very common theme among loss parents was how providers had made comments about how rare stillbirth is after it had just happened to them. Parents expressed that they felt this statistic kept them from getting the care that they needed prior to their loss and then they were told to not worry. Some example quotes include:

“ ‘This only happens to 1% of babies. Very rare.’ (It happened to our baby, and we have to live with this grief our whole lives. She is more than a statistic. She was our hopes, dreams, and future.)”

“I wish doctors didn’t wait to act based on statistics. There’s a lot of us in the 1% of unlikely occurrences.”

“For me, when my practice brushed off my feelings, I knew in my gut something was wrong. They said, ‘We need to wean you from worrying.’”

Another very common theme from parents included examples of helpful and not helpful care they received in the hospital.
 

Help parents make good memories

Many parents mentioned the importance of providing resources for after they go home. Most labor and delivery units have pregnancy loss services and have improved on the care they provide for loss families. One very common positive comment responded to the memories that nurses and providers helped them make after delivery. One parent said the following:

“While with baby and after loss, I think it’s really important to give ideas of what to do/experiences because the moments are so fleeting, and I needed someone to say, ‘You can dress him.’ ‘Let’s take pictures of his toes.’ ‘Save breast milk, etc.’”

“I appreciated the doctors and nurses who acknowledged my child, who looked at him and humanized him. One nurse even held him, which I still love her to this day for.”

“Explain things over, over, and over again, like you are explaining it to a child. I didn’t know what a cuddle cot was, and I didn’t use it because I didn’t understand.”

“Give suggestions and stress the importance of making memories. There are things I wish I did and now regret not doing. Taking pictures, handprints, lock of hair, giving the baby a bath.”

“For unknown losses give a full explanation of the autopsy and what it entails. Parents are making SO many decisions, and they need guidance.”

“Don’t shy away from it. It happened, and it is important to be human and compassionate. If you cannot do it, find someone else who can.”

“Ask to hold the baby and comment how beautiful the baby is. Treat the baby as if it were living.”

Don’t use the ‘silver lining’ theme

A common “don’t” in the hospital and postpartum is the “at least” and “silver lining” theme that is commonly expressed by providers. When I do my teaching sessions with a bereaved parents panel, we always stress that comforting words never begin with “at least.” We say a lot that there is no “silver lining” to a stillbirth. Dr. Brene Brown, in her TED talk on empathy, discussed that an empathic statement never starts with “at least.” However, this response is an all too common experience for women after stillbirth. Here are some examples from the Internet responses:

“‘The silver lining is you and your daughter have taught us so much.’ There is no silver lining, and her life was not for anyone’s easy path to learning lessons. She was wanted and loved.”

“What not to say: From a doctor, ‘You’re going to have lots more children.’ Anything along the lines of ‘at least you can get pregnant/have children’ is not OK.”

“As a teacher, ‘At least you are already a mother to your students.’ (I cannot even tell you how many times I’ve been told this. They already have mothers, and teaching a child 40 minutes once a week is not even close to being a mother to your own child.)”

“I felt it unhelpful for people to tell me how I should feel. I felt comments like ‘oh, you are young you can have another baby’ unhelpful.”

“Do not say, ‘you can have another, it wasn’t God’s plan, God wanted another angel, there is a reason for everything,’ etc.”

“The doctor who told me my baby was dead referred to him as a fetus. I was 38 weeks pregnant and did not refer to my baby as a fetus.”
 

Handling patient care after the loss

A huge portion of the response I received was regarding care from the practice where they delivered after the loss. These parents provided very important advice for any practice after a patient experiences a loss. Emotional support is vital for these patients. They also made it clear that topics such a medications and counseling should be frequently revisited.

“The care a patient receives after can really change their life – not physical care but emotional care. I truly believe I recovered well, and I am the person I am today because of my provider’s phone calls, suggestions for medications, support groups, and counseling. Don’t underestimate what simple phone calls can do. You don’t have to provide a solution or give advice, just listen.”

“Revisit conversations about medications. I have never taken anything in my entire life. In fact, I was very against it. Don’t be afraid to suggest medications time and time again if you think that it is the right plan. After 6 months, I said ‘yes’ to the medication, and it helped immensely.”

“My OB checking in with me constantly. Doctors offering compassionate and informative advice and encouragement. SUPPORT GROUPS. Star Legacy Foundation mentor!!! Klonopin! Psychologist!!”

“Also, I think it’s important for providers to continue to follow-up with patients even if they don’t seem receptive. Keep checking in. After losing your child you are in a fog. You don’t know quite what you need. But those calls, I promise you they mean something.”
 

When the patient returns to the office

The care received by a loss parent after returning to the office is challenging but so important. Some very careful steps can and must be made to help avoid emotionally harmful situations for the staff and patients. Offices need to make special accommodations and mark what happened clearly in the chart regarding the loss. When I have a mother coming in for a postpartum visit after a loss, I make sure she is the last patient of the day and try to bring her to our satellite offices where she can be the only patient there. Many parents made comments about carefully labeling what happened to the baby in the chart.

“Make sure it’s noted in the chart, and don’t AVOID talking about it. We like to have our baby brought up. Make sure staff knows the situation before entering the office so they don’t say something stupid (for example, ‘How is breast feeding going?’)”

“#1 don’t in my book: Not reading the patient’s chart and labels on it before seeing them if you’re not familiar with the patient. ... Nurses, techs and providers alike have assumed or asked “this is your first,” when clearly my chart lists “fetal death in utero.’”

“Many others have stated this, but having a BIG HUGE MASSIVE flag on our accounts and making sure ALL parts of the office are trained on this would be so incredibly helpful.”

“The nurse at my doctor’s office yesterday said, ‘Well, you’ve lost some weight since you were here last, so that’s good!’ My response was, ‘Well, losing a baby will do that.’”

“The follow-up appointment is awful. I went in heartbroken and angry and anxious. A phone call the day before acknowledging those feelings and reassuring me it was okay would have been nice.”

“At my first follow-up after my son died, I walked in, the receptionist pulled up my chart, saw I was there for my post-delivery appointment, and in the loudest, most cheery voice said, ‘Oooooooooh how’s he doing, how’s the baby?!’ It was awful telling her that he died, and I also felt terrible for all the pregnant woman in the waiting room who may have heard it.”

“When I was in emergency for a complication after birth, the only condolence a doctor from our previous practice gave was, ‘Well, that sucks’ (in regard to our daughter).”
 

Continuing care in the office

The care of women in the office immediately after loss and in years to come is a very important piece of the care they receive. In the same BJOG meta-analysis they found, “Parents frequently encountered professionals who were unaware of their history, through lack of access to/or reading of notes before a consultation. Dismissive attitudes to fears and concerns and insensitive and inappropriate comments sometimes resulted. These often remained with parents long after the event. In contrast, emotional wellbeing was enhanced when care providers demonstrated empathy, listened to concerns and committed to a collaborative and supportive relationship. Parents valued direct acknowledgment of the baby who had died, including using his or her name. Flexible antenatal care including extra appointments, routinely or on request, was also welcomed.”1 These findings were very similar to those reflected in the comments that I received.

“To the mother, there is no difference between a living baby and a stillborn baby. This stillborn baby is JUST AS MUCH a life to us. I’ve had four kids, and I can’t differentiate between how I feel about them.”

“Also, if staying with the same provider, ‘do’ ask what accommodations can be made moving forward. (For me I needed a different ultrasound tech and a different office for my ultrasounds in my subsequent pregnancies as I couldn’t go back there but wanted to stay with my same OB).”

“Don’t be afraid to ask about the child. I want people to know I like talking about my son, that he existed and how much love there was in his short but meaningful life.”

“Saying nothing is worse than saying you don’t know what to say and you are sorry.”

“Some moms love the rainbow baby term, and if they use it first, it’s fine to use it and encourage it and promote it. However, some moms do not like it because 1) they don’t like referring to their loss baby as a ‘storm.’ My baby was a BABY, and he was perfect and loved and I don’t like people referring to him as a storm. A storm is derogatory, [and] 2) the notion the subsequent baby makes everything okay is ridiculous. 3) Not everyone has another baby after a loss, so the ‘after every storm comes a rainbow’ phrase is stupid. It makes it seem like you can never be happy again unless you get a rainbow, and that is not true. 4) It’s a signal to the outside world that ‘everything’ is great and ok when in reality you can have grief, joy, sadness, happiness, pain, and hope all at the [same] time forever.”

Patients and their families who have lost their babies deserve our very best. No one grieves the same, and the differences in how our patients grieve must be respected. However, members of the loss community do have some common themes on responses that they appreciated or did not appreciate regarding their care. Most patients who deliver a stillborn baby or experience a neonatal death or pre-viable baby have had no time to prepare, and they are looking for our guidance and support. The more time we spend with them after diagnosis, during delivery, and after will be so appreciated. I hope some of these quotes ring true to many providers and that they either lead to attempts to change care or reinforce the amazing care providers are already providing. Being at our best when our patients are experiencing potentially the worst moments of their lives is our job as obstetrical providers. Our patients deserve the best care we can possibly provide. Hopefully, these suggestions from patients will help the care of future loss families.
 

Dr. Florescue is an ob.gyn. in private practice at Women Gynecology and Childbirth Associates in Rochester, N.Y. She delivers babies at Highland Hospital in Rochester. She has no relevant financial disclosures. Email her at obnews@mdedge.com.

Reference

1. BJOG. 2014 Jul; 121(8):943-50. doi: 10.1111/1471-0528.12656.

As a provider whose passion is helping women after stillbirth or neonatal loss, I get many transfers of women from their previous practice after a loss. Sometimes they transfer because they need a “fresh start,” but often, it is because they were let down by the practice – not by the medical care they received but by the emotional care and support and what was said or not said after the loss of the baby. A 2014 meta-analysis in the British Journal of Obstetrics and Gynaecology found that “Parents regarded contacts with health professionals as their central source of reassurance; but experiences often fell short of expectations.”¹ I decided to conduct a survey via local and national support groups about what “loss parents” felt helpful or not helpful after the loss of a child. I purposely made these quotes the dominant part of this article, as I believe our patients are often our best teachers.

Inappropriate comments providers make

A very common theme among loss parents was how providers had made comments about how rare stillbirth is after it had just happened to them. Parents expressed that they felt this statistic kept them from getting the care that they needed prior to their loss and then they were told to not worry. Some example quotes include:

“ ‘This only happens to 1% of babies. Very rare.’ (It happened to our baby, and we have to live with this grief our whole lives. She is more than a statistic. She was our hopes, dreams, and future.)”

“I wish doctors didn’t wait to act based on statistics. There’s a lot of us in the 1% of unlikely occurrences.”

“For me, when my practice brushed off my feelings, I knew in my gut something was wrong. They said, ‘We need to wean you from worrying.’”

Another very common theme from parents included examples of helpful and not helpful care they received in the hospital.
 

Help parents make good memories

Many parents mentioned the importance of providing resources for after they go home. Most labor and delivery units have pregnancy loss services and have improved on the care they provide for loss families. One very common positive comment responded to the memories that nurses and providers helped them make after delivery. One parent said the following:

“While with baby and after loss, I think it’s really important to give ideas of what to do/experiences because the moments are so fleeting, and I needed someone to say, ‘You can dress him.’ ‘Let’s take pictures of his toes.’ ‘Save breast milk, etc.’”

“I appreciated the doctors and nurses who acknowledged my child, who looked at him and humanized him. One nurse even held him, which I still love her to this day for.”

“Explain things over, over, and over again, like you are explaining it to a child. I didn’t know what a cuddle cot was, and I didn’t use it because I didn’t understand.”

“Give suggestions and stress the importance of making memories. There are things I wish I did and now regret not doing. Taking pictures, handprints, lock of hair, giving the baby a bath.”

“For unknown losses give a full explanation of the autopsy and what it entails. Parents are making SO many decisions, and they need guidance.”

“Don’t shy away from it. It happened, and it is important to be human and compassionate. If you cannot do it, find someone else who can.”

“Ask to hold the baby and comment how beautiful the baby is. Treat the baby as if it were living.”

Don’t use the ‘silver lining’ theme

A common “don’t” in the hospital and postpartum is the “at least” and “silver lining” theme that is commonly expressed by providers. When I do my teaching sessions with a bereaved parents panel, we always stress that comforting words never begin with “at least.” We say a lot that there is no “silver lining” to a stillbirth. Dr. Brene Brown, in her TED talk on empathy, discussed that an empathic statement never starts with “at least.” However, this response is an all too common experience for women after stillbirth. Here are some examples from the Internet responses:

“‘The silver lining is you and your daughter have taught us so much.’ There is no silver lining, and her life was not for anyone’s easy path to learning lessons. She was wanted and loved.”

“What not to say: From a doctor, ‘You’re going to have lots more children.’ Anything along the lines of ‘at least you can get pregnant/have children’ is not OK.”

“As a teacher, ‘At least you are already a mother to your students.’ (I cannot even tell you how many times I’ve been told this. They already have mothers, and teaching a child 40 minutes once a week is not even close to being a mother to your own child.)”

“I felt it unhelpful for people to tell me how I should feel. I felt comments like ‘oh, you are young you can have another baby’ unhelpful.”

“Do not say, ‘you can have another, it wasn’t God’s plan, God wanted another angel, there is a reason for everything,’ etc.”

“The doctor who told me my baby was dead referred to him as a fetus. I was 38 weeks pregnant and did not refer to my baby as a fetus.”
 

Handling patient care after the loss

A huge portion of the response I received was regarding care from the practice where they delivered after the loss. These parents provided very important advice for any practice after a patient experiences a loss. Emotional support is vital for these patients. They also made it clear that topics such a medications and counseling should be frequently revisited.

“The care a patient receives after can really change their life – not physical care but emotional care. I truly believe I recovered well, and I am the person I am today because of my provider’s phone calls, suggestions for medications, support groups, and counseling. Don’t underestimate what simple phone calls can do. You don’t have to provide a solution or give advice, just listen.”

“Revisit conversations about medications. I have never taken anything in my entire life. In fact, I was very against it. Don’t be afraid to suggest medications time and time again if you think that it is the right plan. After 6 months, I said ‘yes’ to the medication, and it helped immensely.”

“My OB checking in with me constantly. Doctors offering compassionate and informative advice and encouragement. SUPPORT GROUPS. Star Legacy Foundation mentor!!! Klonopin! Psychologist!!”

“Also, I think it’s important for providers to continue to follow-up with patients even if they don’t seem receptive. Keep checking in. After losing your child you are in a fog. You don’t know quite what you need. But those calls, I promise you they mean something.”
 

When the patient returns to the office

The care received by a loss parent after returning to the office is challenging but so important. Some very careful steps can and must be made to help avoid emotionally harmful situations for the staff and patients. Offices need to make special accommodations and mark what happened clearly in the chart regarding the loss. When I have a mother coming in for a postpartum visit after a loss, I make sure she is the last patient of the day and try to bring her to our satellite offices where she can be the only patient there. Many parents made comments about carefully labeling what happened to the baby in the chart.

“Make sure it’s noted in the chart, and don’t AVOID talking about it. We like to have our baby brought up. Make sure staff knows the situation before entering the office so they don’t say something stupid (for example, ‘How is breast feeding going?’)”

“#1 don’t in my book: Not reading the patient’s chart and labels on it before seeing them if you’re not familiar with the patient. ... Nurses, techs and providers alike have assumed or asked “this is your first,” when clearly my chart lists “fetal death in utero.’”

“Many others have stated this, but having a BIG HUGE MASSIVE flag on our accounts and making sure ALL parts of the office are trained on this would be so incredibly helpful.”

“The nurse at my doctor’s office yesterday said, ‘Well, you’ve lost some weight since you were here last, so that’s good!’ My response was, ‘Well, losing a baby will do that.’”

“The follow-up appointment is awful. I went in heartbroken and angry and anxious. A phone call the day before acknowledging those feelings and reassuring me it was okay would have been nice.”

“At my first follow-up after my son died, I walked in, the receptionist pulled up my chart, saw I was there for my post-delivery appointment, and in the loudest, most cheery voice said, ‘Oooooooooh how’s he doing, how’s the baby?!’ It was awful telling her that he died, and I also felt terrible for all the pregnant woman in the waiting room who may have heard it.”

“When I was in emergency for a complication after birth, the only condolence a doctor from our previous practice gave was, ‘Well, that sucks’ (in regard to our daughter).”
 

Continuing care in the office

The care of women in the office immediately after loss and in years to come is a very important piece of the care they receive. In the same BJOG meta-analysis they found, “Parents frequently encountered professionals who were unaware of their history, through lack of access to/or reading of notes before a consultation. Dismissive attitudes to fears and concerns and insensitive and inappropriate comments sometimes resulted. These often remained with parents long after the event. In contrast, emotional wellbeing was enhanced when care providers demonstrated empathy, listened to concerns and committed to a collaborative and supportive relationship. Parents valued direct acknowledgment of the baby who had died, including using his or her name. Flexible antenatal care including extra appointments, routinely or on request, was also welcomed.”1 These findings were very similar to those reflected in the comments that I received.

“To the mother, there is no difference between a living baby and a stillborn baby. This stillborn baby is JUST AS MUCH a life to us. I’ve had four kids, and I can’t differentiate between how I feel about them.”

“Also, if staying with the same provider, ‘do’ ask what accommodations can be made moving forward. (For me I needed a different ultrasound tech and a different office for my ultrasounds in my subsequent pregnancies as I couldn’t go back there but wanted to stay with my same OB).”

“Don’t be afraid to ask about the child. I want people to know I like talking about my son, that he existed and how much love there was in his short but meaningful life.”

“Saying nothing is worse than saying you don’t know what to say and you are sorry.”

“Some moms love the rainbow baby term, and if they use it first, it’s fine to use it and encourage it and promote it. However, some moms do not like it because 1) they don’t like referring to their loss baby as a ‘storm.’ My baby was a BABY, and he was perfect and loved and I don’t like people referring to him as a storm. A storm is derogatory, [and] 2) the notion the subsequent baby makes everything okay is ridiculous. 3) Not everyone has another baby after a loss, so the ‘after every storm comes a rainbow’ phrase is stupid. It makes it seem like you can never be happy again unless you get a rainbow, and that is not true. 4) It’s a signal to the outside world that ‘everything’ is great and ok when in reality you can have grief, joy, sadness, happiness, pain, and hope all at the [same] time forever.”

Patients and their families who have lost their babies deserve our very best. No one grieves the same, and the differences in how our patients grieve must be respected. However, members of the loss community do have some common themes on responses that they appreciated or did not appreciate regarding their care. Most patients who deliver a stillborn baby or experience a neonatal death or pre-viable baby have had no time to prepare, and they are looking for our guidance and support. The more time we spend with them after diagnosis, during delivery, and after will be so appreciated. I hope some of these quotes ring true to many providers and that they either lead to attempts to change care or reinforce the amazing care providers are already providing. Being at our best when our patients are experiencing potentially the worst moments of their lives is our job as obstetrical providers. Our patients deserve the best care we can possibly provide. Hopefully, these suggestions from patients will help the care of future loss families.
 

Dr. Florescue is an ob.gyn. in private practice at Women Gynecology and Childbirth Associates in Rochester, N.Y. She delivers babies at Highland Hospital in Rochester. She has no relevant financial disclosures. Email her at obnews@mdedge.com.

Reference

1. BJOG. 2014 Jul; 121(8):943-50. doi: 10.1111/1471-0528.12656.

As a provider whose passion is helping women after stillbirth or neonatal loss, I get many transfers of women from their previous practice after a loss. Sometimes they transfer because they need a “fresh start,” but often, it is because they were let down by the practice – not by the medical care they received but by the emotional care and support and what was said or not said after the loss of the baby. A 2014 meta-analysis in the British Journal of Obstetrics and Gynaecology found that “Parents regarded contacts with health professionals as their central source of reassurance; but experiences often fell short of expectations.”¹ I decided to conduct a survey via local and national support groups about what “loss parents” felt helpful or not helpful after the loss of a child. I purposely made these quotes the dominant part of this article, as I believe our patients are often our best teachers.

Inappropriate comments providers make

A very common theme among loss parents was how providers had made comments about how rare stillbirth is after it had just happened to them. Parents expressed that they felt this statistic kept them from getting the care that they needed prior to their loss and then they were told to not worry. Some example quotes include:

“ ‘This only happens to 1% of babies. Very rare.’ (It happened to our baby, and we have to live with this grief our whole lives. She is more than a statistic. She was our hopes, dreams, and future.)”

“I wish doctors didn’t wait to act based on statistics. There’s a lot of us in the 1% of unlikely occurrences.”

“For me, when my practice brushed off my feelings, I knew in my gut something was wrong. They said, ‘We need to wean you from worrying.’”

Another very common theme from parents included examples of helpful and not helpful care they received in the hospital.
 

Help parents make good memories

Many parents mentioned the importance of providing resources for after they go home. Most labor and delivery units have pregnancy loss services and have improved on the care they provide for loss families. One very common positive comment responded to the memories that nurses and providers helped them make after delivery. One parent said the following:

“While with baby and after loss, I think it’s really important to give ideas of what to do/experiences because the moments are so fleeting, and I needed someone to say, ‘You can dress him.’ ‘Let’s take pictures of his toes.’ ‘Save breast milk, etc.’”

“I appreciated the doctors and nurses who acknowledged my child, who looked at him and humanized him. One nurse even held him, which I still love her to this day for.”

“Explain things over, over, and over again, like you are explaining it to a child. I didn’t know what a cuddle cot was, and I didn’t use it because I didn’t understand.”

“Give suggestions and stress the importance of making memories. There are things I wish I did and now regret not doing. Taking pictures, handprints, lock of hair, giving the baby a bath.”

“For unknown losses give a full explanation of the autopsy and what it entails. Parents are making SO many decisions, and they need guidance.”

“Don’t shy away from it. It happened, and it is important to be human and compassionate. If you cannot do it, find someone else who can.”

“Ask to hold the baby and comment how beautiful the baby is. Treat the baby as if it were living.”

Don’t use the ‘silver lining’ theme

A common “don’t” in the hospital and postpartum is the “at least” and “silver lining” theme that is commonly expressed by providers. When I do my teaching sessions with a bereaved parents panel, we always stress that comforting words never begin with “at least.” We say a lot that there is no “silver lining” to a stillbirth. Dr. Brene Brown, in her TED talk on empathy, discussed that an empathic statement never starts with “at least.” However, this response is an all too common experience for women after stillbirth. Here are some examples from the Internet responses:

“‘The silver lining is you and your daughter have taught us so much.’ There is no silver lining, and her life was not for anyone’s easy path to learning lessons. She was wanted and loved.”

“What not to say: From a doctor, ‘You’re going to have lots more children.’ Anything along the lines of ‘at least you can get pregnant/have children’ is not OK.”

“As a teacher, ‘At least you are already a mother to your students.’ (I cannot even tell you how many times I’ve been told this. They already have mothers, and teaching a child 40 minutes once a week is not even close to being a mother to your own child.)”

“I felt it unhelpful for people to tell me how I should feel. I felt comments like ‘oh, you are young you can have another baby’ unhelpful.”

“Do not say, ‘you can have another, it wasn’t God’s plan, God wanted another angel, there is a reason for everything,’ etc.”

“The doctor who told me my baby was dead referred to him as a fetus. I was 38 weeks pregnant and did not refer to my baby as a fetus.”
 

Handling patient care after the loss

A huge portion of the response I received was regarding care from the practice where they delivered after the loss. These parents provided very important advice for any practice after a patient experiences a loss. Emotional support is vital for these patients. They also made it clear that topics such a medications and counseling should be frequently revisited.

“The care a patient receives after can really change their life – not physical care but emotional care. I truly believe I recovered well, and I am the person I am today because of my provider’s phone calls, suggestions for medications, support groups, and counseling. Don’t underestimate what simple phone calls can do. You don’t have to provide a solution or give advice, just listen.”

“Revisit conversations about medications. I have never taken anything in my entire life. In fact, I was very against it. Don’t be afraid to suggest medications time and time again if you think that it is the right plan. After 6 months, I said ‘yes’ to the medication, and it helped immensely.”

“My OB checking in with me constantly. Doctors offering compassionate and informative advice and encouragement. SUPPORT GROUPS. Star Legacy Foundation mentor!!! Klonopin! Psychologist!!”

“Also, I think it’s important for providers to continue to follow-up with patients even if they don’t seem receptive. Keep checking in. After losing your child you are in a fog. You don’t know quite what you need. But those calls, I promise you they mean something.”
 

When the patient returns to the office

The care received by a loss parent after returning to the office is challenging but so important. Some very careful steps can and must be made to help avoid emotionally harmful situations for the staff and patients. Offices need to make special accommodations and mark what happened clearly in the chart regarding the loss. When I have a mother coming in for a postpartum visit after a loss, I make sure she is the last patient of the day and try to bring her to our satellite offices where she can be the only patient there. Many parents made comments about carefully labeling what happened to the baby in the chart.

“Make sure it’s noted in the chart, and don’t AVOID talking about it. We like to have our baby brought up. Make sure staff knows the situation before entering the office so they don’t say something stupid (for example, ‘How is breast feeding going?’)”

“#1 don’t in my book: Not reading the patient’s chart and labels on it before seeing them if you’re not familiar with the patient. ... Nurses, techs and providers alike have assumed or asked “this is your first,” when clearly my chart lists “fetal death in utero.’”

“Many others have stated this, but having a BIG HUGE MASSIVE flag on our accounts and making sure ALL parts of the office are trained on this would be so incredibly helpful.”

“The nurse at my doctor’s office yesterday said, ‘Well, you’ve lost some weight since you were here last, so that’s good!’ My response was, ‘Well, losing a baby will do that.’”

“The follow-up appointment is awful. I went in heartbroken and angry and anxious. A phone call the day before acknowledging those feelings and reassuring me it was okay would have been nice.”

“At my first follow-up after my son died, I walked in, the receptionist pulled up my chart, saw I was there for my post-delivery appointment, and in the loudest, most cheery voice said, ‘Oooooooooh how’s he doing, how’s the baby?!’ It was awful telling her that he died, and I also felt terrible for all the pregnant woman in the waiting room who may have heard it.”

“When I was in emergency for a complication after birth, the only condolence a doctor from our previous practice gave was, ‘Well, that sucks’ (in regard to our daughter).”
 

Continuing care in the office

The care of women in the office immediately after loss and in years to come is a very important piece of the care they receive. In the same BJOG meta-analysis they found, “Parents frequently encountered professionals who were unaware of their history, through lack of access to/or reading of notes before a consultation. Dismissive attitudes to fears and concerns and insensitive and inappropriate comments sometimes resulted. These often remained with parents long after the event. In contrast, emotional wellbeing was enhanced when care providers demonstrated empathy, listened to concerns and committed to a collaborative and supportive relationship. Parents valued direct acknowledgment of the baby who had died, including using his or her name. Flexible antenatal care including extra appointments, routinely or on request, was also welcomed.”1 These findings were very similar to those reflected in the comments that I received.

“To the mother, there is no difference between a living baby and a stillborn baby. This stillborn baby is JUST AS MUCH a life to us. I’ve had four kids, and I can’t differentiate between how I feel about them.”

“Also, if staying with the same provider, ‘do’ ask what accommodations can be made moving forward. (For me I needed a different ultrasound tech and a different office for my ultrasounds in my subsequent pregnancies as I couldn’t go back there but wanted to stay with my same OB).”

“Don’t be afraid to ask about the child. I want people to know I like talking about my son, that he existed and how much love there was in his short but meaningful life.”

“Saying nothing is worse than saying you don’t know what to say and you are sorry.”

“Some moms love the rainbow baby term, and if they use it first, it’s fine to use it and encourage it and promote it. However, some moms do not like it because 1) they don’t like referring to their loss baby as a ‘storm.’ My baby was a BABY, and he was perfect and loved and I don’t like people referring to him as a storm. A storm is derogatory, [and] 2) the notion the subsequent baby makes everything okay is ridiculous. 3) Not everyone has another baby after a loss, so the ‘after every storm comes a rainbow’ phrase is stupid. It makes it seem like you can never be happy again unless you get a rainbow, and that is not true. 4) It’s a signal to the outside world that ‘everything’ is great and ok when in reality you can have grief, joy, sadness, happiness, pain, and hope all at the [same] time forever.”

Patients and their families who have lost their babies deserve our very best. No one grieves the same, and the differences in how our patients grieve must be respected. However, members of the loss community do have some common themes on responses that they appreciated or did not appreciate regarding their care. Most patients who deliver a stillborn baby or experience a neonatal death or pre-viable baby have had no time to prepare, and they are looking for our guidance and support. The more time we spend with them after diagnosis, during delivery, and after will be so appreciated. I hope some of these quotes ring true to many providers and that they either lead to attempts to change care or reinforce the amazing care providers are already providing. Being at our best when our patients are experiencing potentially the worst moments of their lives is our job as obstetrical providers. Our patients deserve the best care we can possibly provide. Hopefully, these suggestions from patients will help the care of future loss families.
 

Dr. Florescue is an ob.gyn. in private practice at Women Gynecology and Childbirth Associates in Rochester, N.Y. She delivers babies at Highland Hospital in Rochester. She has no relevant financial disclosures. Email her at obnews@mdedge.com.

Reference

1. BJOG. 2014 Jul; 121(8):943-50. doi: 10.1111/1471-0528.12656.

Black women living with HIV are a high-risk population for peripartum depressive symptoms, based on data from 143 women.

Women with high-risk pregnancies because of chronic conditions are at increased risk for developing postpartum depression, and HIV may be one such risk. However, risk factors for women living with HIV, particularly Black women, have not been well studied, wrote Emmanuela Nneamaka Ojukwu of the University of Miami School of Nursing, and colleagues.

Data suggest that as many as half of cases of postpartum depression (PPD) begin before delivery, the researchers noted. “Therefore, for this study, the symptoms of both PND (prenatal depression) and PPD have been classified in what we have termed peripartum depressive symptoms (PDS),” and defined as depressive symptoms during pregnancy and within 1 year postpartum, they said.

In a study published in the Archives of Psychiatric Nursing, the researchers conducted a secondary analysis of 143 Black women living with HIV seen at specialty prenatal and women’s health clinics in Miami.

Overall, 81 women (57%) reported either perinatal or postpartum depressive symptoms, or both. “Some of the symptoms prevalent among women in our study included restlessness, depressed mood, apathy, guilt, hopelessness, and social isolation,” the researchers said.
 

Social factors show significant impact

In a multivariate analysis, low income, intimate partner violence, and childcare burden were significant predictors of PDS (P less than .05). Women who reported intimate partner violence or abuse were 6.5 times more likely to experience PDS than were women who did not report abuse, and women with a childcare burden involving two children were 4.6 times more likely to experience PDS than were women with no childcare burden or only one child needing child care.

The average age of the women studied was 29 years, and 59% were above the federal poverty level. Nearly two-thirds (62%) were Black and 38% were Haitian; 63% were unemployed, 62% had a high school diploma or less, and 59% received care through Medicaid.

The researchers assessed four categories of health: HIV-related, gynecologic, obstetric, and psychosocial. The average viral load among the patients was 22,359 copies/mL at baseline, and they averaged 2.5 medical comorbidities. The most common comorbid conditions were other sexually transmitted infections and blood disorders, followed by cardiovascular and metabolic conditions.
 

Quantitative studies needed

Larger quantitative studies of Black pregnant women living with HIV are needed to analyze social factors at multiple levels, the researchers said. “To address depression among Black women living with HIV, local and federal governments should enact measures that increase the family income and diminish the prevalence of [intimate partner violence] among these women,” they said.

The study findings were limited by several factors including retrospective design and use of self-reports, as well as the small sample size and lack of generalizability to women living with HIV of other races or from other regions, the researchers noted. However, the results reflect data from previous studies and support the value of early screening and referral to improve well being for Black women living with HIV, as well as the importance of comprehensive medical care, they said.

“Women should be counseled that postpartum physical and psychological changes (and the stresses and demands of caring for a new baby) may make [antiretroviral] adherence more difficult and that additional support may be needed during this period,” the researchers wrote.

The study received no outside funding. The researchers had no financial conflicts to disclose.

SOURCE: Ojukwu EN et al. Arch Psychiatr Nurs. 2020 May 22. doi: 10.1016/j.apnu.2020.05.004.

Black women living with HIV are a high-risk population for peripartum depressive symptoms, based on data from 143 women.

Women with high-risk pregnancies because of chronic conditions are at increased risk for developing postpartum depression, and HIV may be one such risk. However, risk factors for women living with HIV, particularly Black women, have not been well studied, wrote Emmanuela Nneamaka Ojukwu of the University of Miami School of Nursing, and colleagues.

Data suggest that as many as half of cases of postpartum depression (PPD) begin before delivery, the researchers noted. “Therefore, for this study, the symptoms of both PND (prenatal depression) and PPD have been classified in what we have termed peripartum depressive symptoms (PDS),” and defined as depressive symptoms during pregnancy and within 1 year postpartum, they said.

In a study published in the Archives of Psychiatric Nursing, the researchers conducted a secondary analysis of 143 Black women living with HIV seen at specialty prenatal and women’s health clinics in Miami.

Overall, 81 women (57%) reported either perinatal or postpartum depressive symptoms, or both. “Some of the symptoms prevalent among women in our study included restlessness, depressed mood, apathy, guilt, hopelessness, and social isolation,” the researchers said.
 

Social factors show significant impact

In a multivariate analysis, low income, intimate partner violence, and childcare burden were significant predictors of PDS (P less than .05). Women who reported intimate partner violence or abuse were 6.5 times more likely to experience PDS than were women who did not report abuse, and women with a childcare burden involving two children were 4.6 times more likely to experience PDS than were women with no childcare burden or only one child needing child care.

The average age of the women studied was 29 years, and 59% were above the federal poverty level. Nearly two-thirds (62%) were Black and 38% were Haitian; 63% were unemployed, 62% had a high school diploma or less, and 59% received care through Medicaid.

The researchers assessed four categories of health: HIV-related, gynecologic, obstetric, and psychosocial. The average viral load among the patients was 22,359 copies/mL at baseline, and they averaged 2.5 medical comorbidities. The most common comorbid conditions were other sexually transmitted infections and blood disorders, followed by cardiovascular and metabolic conditions.
 

Quantitative studies needed

Larger quantitative studies of Black pregnant women living with HIV are needed to analyze social factors at multiple levels, the researchers said. “To address depression among Black women living with HIV, local and federal governments should enact measures that increase the family income and diminish the prevalence of [intimate partner violence] among these women,” they said.

The study findings were limited by several factors including retrospective design and use of self-reports, as well as the small sample size and lack of generalizability to women living with HIV of other races or from other regions, the researchers noted. However, the results reflect data from previous studies and support the value of early screening and referral to improve well being for Black women living with HIV, as well as the importance of comprehensive medical care, they said.

“Women should be counseled that postpartum physical and psychological changes (and the stresses and demands of caring for a new baby) may make [antiretroviral] adherence more difficult and that additional support may be needed during this period,” the researchers wrote.

The study received no outside funding. The researchers had no financial conflicts to disclose.

SOURCE: Ojukwu EN et al. Arch Psychiatr Nurs. 2020 May 22. doi: 10.1016/j.apnu.2020.05.004.

Black women living with HIV are a high-risk population for peripartum depressive symptoms, based on data from 143 women.

Women with high-risk pregnancies because of chronic conditions are at increased risk for developing postpartum depression, and HIV may be one such risk. However, risk factors for women living with HIV, particularly Black women, have not been well studied, wrote Emmanuela Nneamaka Ojukwu of the University of Miami School of Nursing, and colleagues.

Data suggest that as many as half of cases of postpartum depression (PPD) begin before delivery, the researchers noted. “Therefore, for this study, the symptoms of both PND (prenatal depression) and PPD have been classified in what we have termed peripartum depressive symptoms (PDS),” and defined as depressive symptoms during pregnancy and within 1 year postpartum, they said.

In a study published in the Archives of Psychiatric Nursing, the researchers conducted a secondary analysis of 143 Black women living with HIV seen at specialty prenatal and women’s health clinics in Miami.

Overall, 81 women (57%) reported either perinatal or postpartum depressive symptoms, or both. “Some of the symptoms prevalent among women in our study included restlessness, depressed mood, apathy, guilt, hopelessness, and social isolation,” the researchers said.
 

Social factors show significant impact

In a multivariate analysis, low income, intimate partner violence, and childcare burden were significant predictors of PDS (P less than .05). Women who reported intimate partner violence or abuse were 6.5 times more likely to experience PDS than were women who did not report abuse, and women with a childcare burden involving two children were 4.6 times more likely to experience PDS than were women with no childcare burden or only one child needing child care.

The average age of the women studied was 29 years, and 59% were above the federal poverty level. Nearly two-thirds (62%) were Black and 38% were Haitian; 63% were unemployed, 62% had a high school diploma or less, and 59% received care through Medicaid.

The researchers assessed four categories of health: HIV-related, gynecologic, obstetric, and psychosocial. The average viral load among the patients was 22,359 copies/mL at baseline, and they averaged 2.5 medical comorbidities. The most common comorbid conditions were other sexually transmitted infections and blood disorders, followed by cardiovascular and metabolic conditions.
 

Quantitative studies needed

Larger quantitative studies of Black pregnant women living with HIV are needed to analyze social factors at multiple levels, the researchers said. “To address depression among Black women living with HIV, local and federal governments should enact measures that increase the family income and diminish the prevalence of [intimate partner violence] among these women,” they said.

The study findings were limited by several factors including retrospective design and use of self-reports, as well as the small sample size and lack of generalizability to women living with HIV of other races or from other regions, the researchers noted. However, the results reflect data from previous studies and support the value of early screening and referral to improve well being for Black women living with HIV, as well as the importance of comprehensive medical care, they said.

“Women should be counseled that postpartum physical and psychological changes (and the stresses and demands of caring for a new baby) may make [antiretroviral] adherence more difficult and that additional support may be needed during this period,” the researchers wrote.

The study received no outside funding. The researchers had no financial conflicts to disclose.

SOURCE: Ojukwu EN et al. Arch Psychiatr Nurs. 2020 May 22. doi: 10.1016/j.apnu.2020.05.004.

Adam is a 14-year-old who presents for “behavioral concerns” as recommended by his teacher. He is in the eighth grade and is struggling academically and socially. He has intermittent outbursts and poor engagement with other children, and often refuses to do schoolwork. He is seen in the outpatient primary care clinic, usually with his mother and two older siblings, one of whom typically translates for his Arabic-speaking mother. Adam is bilingual, although he prefers Arabic. It is difficult to understand the presenting concern as Adam states that he is doing well and is unsure why the teacher would have made such a report. Mother notes that she does not see these behaviors at home either.

What must we consider? Are there potential barriers, alternate ways to engage, and what role may culture have?

There are many things to consider in the above case, including language barriers, nuanced interactions, and cultural expectations and norms. To understand the scope, statistics reveal that the United States leads the world in its immigrant population with about 44.8 million foreign-born persons in 2018, which accounts for approximately 13.7% of the U.S. population.¹ In 2019, 30,000 refugees were resettled in the United States.² In 2017, immigrant children made up 27% (19.6 million) of U.S. children, of which second-generation children (born in the United States to immigrant parents) were the vast majority at 16.7 million.³ Given this information, it is self-evident that we live in a multicultural society; it is imperative to consider the cultural context in which our patients and families are presenting.

FatCamera/E+

Culture is defined as a set of shared beliefs, norms, values, and behaviors exhibited by a group. Culture plays a role and impacts children in various ways throughout their development. Health care providers would benefit from aspiring to exude cultural humility – learning with and from patients and their families with openness, kindness, and a desire for collaboration. The provider also must consider a family’s history of migration as the response to migration may vary based on age, personal experiences, age at which migration occurred, language abilities, and amount of cultural engagement in the new country (i.e. acculturation).^4,5
 

Cultural framework model

One example of a potential framework to use to engage within a cultural context includes the LEARN (Listen, Explain, Acknowledge, Recommend, Negotiate) model,^6,7 which initially was developed to be used within a family medicine clinic. It includes the following:

Listen with sympathy and understanding to the patient’s perception of the problem. Try to understand their perspective of symptoms through considering their thoughts regarding etiology and treatment options.

Explain your perception of the problem. Have a dialogue about what you perceive is the likely cause based on a medical perspective.

Acknowledge and discuss the differences and similarities. Engage in open conversation while being cognizant that there may be similarities and differences in the perception you may have versus your patient’s perception. Try to find areas that can be engaged in and an alliance built upon, as well as respectfully and humbly addressing any concerns about potentially harmful patient understandings.

Recommend treatment. Present a treatment recommendation that considers both yours and the patient’s perspectives.

Negotiate agreement. Discuss, collaborate, and finalize a treatment plan that considers a biopsychosocial and spiritual/religious model of care that is patient-centered and personalized such that the main goal is optimal health and wellness for the patient/family.

The following are tips to consider in the life-long process of becoming more culturally aware:

• Be willing to learn with your patients and be thoughtful about your own feelings/thoughts/behaviors that may be positively or negatively impacting those interactions.
• Be aware of your own identity and what that may contribute to the clinical space.
• Recognize that you are not meant to know everything, but being open to the journey and learning process will go a long way.
• Try to shift the focus from paternalistic medicine to collaborative and patient-centered approaches.

The case at hand

In returning to our case and applying the LEARN model and cultural humility, we may be able to uncover more of the story. Adam is seen at a subsequent appointment, and you determine it best to obtain an in-person interpreter for this appointment. As you listen to the story, you learn that his father was killed early in Adam’s life, his mother has suffered from depression, and they moved here 3 years ago from a refugee camp, where most of their family continues to reside. He notes that at times he feels that he is back in that space and that he also feels frustrated. He is accustomed to doing well academically, but English has been difficult to learn.

You explain your understanding and acknowledge concerns for his past experiences playing a role, the importance of having community supports, and that learning a new language is challenging. You recommend that the school offer culturally appropriate interventions, trauma-informed assessments, and English-language opportunities. Adam and his mother note willingness to engage in this plan but would like to speak to their local religious leader as well.

Collaborating in a manner similar to this will likely build a therapeutic alliance between the patient, their family, and caretakers, thus leading to improved outcomes.

For further reading, consider AACAP Finding Mental Healthcare for Children of Immigrants and the American Academy of Pediatrics Providing Culturally Effective Care Toolkit.
 

Dr. Abdul-Karim, a child and adolescent psychiatrist, is assistant professor of psychiatry at the University of Vermont, Burlington. She said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.

References

1. “Key findings about U.S. immigrants.” Pew Research Center, Washington, D.C. (2020)

2. “Key facts about refugees to the U.S.” Pew Research Center, Washington, D.C. (2019)

3. “Immigrant Children.” Child Trends, Bethesda, MD (2018).

4. Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 11th ed. (Philadelphia: Lippincott Williams & Wilkins, 2015, pp. 139-45).

5. Lewis’sChild and Adolescent Psychiatry: A Comprehensive Textbook, 5th ed. (Philadelphia: Lippincott Williams & Wilkins, 2017, pp. 111-22).

6. Berlin EA, Fowkes WA Jr.A teaching framework for cross-cultural health care. Application in family practice. West J Med 1983;139(6):934-8.

7. Paediatr Child Health. 2018 Feb;23(1):66-9.

Adam is a 14-year-old who presents for “behavioral concerns” as recommended by his teacher. He is in the eighth grade and is struggling academically and socially. He has intermittent outbursts and poor engagement with other children, and often refuses to do schoolwork. He is seen in the outpatient primary care clinic, usually with his mother and two older siblings, one of whom typically translates for his Arabic-speaking mother. Adam is bilingual, although he prefers Arabic. It is difficult to understand the presenting concern as Adam states that he is doing well and is unsure why the teacher would have made such a report. Mother notes that she does not see these behaviors at home either.

What must we consider? Are there potential barriers, alternate ways to engage, and what role may culture have?

There are many things to consider in the above case, including language barriers, nuanced interactions, and cultural expectations and norms. To understand the scope, statistics reveal that the United States leads the world in its immigrant population with about 44.8 million foreign-born persons in 2018, which accounts for approximately 13.7% of the U.S. population.¹ In 2019, 30,000 refugees were resettled in the United States.² In 2017, immigrant children made up 27% (19.6 million) of U.S. children, of which second-generation children (born in the United States to immigrant parents) were the vast majority at 16.7 million.³ Given this information, it is self-evident that we live in a multicultural society; it is imperative to consider the cultural context in which our patients and families are presenting.

FatCamera/E+

Culture is defined as a set of shared beliefs, norms, values, and behaviors exhibited by a group. Culture plays a role and impacts children in various ways throughout their development. Health care providers would benefit from aspiring to exude cultural humility – learning with and from patients and their families with openness, kindness, and a desire for collaboration. The provider also must consider a family’s history of migration as the response to migration may vary based on age, personal experiences, age at which migration occurred, language abilities, and amount of cultural engagement in the new country (i.e. acculturation).^4,5
 

Cultural framework model

One example of a potential framework to use to engage within a cultural context includes the LEARN (Listen, Explain, Acknowledge, Recommend, Negotiate) model,^6,7 which initially was developed to be used within a family medicine clinic. It includes the following:

Listen with sympathy and understanding to the patient’s perception of the problem. Try to understand their perspective of symptoms through considering their thoughts regarding etiology and treatment options.

Explain your perception of the problem. Have a dialogue about what you perceive is the likely cause based on a medical perspective.

Acknowledge and discuss the differences and similarities. Engage in open conversation while being cognizant that there may be similarities and differences in the perception you may have versus your patient’s perception. Try to find areas that can be engaged in and an alliance built upon, as well as respectfully and humbly addressing any concerns about potentially harmful patient understandings.

Recommend treatment. Present a treatment recommendation that considers both yours and the patient’s perspectives.

Negotiate agreement. Discuss, collaborate, and finalize a treatment plan that considers a biopsychosocial and spiritual/religious model of care that is patient-centered and personalized such that the main goal is optimal health and wellness for the patient/family.

The following are tips to consider in the life-long process of becoming more culturally aware:

• Be willing to learn with your patients and be thoughtful about your own feelings/thoughts/behaviors that may be positively or negatively impacting those interactions.
• Be aware of your own identity and what that may contribute to the clinical space.
• Recognize that you are not meant to know everything, but being open to the journey and learning process will go a long way.
• Try to shift the focus from paternalistic medicine to collaborative and patient-centered approaches.

The case at hand

In returning to our case and applying the LEARN model and cultural humility, we may be able to uncover more of the story. Adam is seen at a subsequent appointment, and you determine it best to obtain an in-person interpreter for this appointment. As you listen to the story, you learn that his father was killed early in Adam’s life, his mother has suffered from depression, and they moved here 3 years ago from a refugee camp, where most of their family continues to reside. He notes that at times he feels that he is back in that space and that he also feels frustrated. He is accustomed to doing well academically, but English has been difficult to learn.

You explain your understanding and acknowledge concerns for his past experiences playing a role, the importance of having community supports, and that learning a new language is challenging. You recommend that the school offer culturally appropriate interventions, trauma-informed assessments, and English-language opportunities. Adam and his mother note willingness to engage in this plan but would like to speak to their local religious leader as well.

Collaborating in a manner similar to this will likely build a therapeutic alliance between the patient, their family, and caretakers, thus leading to improved outcomes.

For further reading, consider AACAP Finding Mental Healthcare for Children of Immigrants and the American Academy of Pediatrics Providing Culturally Effective Care Toolkit.
 

Dr. Abdul-Karim, a child and adolescent psychiatrist, is assistant professor of psychiatry at the University of Vermont, Burlington. She said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.

References

1. “Key findings about U.S. immigrants.” Pew Research Center, Washington, D.C. (2020)

2. “Key facts about refugees to the U.S.” Pew Research Center, Washington, D.C. (2019)

3. “Immigrant Children.” Child Trends, Bethesda, MD (2018).

4. Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 11th ed. (Philadelphia: Lippincott Williams & Wilkins, 2015, pp. 139-45).

5. Lewis’sChild and Adolescent Psychiatry: A Comprehensive Textbook, 5th ed. (Philadelphia: Lippincott Williams & Wilkins, 2017, pp. 111-22).

6. Berlin EA, Fowkes WA Jr.A teaching framework for cross-cultural health care. Application in family practice. West J Med 1983;139(6):934-8.

7. Paediatr Child Health. 2018 Feb;23(1):66-9.

Adam is a 14-year-old who presents for “behavioral concerns” as recommended by his teacher. He is in the eighth grade and is struggling academically and socially. He has intermittent outbursts and poor engagement with other children, and often refuses to do schoolwork. He is seen in the outpatient primary care clinic, usually with his mother and two older siblings, one of whom typically translates for his Arabic-speaking mother. Adam is bilingual, although he prefers Arabic. It is difficult to understand the presenting concern as Adam states that he is doing well and is unsure why the teacher would have made such a report. Mother notes that she does not see these behaviors at home either.

What must we consider? Are there potential barriers, alternate ways to engage, and what role may culture have?

There are many things to consider in the above case, including language barriers, nuanced interactions, and cultural expectations and norms. To understand the scope, statistics reveal that the United States leads the world in its immigrant population with about 44.8 million foreign-born persons in 2018, which accounts for approximately 13.7% of the U.S. population.¹ In 2019, 30,000 refugees were resettled in the United States.² In 2017, immigrant children made up 27% (19.6 million) of U.S. children, of which second-generation children (born in the United States to immigrant parents) were the vast majority at 16.7 million.³ Given this information, it is self-evident that we live in a multicultural society; it is imperative to consider the cultural context in which our patients and families are presenting.

FatCamera/E+

Culture is defined as a set of shared beliefs, norms, values, and behaviors exhibited by a group. Culture plays a role and impacts children in various ways throughout their development. Health care providers would benefit from aspiring to exude cultural humility – learning with and from patients and their families with openness, kindness, and a desire for collaboration. The provider also must consider a family’s history of migration as the response to migration may vary based on age, personal experiences, age at which migration occurred, language abilities, and amount of cultural engagement in the new country (i.e. acculturation).^4,5
 

Cultural framework model

One example of a potential framework to use to engage within a cultural context includes the LEARN (Listen, Explain, Acknowledge, Recommend, Negotiate) model,^6,7 which initially was developed to be used within a family medicine clinic. It includes the following:

Listen with sympathy and understanding to the patient’s perception of the problem. Try to understand their perspective of symptoms through considering their thoughts regarding etiology and treatment options.

Explain your perception of the problem. Have a dialogue about what you perceive is the likely cause based on a medical perspective.

Acknowledge and discuss the differences and similarities. Engage in open conversation while being cognizant that there may be similarities and differences in the perception you may have versus your patient’s perception. Try to find areas that can be engaged in and an alliance built upon, as well as respectfully and humbly addressing any concerns about potentially harmful patient understandings.

Recommend treatment. Present a treatment recommendation that considers both yours and the patient’s perspectives.

Negotiate agreement. Discuss, collaborate, and finalize a treatment plan that considers a biopsychosocial and spiritual/religious model of care that is patient-centered and personalized such that the main goal is optimal health and wellness for the patient/family.

The following are tips to consider in the life-long process of becoming more culturally aware:

• Be willing to learn with your patients and be thoughtful about your own feelings/thoughts/behaviors that may be positively or negatively impacting those interactions.
• Be aware of your own identity and what that may contribute to the clinical space.
• Recognize that you are not meant to know everything, but being open to the journey and learning process will go a long way.
• Try to shift the focus from paternalistic medicine to collaborative and patient-centered approaches.

The case at hand

In returning to our case and applying the LEARN model and cultural humility, we may be able to uncover more of the story. Adam is seen at a subsequent appointment, and you determine it best to obtain an in-person interpreter for this appointment. As you listen to the story, you learn that his father was killed early in Adam’s life, his mother has suffered from depression, and they moved here 3 years ago from a refugee camp, where most of their family continues to reside. He notes that at times he feels that he is back in that space and that he also feels frustrated. He is accustomed to doing well academically, but English has been difficult to learn.

You explain your understanding and acknowledge concerns for his past experiences playing a role, the importance of having community supports, and that learning a new language is challenging. You recommend that the school offer culturally appropriate interventions, trauma-informed assessments, and English-language opportunities. Adam and his mother note willingness to engage in this plan but would like to speak to their local religious leader as well.

Collaborating in a manner similar to this will likely build a therapeutic alliance between the patient, their family, and caretakers, thus leading to improved outcomes.

For further reading, consider AACAP Finding Mental Healthcare for Children of Immigrants and the American Academy of Pediatrics Providing Culturally Effective Care Toolkit.
 

Dr. Abdul-Karim, a child and adolescent psychiatrist, is assistant professor of psychiatry at the University of Vermont, Burlington. She said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.

References

1. “Key findings about U.S. immigrants.” Pew Research Center, Washington, D.C. (2020)

2. “Key facts about refugees to the U.S.” Pew Research Center, Washington, D.C. (2019)

3. “Immigrant Children.” Child Trends, Bethesda, MD (2018).

4. Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 11th ed. (Philadelphia: Lippincott Williams & Wilkins, 2015, pp. 139-45).

5. Lewis’sChild and Adolescent Psychiatry: A Comprehensive Textbook, 5th ed. (Philadelphia: Lippincott Williams & Wilkins, 2017, pp. 111-22).

6. Berlin EA, Fowkes WA Jr.A teaching framework for cross-cultural health care. Application in family practice. West J Med 1983;139(6):934-8.

7. Paediatr Child Health. 2018 Feb;23(1):66-9.

The mental health consequences of COVID-19 deaths are likely to overwhelm an already tattered U.S. mental health system, leading to a lack of access, particularly for the most vulnerable, experts warn.

“A second wave of devastation is imminent, attributable to mental health consequences of COVID-19,” write Naomi Simon, MD, and coauthors with the department of psychiatry, New York University.

In a Viewpoint article published in JAMA on Oct. 12, physicians offer some sobering statistics.

Since February 2020, COVID-19 has taken the lives of more than 214,000 Americans. The number of deaths currently attributed to the virus is nearly four times the number of Americans killed during the Vietnam War. The magnitude of death over a short period is a tragedy on a “historic scale,” wrote Dr. Simon and colleagues.

The surge in mental health problems related to COVID-19 deaths will bring further challenges to individuals, families, and communities, including a spike in deaths from suicide and drug overdoses, they warned.

It’s important to consider, they noted, that each COVID-19 death leaves an estimated nine family members bereaved, which is projected to lead to an estimated 2 million bereaved individuals in the United States.

“This interpersonal loss on a massive scale is compounded by societal disruption,” they wrote. The necessary social distancing and quarantine measures implemented to fight the virus have amplified emotional turmoil and have disrupted the ability of personal support networks and communities to come together and grieve.

“Of central concern is the transformation of normal grief and distress into prolonged grief and major depressive disorder and symptoms of posttraumatic stress disorder,” Simon and colleagues said.

“Once established, these conditions can become chronic with additional comorbidities such as substance use disorders. Prolonged grief affects approximately 10% of bereaved individuals, but this is likely an underestimate for grief related to deaths from COVID-19,” they wrote.

As with the first COVID-19 wave, the mental health wave will disproportionately affect Black persons, Hispanic persons, older adults, persons in lower socioeconomic groups of all races and ethnicities, and healthcare workers, they note.

The psychological risks for health care and other essential workers are of particular concern, they say. “Supporting the mental health of these and other essential workforce is critical to readiness for managing recurrent waves of the pandemic,” they stated.

How will the United States manage this impending wave of mental health problems?

“The solution will require increased funding for mental health; widespread screening to identify individuals at highest risk including suicide risk; availability of primary care clinicians and mental health professionals trained to treat those with prolonged grief, depression, traumatic stress, and substance abuse; and a diligent focus on families and communities to creatively restore the approaches by which they have managed tragedy and loss over generations,” the authors wrote.

“History has shown that societies recover from such devastation when leaders and members are joined by a shared purpose, acting in a unified way to facilitate recovery. In such societies, there is a shared understanding that its members must care for one another because the loss of one is a loss for all. Above all, this shared understanding must be restored,” they concluded.

Dr. Simon has received personal fees from Vanda Pharmaceuticals Inc, MGH Psychiatry Academy, Axovant Sciences, Springworks, Praxis Therapeutics, Aptinyx, Genomind, and Wiley (deputy editor, Depression and Anxiety). Saxe has received royalties from Guilford Press for the book Trauma Systems Therapy for Children and Teens (2016). Marmar serves on the scientific advisory board and owns equity in Receptor Life Sciences and serves on the PTSD advisory board for Otsuka Pharmaceutical.
 

A version of this article originally appeared on Medscape.com.

The mental health consequences of COVID-19 deaths are likely to overwhelm an already tattered U.S. mental health system, leading to a lack of access, particularly for the most vulnerable, experts warn.

“A second wave of devastation is imminent, attributable to mental health consequences of COVID-19,” write Naomi Simon, MD, and coauthors with the department of psychiatry, New York University.

In a Viewpoint article published in JAMA on Oct. 12, physicians offer some sobering statistics.

Since February 2020, COVID-19 has taken the lives of more than 214,000 Americans. The number of deaths currently attributed to the virus is nearly four times the number of Americans killed during the Vietnam War. The magnitude of death over a short period is a tragedy on a “historic scale,” wrote Dr. Simon and colleagues.

The surge in mental health problems related to COVID-19 deaths will bring further challenges to individuals, families, and communities, including a spike in deaths from suicide and drug overdoses, they warned.

It’s important to consider, they noted, that each COVID-19 death leaves an estimated nine family members bereaved, which is projected to lead to an estimated 2 million bereaved individuals in the United States.

“This interpersonal loss on a massive scale is compounded by societal disruption,” they wrote. The necessary social distancing and quarantine measures implemented to fight the virus have amplified emotional turmoil and have disrupted the ability of personal support networks and communities to come together and grieve.

“Of central concern is the transformation of normal grief and distress into prolonged grief and major depressive disorder and symptoms of posttraumatic stress disorder,” Simon and colleagues said.

“Once established, these conditions can become chronic with additional comorbidities such as substance use disorders. Prolonged grief affects approximately 10% of bereaved individuals, but this is likely an underestimate for grief related to deaths from COVID-19,” they wrote.

As with the first COVID-19 wave, the mental health wave will disproportionately affect Black persons, Hispanic persons, older adults, persons in lower socioeconomic groups of all races and ethnicities, and healthcare workers, they note.

The psychological risks for health care and other essential workers are of particular concern, they say. “Supporting the mental health of these and other essential workforce is critical to readiness for managing recurrent waves of the pandemic,” they stated.

How will the United States manage this impending wave of mental health problems?

“The solution will require increased funding for mental health; widespread screening to identify individuals at highest risk including suicide risk; availability of primary care clinicians and mental health professionals trained to treat those with prolonged grief, depression, traumatic stress, and substance abuse; and a diligent focus on families and communities to creatively restore the approaches by which they have managed tragedy and loss over generations,” the authors wrote.

“History has shown that societies recover from such devastation when leaders and members are joined by a shared purpose, acting in a unified way to facilitate recovery. In such societies, there is a shared understanding that its members must care for one another because the loss of one is a loss for all. Above all, this shared understanding must be restored,” they concluded.

Dr. Simon has received personal fees from Vanda Pharmaceuticals Inc, MGH Psychiatry Academy, Axovant Sciences, Springworks, Praxis Therapeutics, Aptinyx, Genomind, and Wiley (deputy editor, Depression and Anxiety). Saxe has received royalties from Guilford Press for the book Trauma Systems Therapy for Children and Teens (2016). Marmar serves on the scientific advisory board and owns equity in Receptor Life Sciences and serves on the PTSD advisory board for Otsuka Pharmaceutical.
 

A version of this article originally appeared on Medscape.com.

The mental health consequences of COVID-19 deaths are likely to overwhelm an already tattered U.S. mental health system, leading to a lack of access, particularly for the most vulnerable, experts warn.

“A second wave of devastation is imminent, attributable to mental health consequences of COVID-19,” write Naomi Simon, MD, and coauthors with the department of psychiatry, New York University.

In a Viewpoint article published in JAMA on Oct. 12, physicians offer some sobering statistics.

Since February 2020, COVID-19 has taken the lives of more than 214,000 Americans. The number of deaths currently attributed to the virus is nearly four times the number of Americans killed during the Vietnam War. The magnitude of death over a short period is a tragedy on a “historic scale,” wrote Dr. Simon and colleagues.

The surge in mental health problems related to COVID-19 deaths will bring further challenges to individuals, families, and communities, including a spike in deaths from suicide and drug overdoses, they warned.

It’s important to consider, they noted, that each COVID-19 death leaves an estimated nine family members bereaved, which is projected to lead to an estimated 2 million bereaved individuals in the United States.

“This interpersonal loss on a massive scale is compounded by societal disruption,” they wrote. The necessary social distancing and quarantine measures implemented to fight the virus have amplified emotional turmoil and have disrupted the ability of personal support networks and communities to come together and grieve.

“Of central concern is the transformation of normal grief and distress into prolonged grief and major depressive disorder and symptoms of posttraumatic stress disorder,” Simon and colleagues said.

“Once established, these conditions can become chronic with additional comorbidities such as substance use disorders. Prolonged grief affects approximately 10% of bereaved individuals, but this is likely an underestimate for grief related to deaths from COVID-19,” they wrote.

As with the first COVID-19 wave, the mental health wave will disproportionately affect Black persons, Hispanic persons, older adults, persons in lower socioeconomic groups of all races and ethnicities, and healthcare workers, they note.

The psychological risks for health care and other essential workers are of particular concern, they say. “Supporting the mental health of these and other essential workforce is critical to readiness for managing recurrent waves of the pandemic,” they stated.

How will the United States manage this impending wave of mental health problems?

“The solution will require increased funding for mental health; widespread screening to identify individuals at highest risk including suicide risk; availability of primary care clinicians and mental health professionals trained to treat those with prolonged grief, depression, traumatic stress, and substance abuse; and a diligent focus on families and communities to creatively restore the approaches by which they have managed tragedy and loss over generations,” the authors wrote.

“History has shown that societies recover from such devastation when leaders and members are joined by a shared purpose, acting in a unified way to facilitate recovery. In such societies, there is a shared understanding that its members must care for one another because the loss of one is a loss for all. Above all, this shared understanding must be restored,” they concluded.

Dr. Simon has received personal fees from Vanda Pharmaceuticals Inc, MGH Psychiatry Academy, Axovant Sciences, Springworks, Praxis Therapeutics, Aptinyx, Genomind, and Wiley (deputy editor, Depression and Anxiety). Saxe has received royalties from Guilford Press for the book Trauma Systems Therapy for Children and Teens (2016). Marmar serves on the scientific advisory board and owns equity in Receptor Life Sciences and serves on the PTSD advisory board for Otsuka Pharmaceutical.
 

A version of this article originally appeared on Medscape.com.

Have you been surprised and impressed by a child who says after a visit, “Thank you, Doctor [Howard]”? While it may seem antiquated to teach such manners to children these days, there are several important benefits to this education.

monkeybusinessimages/thinkstockphotos.com

Manners serve important functions in benefiting a person’s group with cohesiveness and the individuals themselves with acceptance in the group. Use of manners instantly suggests a more trustworthy person.

There are three main categories of manners: hygiene, courtesy, and cultural norm manners.

Hygiene manners, from using the toilet to refraining from picking one’s nose, have obvious health benefits of not spreading disease. Hygiene manners take time to teach, but parents are motivated and helped by natural reactions of disgust that even infants recognize.

Courtesy manners, on the other hand, are habits of self-control and good-faith behaviors that signal that one is putting the interests of others ahead of one’s own for the moment. Taking another’s comfort into account, basic to kindness and respect, does not require agreeing with or submitting to the other. Courtesy manners require a developing self-awareness (I can choose to act this way) and awareness of social status (I am not more important than everyone else) that begins in toddlerhood. Modeling manners around the child is the most important way to teach courtesy. Parents usually start actively teaching the child to say “please” and “thank you,” and show pride in this apparent “demonstration of appreciation” even when it is simply reinforced behavior at first. The delight of grandparents reinforces both the parents and children, and reflects manners as building tribe cohesiveness.
 

Good manners become a habit

Manners such as warm greetings, a firm handshake (before COVID-19), and prompt thanks are most believable when occurring promptly when appropriate – when they come from habit. This immediate reaction, a result of so-called “fast thinking,” develops when behaviors learned from “slow thinking” are instilled early and often until they are automatic. The other benefit of this overlearning is that the behavior then looks unambivalent; a lag of too many milliseconds makes the recipient doubt genuineness.

Parents often ask us how to handle their child‘s rude or disrespectful behavior. Praise for manners is a simple start. Toddlers and preschoolers are taught manners best by adult modeling, but also by reinforcement and praise for the basics: to say “Hello,” ask “Please,” and say “Thank you,” “Excuse me,” “You’re welcome,” or “Would you help me, please?” The behaviors also include avoiding raising one’s voice, suppressing interrupting, and apologizing when appropriate. Even shy children can learn eye contact by making a game of figuring out the other’s eye color. Shaming, yelling, and punishing for poor manners usually backfires because it shows disrespect of the child who will likely give this back.

Older children can be taught to offer other people the opportunity to go through a door first, to be first to select a seat, speak first and without interruption, or order first. There are daily opportunities for these manners of showing respect. Opening doors for others, or standing when a guest enters the room are more formal but still appreciated. Parents who use and expect courtesy manners with everyone – irrespective of gender, race, ethnicity, or role as a server versus professional – show that they value others and build antiracism.

School age is a time to learn to wait before speaking to consider whether what they say could be experienced as hurtful to the other person. This requires taking someone else’s point of view, an ability that emerges around age 6 years and can be promoted when parents review with their child “How would you feel if it were you?” Role playing common scenarios of how to behave and speak when seeing a person who looks or acts different is also effective. Avoiding interrupting may be more difficult for very talkative or impulsive children, especially those with ADHD. Practicing waiting for permission to speak by being handed a “talking stick” at the dinner table can be good practice for everyone.
 

Manners are a group asset

Beyond personal benefits, manners are the basis of a civil society. Manners contribute to mutual respect, effective communication, and team collaboration. Cultural norm manners are particular to groups, helping members feel affiliated, as well as identifying those with different manners as “other.”

Teens are particularly likely to use a different code of behavior to fit in with a subgroup. This may be acceptable if restricted to within their group (such as swear words) or within certain agreed-upon limits with family members. But teens need to understand the value of learning, practicing, and using manners for their own, as well as their group’s and nation’s, well-being.

As a developmental-behavioral pediatrician, I have cared for many children with intellectual disabilities and autism spectrum disorder (ASD). Deficits in social interaction skills are a basic criterion for the diagnosis of ASD. Overtraining is especially needed for children with ASD whose mirror movements, social attention, and imitation are weak. For children with these conditions, making manners a strong habit takes more effort but is even more vital than for neurotypical children. Temple Grandin, a famous adult with ASD, has described how her mother taught her manners as a survival skill. She reports incorporating manners very consciously and methodically because they did not come naturally. Children with even rote social skills are liked better by peers and teachers, their atypical behaviors is better tolerated, and they get more positive feedback that encourages integration inside and outside the classroom. Manners may make the difference between being allowed in or expelled from classrooms, libraries, clubs, teams, or religious institutions. When it is time to get a job, social skills are the key factor for employment for these individuals and a significant help for neurotypical individuals as well. Failure to signal socially appropriate behavior can make a person appear threatening and has had the rare but tragic result of rough or fatal handling by police.

Has the teaching of manners waned? Perhaps, because, for some families, the child is being socialized mostly by nonfamily caregivers who have low use of manners. Some parents have made teaching manners a low priority or even resisted using manners themselves as inauthentic. This may reflect prioritizing a “laid-back” lifestyle and speaking crudely as a sign of independence, perhaps in reaction to lack of autonomy at work. Mastering the careful interactions developed over time to avoid invoking an aggressive response depend on direct feedback from reactions of the recipient. With so much of our communication done electronically, asynchronously, even anonymously, the usual feedback has been reduced. Practicing curses, insults, and put-downs online easily extends to in-person interactions without the perpetrator even noticing and are generally reinforced and repeated without parental supervision. Disrespectful behavior from community leaders also reduces the threshold for society.

When people are ignorant of or choose not to use manners they may be perceived as “other” and hostile. This may lead to distrust, dislike, and lowered ability to find the common ground needed for making decisions that benefit the greater society. Oliver Wendell Holmes said “Under bad manners ... lies very commonly an overestimate of our special individuality, as distinguished from our generic humanity (“The Professor at the Breakfast Table,” 1858). Working for major goals that benefit all of humanity is essential to survival in our highly interconnected world. Considering all of humanity is a difficult concept for children, and even for many adults, but it starts with using civil behavior at home, in school, and in one’s community.
 

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

Have you been surprised and impressed by a child who says after a visit, “Thank you, Doctor [Howard]”? While it may seem antiquated to teach such manners to children these days, there are several important benefits to this education.

monkeybusinessimages/thinkstockphotos.com

Manners serve important functions in benefiting a person’s group with cohesiveness and the individuals themselves with acceptance in the group. Use of manners instantly suggests a more trustworthy person.

There are three main categories of manners: hygiene, courtesy, and cultural norm manners.

Hygiene manners, from using the toilet to refraining from picking one’s nose, have obvious health benefits of not spreading disease. Hygiene manners take time to teach, but parents are motivated and helped by natural reactions of disgust that even infants recognize.

Courtesy manners, on the other hand, are habits of self-control and good-faith behaviors that signal that one is putting the interests of others ahead of one’s own for the moment. Taking another’s comfort into account, basic to kindness and respect, does not require agreeing with or submitting to the other. Courtesy manners require a developing self-awareness (I can choose to act this way) and awareness of social status (I am not more important than everyone else) that begins in toddlerhood. Modeling manners around the child is the most important way to teach courtesy. Parents usually start actively teaching the child to say “please” and “thank you,” and show pride in this apparent “demonstration of appreciation” even when it is simply reinforced behavior at first. The delight of grandparents reinforces both the parents and children, and reflects manners as building tribe cohesiveness.
 

Good manners become a habit

Manners such as warm greetings, a firm handshake (before COVID-19), and prompt thanks are most believable when occurring promptly when appropriate – when they come from habit. This immediate reaction, a result of so-called “fast thinking,” develops when behaviors learned from “slow thinking” are instilled early and often until they are automatic. The other benefit of this overlearning is that the behavior then looks unambivalent; a lag of too many milliseconds makes the recipient doubt genuineness.

Parents often ask us how to handle their child‘s rude or disrespectful behavior. Praise for manners is a simple start. Toddlers and preschoolers are taught manners best by adult modeling, but also by reinforcement and praise for the basics: to say “Hello,” ask “Please,” and say “Thank you,” “Excuse me,” “You’re welcome,” or “Would you help me, please?” The behaviors also include avoiding raising one’s voice, suppressing interrupting, and apologizing when appropriate. Even shy children can learn eye contact by making a game of figuring out the other’s eye color. Shaming, yelling, and punishing for poor manners usually backfires because it shows disrespect of the child who will likely give this back.

Older children can be taught to offer other people the opportunity to go through a door first, to be first to select a seat, speak first and without interruption, or order first. There are daily opportunities for these manners of showing respect. Opening doors for others, or standing when a guest enters the room are more formal but still appreciated. Parents who use and expect courtesy manners with everyone – irrespective of gender, race, ethnicity, or role as a server versus professional – show that they value others and build antiracism.

School age is a time to learn to wait before speaking to consider whether what they say could be experienced as hurtful to the other person. This requires taking someone else’s point of view, an ability that emerges around age 6 years and can be promoted when parents review with their child “How would you feel if it were you?” Role playing common scenarios of how to behave and speak when seeing a person who looks or acts different is also effective. Avoiding interrupting may be more difficult for very talkative or impulsive children, especially those with ADHD. Practicing waiting for permission to speak by being handed a “talking stick” at the dinner table can be good practice for everyone.
 

Manners are a group asset

Beyond personal benefits, manners are the basis of a civil society. Manners contribute to mutual respect, effective communication, and team collaboration. Cultural norm manners are particular to groups, helping members feel affiliated, as well as identifying those with different manners as “other.”

Teens are particularly likely to use a different code of behavior to fit in with a subgroup. This may be acceptable if restricted to within their group (such as swear words) or within certain agreed-upon limits with family members. But teens need to understand the value of learning, practicing, and using manners for their own, as well as their group’s and nation’s, well-being.

As a developmental-behavioral pediatrician, I have cared for many children with intellectual disabilities and autism spectrum disorder (ASD). Deficits in social interaction skills are a basic criterion for the diagnosis of ASD. Overtraining is especially needed for children with ASD whose mirror movements, social attention, and imitation are weak. For children with these conditions, making manners a strong habit takes more effort but is even more vital than for neurotypical children. Temple Grandin, a famous adult with ASD, has described how her mother taught her manners as a survival skill. She reports incorporating manners very consciously and methodically because they did not come naturally. Children with even rote social skills are liked better by peers and teachers, their atypical behaviors is better tolerated, and they get more positive feedback that encourages integration inside and outside the classroom. Manners may make the difference between being allowed in or expelled from classrooms, libraries, clubs, teams, or religious institutions. When it is time to get a job, social skills are the key factor for employment for these individuals and a significant help for neurotypical individuals as well. Failure to signal socially appropriate behavior can make a person appear threatening and has had the rare but tragic result of rough or fatal handling by police.

Has the teaching of manners waned? Perhaps, because, for some families, the child is being socialized mostly by nonfamily caregivers who have low use of manners. Some parents have made teaching manners a low priority or even resisted using manners themselves as inauthentic. This may reflect prioritizing a “laid-back” lifestyle and speaking crudely as a sign of independence, perhaps in reaction to lack of autonomy at work. Mastering the careful interactions developed over time to avoid invoking an aggressive response depend on direct feedback from reactions of the recipient. With so much of our communication done electronically, asynchronously, even anonymously, the usual feedback has been reduced. Practicing curses, insults, and put-downs online easily extends to in-person interactions without the perpetrator even noticing and are generally reinforced and repeated without parental supervision. Disrespectful behavior from community leaders also reduces the threshold for society.

When people are ignorant of or choose not to use manners they may be perceived as “other” and hostile. This may lead to distrust, dislike, and lowered ability to find the common ground needed for making decisions that benefit the greater society. Oliver Wendell Holmes said “Under bad manners ... lies very commonly an overestimate of our special individuality, as distinguished from our generic humanity (“The Professor at the Breakfast Table,” 1858). Working for major goals that benefit all of humanity is essential to survival in our highly interconnected world. Considering all of humanity is a difficult concept for children, and even for many adults, but it starts with using civil behavior at home, in school, and in one’s community.
 

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

Have you been surprised and impressed by a child who says after a visit, “Thank you, Doctor [Howard]”? While it may seem antiquated to teach such manners to children these days, there are several important benefits to this education.

monkeybusinessimages/thinkstockphotos.com

Manners serve important functions in benefiting a person’s group with cohesiveness and the individuals themselves with acceptance in the group. Use of manners instantly suggests a more trustworthy person.

There are three main categories of manners: hygiene, courtesy, and cultural norm manners.

Hygiene manners, from using the toilet to refraining from picking one’s nose, have obvious health benefits of not spreading disease. Hygiene manners take time to teach, but parents are motivated and helped by natural reactions of disgust that even infants recognize.

Courtesy manners, on the other hand, are habits of self-control and good-faith behaviors that signal that one is putting the interests of others ahead of one’s own for the moment. Taking another’s comfort into account, basic to kindness and respect, does not require agreeing with or submitting to the other. Courtesy manners require a developing self-awareness (I can choose to act this way) and awareness of social status (I am not more important than everyone else) that begins in toddlerhood. Modeling manners around the child is the most important way to teach courtesy. Parents usually start actively teaching the child to say “please” and “thank you,” and show pride in this apparent “demonstration of appreciation” even when it is simply reinforced behavior at first. The delight of grandparents reinforces both the parents and children, and reflects manners as building tribe cohesiveness.
 

Good manners become a habit

Manners such as warm greetings, a firm handshake (before COVID-19), and prompt thanks are most believable when occurring promptly when appropriate – when they come from habit. This immediate reaction, a result of so-called “fast thinking,” develops when behaviors learned from “slow thinking” are instilled early and often until they are automatic. The other benefit of this overlearning is that the behavior then looks unambivalent; a lag of too many milliseconds makes the recipient doubt genuineness.

Parents often ask us how to handle their child‘s rude or disrespectful behavior. Praise for manners is a simple start. Toddlers and preschoolers are taught manners best by adult modeling, but also by reinforcement and praise for the basics: to say “Hello,” ask “Please,” and say “Thank you,” “Excuse me,” “You’re welcome,” or “Would you help me, please?” The behaviors also include avoiding raising one’s voice, suppressing interrupting, and apologizing when appropriate. Even shy children can learn eye contact by making a game of figuring out the other’s eye color. Shaming, yelling, and punishing for poor manners usually backfires because it shows disrespect of the child who will likely give this back.

Older children can be taught to offer other people the opportunity to go through a door first, to be first to select a seat, speak first and without interruption, or order first. There are daily opportunities for these manners of showing respect. Opening doors for others, or standing when a guest enters the room are more formal but still appreciated. Parents who use and expect courtesy manners with everyone – irrespective of gender, race, ethnicity, or role as a server versus professional – show that they value others and build antiracism.

School age is a time to learn to wait before speaking to consider whether what they say could be experienced as hurtful to the other person. This requires taking someone else’s point of view, an ability that emerges around age 6 years and can be promoted when parents review with their child “How would you feel if it were you?” Role playing common scenarios of how to behave and speak when seeing a person who looks or acts different is also effective. Avoiding interrupting may be more difficult for very talkative or impulsive children, especially those with ADHD. Practicing waiting for permission to speak by being handed a “talking stick” at the dinner table can be good practice for everyone.
 

Manners are a group asset

Beyond personal benefits, manners are the basis of a civil society. Manners contribute to mutual respect, effective communication, and team collaboration. Cultural norm manners are particular to groups, helping members feel affiliated, as well as identifying those with different manners as “other.”

Teens are particularly likely to use a different code of behavior to fit in with a subgroup. This may be acceptable if restricted to within their group (such as swear words) or within certain agreed-upon limits with family members. But teens need to understand the value of learning, practicing, and using manners for their own, as well as their group’s and nation’s, well-being.

As a developmental-behavioral pediatrician, I have cared for many children with intellectual disabilities and autism spectrum disorder (ASD). Deficits in social interaction skills are a basic criterion for the diagnosis of ASD. Overtraining is especially needed for children with ASD whose mirror movements, social attention, and imitation are weak. For children with these conditions, making manners a strong habit takes more effort but is even more vital than for neurotypical children. Temple Grandin, a famous adult with ASD, has described how her mother taught her manners as a survival skill. She reports incorporating manners very consciously and methodically because they did not come naturally. Children with even rote social skills are liked better by peers and teachers, their atypical behaviors is better tolerated, and they get more positive feedback that encourages integration inside and outside the classroom. Manners may make the difference between being allowed in or expelled from classrooms, libraries, clubs, teams, or religious institutions. When it is time to get a job, social skills are the key factor for employment for these individuals and a significant help for neurotypical individuals as well. Failure to signal socially appropriate behavior can make a person appear threatening and has had the rare but tragic result of rough or fatal handling by police.

Has the teaching of manners waned? Perhaps, because, for some families, the child is being socialized mostly by nonfamily caregivers who have low use of manners. Some parents have made teaching manners a low priority or even resisted using manners themselves as inauthentic. This may reflect prioritizing a “laid-back” lifestyle and speaking crudely as a sign of independence, perhaps in reaction to lack of autonomy at work. Mastering the careful interactions developed over time to avoid invoking an aggressive response depend on direct feedback from reactions of the recipient. With so much of our communication done electronically, asynchronously, even anonymously, the usual feedback has been reduced. Practicing curses, insults, and put-downs online easily extends to in-person interactions without the perpetrator even noticing and are generally reinforced and repeated without parental supervision. Disrespectful behavior from community leaders also reduces the threshold for society.

When people are ignorant of or choose not to use manners they may be perceived as “other” and hostile. This may lead to distrust, dislike, and lowered ability to find the common ground needed for making decisions that benefit the greater society. Oliver Wendell Holmes said “Under bad manners ... lies very commonly an overestimate of our special individuality, as distinguished from our generic humanity (“The Professor at the Breakfast Table,” 1858). Working for major goals that benefit all of humanity is essential to survival in our highly interconnected world. Considering all of humanity is a difficult concept for children, and even for many adults, but it starts with using civil behavior at home, in school, and in one’s community.
 

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

Starting early intervention (EI) enrollment before age 6 months in children who are deaf or hard of hearing may have a lasting influence on ensuring kindergarten readiness, Jareen Meinzen-Derr, PhD, MPH of Cincinnati Children’s Hospital Medical Center and colleagues reported in Pediatrics.

The researchers created a comprehensive, longitudinal, population-based database, which linked hearing screening and diagnostic data to that of early intervention data and educational records for 1,746 infants identified with permanent hearing loss who were born between Jan. 1, 2008 and Dec. 31, 2014 The database was established in partnership with the Ohio Departments of Health, Developmental Disabilities and Education, and with the support of the Centers for Disease Control and Prevention and the National Center on Birth Defects and Developmental Disabilities.

Of those, 784 children ranging from preschool to fourth grade were evaluated based on education data available for the 2017 and 2018 school year that had been linked by way of an identifier that flagged students enrolled in EI.

All together, 417 students had kindergarten assessment records, and of those, 385 had Kindergarten Readiness Assessments (KRAs) between 2014 and 2018; 222 (58%) had been enrolled in EI before the age of 6 months. Of those who were enrolled early, the median age of EI enrollment was 3.4 months (2.4-4.3 months) and in those enrolled later, the median age was 9.2 months (7.5-15.4 months).
 

The importance of EI prior to 6 months

A total of 109 children (28%) receiving services as part of Ohio’s early intervention programs demonstrated kindergarten readiness on their overall KRA scores. The scores revealed that children receiving EI early (34%, n = 75) were more likely to be ready for kindergarten than were those who entered later (21%, n = 34; P = .005). They also were more likely to have on track language and literacy scores (60% vs. 42%, respectively; P = .0006).

Dr. Meinzen-Derr and colleagues noted that factors identified with “an increased odds of being on track included having private insurance and some college education for the mother.” Conversely, factors identified with a decreased likelihood included having a diagnosed disability and bilateral hearing loss.

The researchers cautioned that children transitioned from EI to academic settings will face challenges that may go underrecognized because a school’s focus often is largely on social and academic performance. Thus, working with linked data systems can provide the data to track outcomes that might otherwise be missed, the researchers noted.

Furthermore, they cautioned that even though kindergarten readiness offers some glimpse into future academic success, these measures alone may not be sufficient predictors for children who are deaf or hard of hearing. Risk for communication, social, and academic delays persist throughout school so it is important to employ alternative methods of reading instruction in order to “achieve more complex skills (e.g., complex syntax and advanced vocabulary) necessary for reading proficiency,” the researchers said.

Collecting data from public health and education systems posed limitations for the study. In addition, the absence of kindergarten language assessments prevented Dr. Meinzen-Derr and colleagues from better elucidating reasons for kindergarten readiness. Also beyond the scope of the study was the ability to evaluate the effect service types may have had on outcomes.

The next step in the research process is to evaluate the link between outcomes and specific EI parameters, they said. “Our study demonstrates that an integrated data system can address relevant and important topics regarding early academic outcomes (kindergarten readiness and reading levels) among children who received EI. The current findings provide a new context by evaluating later outcomes among children who are deaf or hard of hearing,” they added, noting that more research is needed to grasp how various EI services impact outcomes since enrollment age is a marker of EI exposure.
 

Early intervention is everyone’s business

In a separate interview, Amy Hardy M.S. CCC-SLP, speech language pathologist and clinical professor at Idaho State University, emphasized the importance of early intervention, citing reports from the National Center for Hearing Assessment and Management, which credits detection and treatment of hearing loss at birth per child to saving $400,000 in special education costs by the time they graduate from high school (https://www.ncsl.org/research/health/newborn-hearing-screening-state-laws.aspx).

Earliest possible hearing detection is and should be a standard of care for infants and children, and the importance of follow up appointments also cannot be understated,” Ms. Hardy said. Perhaps the biggest challenge for professionals involved with early learning is that many children are delayed in receiving follow up appointments for hearing detection, she added. When families fail to receive a follow-up notice or opt not attend the follow-up appointment, this leaves infants that may be deaf or hard of hearing unidentified, she explained, noting that in some states, lack of consistent and stable state funding needed for effective follow-up with these children and families is a factor.

Ms. Hardy urged that anyone who knows an expectant family can tout the importance of early screenings. Even daycare workers have a responsibility to play a role in early hearing detection, she noted.

Although speech language pathologists routinely advocate for early intervention, “it is never too late to work on skills that will assist children in their everyday lives,” she advised.

The authors had no relevant financial disclosures. The study was funded in part by the Disability Research and Dissemination Center via cooperative agreements with the Centers for Disease Control and Prevention.

SOURCE: Meinzen-Derr J et al. Pediatrics. 2020 October. doi: 10.1542/peds.2020-0557.

Starting early intervention (EI) enrollment before age 6 months in children who are deaf or hard of hearing may have a lasting influence on ensuring kindergarten readiness, Jareen Meinzen-Derr, PhD, MPH of Cincinnati Children’s Hospital Medical Center and colleagues reported in Pediatrics.

The researchers created a comprehensive, longitudinal, population-based database, which linked hearing screening and diagnostic data to that of early intervention data and educational records for 1,746 infants identified with permanent hearing loss who were born between Jan. 1, 2008 and Dec. 31, 2014 The database was established in partnership with the Ohio Departments of Health, Developmental Disabilities and Education, and with the support of the Centers for Disease Control and Prevention and the National Center on Birth Defects and Developmental Disabilities.

Of those, 784 children ranging from preschool to fourth grade were evaluated based on education data available for the 2017 and 2018 school year that had been linked by way of an identifier that flagged students enrolled in EI.

All together, 417 students had kindergarten assessment records, and of those, 385 had Kindergarten Readiness Assessments (KRAs) between 2014 and 2018; 222 (58%) had been enrolled in EI before the age of 6 months. Of those who were enrolled early, the median age of EI enrollment was 3.4 months (2.4-4.3 months) and in those enrolled later, the median age was 9.2 months (7.5-15.4 months).
 

The importance of EI prior to 6 months

A total of 109 children (28%) receiving services as part of Ohio’s early intervention programs demonstrated kindergarten readiness on their overall KRA scores. The scores revealed that children receiving EI early (34%, n = 75) were more likely to be ready for kindergarten than were those who entered later (21%, n = 34; P = .005). They also were more likely to have on track language and literacy scores (60% vs. 42%, respectively; P = .0006).

Dr. Meinzen-Derr and colleagues noted that factors identified with “an increased odds of being on track included having private insurance and some college education for the mother.” Conversely, factors identified with a decreased likelihood included having a diagnosed disability and bilateral hearing loss.

The researchers cautioned that children transitioned from EI to academic settings will face challenges that may go underrecognized because a school’s focus often is largely on social and academic performance. Thus, working with linked data systems can provide the data to track outcomes that might otherwise be missed, the researchers noted.

Furthermore, they cautioned that even though kindergarten readiness offers some glimpse into future academic success, these measures alone may not be sufficient predictors for children who are deaf or hard of hearing. Risk for communication, social, and academic delays persist throughout school so it is important to employ alternative methods of reading instruction in order to “achieve more complex skills (e.g., complex syntax and advanced vocabulary) necessary for reading proficiency,” the researchers said.

Collecting data from public health and education systems posed limitations for the study. In addition, the absence of kindergarten language assessments prevented Dr. Meinzen-Derr and colleagues from better elucidating reasons for kindergarten readiness. Also beyond the scope of the study was the ability to evaluate the effect service types may have had on outcomes.

The next step in the research process is to evaluate the link between outcomes and specific EI parameters, they said. “Our study demonstrates that an integrated data system can address relevant and important topics regarding early academic outcomes (kindergarten readiness and reading levels) among children who received EI. The current findings provide a new context by evaluating later outcomes among children who are deaf or hard of hearing,” they added, noting that more research is needed to grasp how various EI services impact outcomes since enrollment age is a marker of EI exposure.
 

Early intervention is everyone’s business

In a separate interview, Amy Hardy M.S. CCC-SLP, speech language pathologist and clinical professor at Idaho State University, emphasized the importance of early intervention, citing reports from the National Center for Hearing Assessment and Management, which credits detection and treatment of hearing loss at birth per child to saving $400,000 in special education costs by the time they graduate from high school (https://www.ncsl.org/research/health/newborn-hearing-screening-state-laws.aspx).

Earliest possible hearing detection is and should be a standard of care for infants and children, and the importance of follow up appointments also cannot be understated,” Ms. Hardy said. Perhaps the biggest challenge for professionals involved with early learning is that many children are delayed in receiving follow up appointments for hearing detection, she added. When families fail to receive a follow-up notice or opt not attend the follow-up appointment, this leaves infants that may be deaf or hard of hearing unidentified, she explained, noting that in some states, lack of consistent and stable state funding needed for effective follow-up with these children and families is a factor.

Ms. Hardy urged that anyone who knows an expectant family can tout the importance of early screenings. Even daycare workers have a responsibility to play a role in early hearing detection, she noted.

Although speech language pathologists routinely advocate for early intervention, “it is never too late to work on skills that will assist children in their everyday lives,” she advised.

The authors had no relevant financial disclosures. The study was funded in part by the Disability Research and Dissemination Center via cooperative agreements with the Centers for Disease Control and Prevention.

SOURCE: Meinzen-Derr J et al. Pediatrics. 2020 October. doi: 10.1542/peds.2020-0557.

Starting early intervention (EI) enrollment before age 6 months in children who are deaf or hard of hearing may have a lasting influence on ensuring kindergarten readiness, Jareen Meinzen-Derr, PhD, MPH of Cincinnati Children’s Hospital Medical Center and colleagues reported in Pediatrics.

The researchers created a comprehensive, longitudinal, population-based database, which linked hearing screening and diagnostic data to that of early intervention data and educational records for 1,746 infants identified with permanent hearing loss who were born between Jan. 1, 2008 and Dec. 31, 2014 The database was established in partnership with the Ohio Departments of Health, Developmental Disabilities and Education, and with the support of the Centers for Disease Control and Prevention and the National Center on Birth Defects and Developmental Disabilities.

Of those, 784 children ranging from preschool to fourth grade were evaluated based on education data available for the 2017 and 2018 school year that had been linked by way of an identifier that flagged students enrolled in EI.

All together, 417 students had kindergarten assessment records, and of those, 385 had Kindergarten Readiness Assessments (KRAs) between 2014 and 2018; 222 (58%) had been enrolled in EI before the age of 6 months. Of those who were enrolled early, the median age of EI enrollment was 3.4 months (2.4-4.3 months) and in those enrolled later, the median age was 9.2 months (7.5-15.4 months).
 

The importance of EI prior to 6 months

A total of 109 children (28%) receiving services as part of Ohio’s early intervention programs demonstrated kindergarten readiness on their overall KRA scores. The scores revealed that children receiving EI early (34%, n = 75) were more likely to be ready for kindergarten than were those who entered later (21%, n = 34; P = .005). They also were more likely to have on track language and literacy scores (60% vs. 42%, respectively; P = .0006).

Dr. Meinzen-Derr and colleagues noted that factors identified with “an increased odds of being on track included having private insurance and some college education for the mother.” Conversely, factors identified with a decreased likelihood included having a diagnosed disability and bilateral hearing loss.

The researchers cautioned that children transitioned from EI to academic settings will face challenges that may go underrecognized because a school’s focus often is largely on social and academic performance. Thus, working with linked data systems can provide the data to track outcomes that might otherwise be missed, the researchers noted.

Furthermore, they cautioned that even though kindergarten readiness offers some glimpse into future academic success, these measures alone may not be sufficient predictors for children who are deaf or hard of hearing. Risk for communication, social, and academic delays persist throughout school so it is important to employ alternative methods of reading instruction in order to “achieve more complex skills (e.g., complex syntax and advanced vocabulary) necessary for reading proficiency,” the researchers said.

Collecting data from public health and education systems posed limitations for the study. In addition, the absence of kindergarten language assessments prevented Dr. Meinzen-Derr and colleagues from better elucidating reasons for kindergarten readiness. Also beyond the scope of the study was the ability to evaluate the effect service types may have had on outcomes.

The next step in the research process is to evaluate the link between outcomes and specific EI parameters, they said. “Our study demonstrates that an integrated data system can address relevant and important topics regarding early academic outcomes (kindergarten readiness and reading levels) among children who received EI. The current findings provide a new context by evaluating later outcomes among children who are deaf or hard of hearing,” they added, noting that more research is needed to grasp how various EI services impact outcomes since enrollment age is a marker of EI exposure.
 

Early intervention is everyone’s business

In a separate interview, Amy Hardy M.S. CCC-SLP, speech language pathologist and clinical professor at Idaho State University, emphasized the importance of early intervention, citing reports from the National Center for Hearing Assessment and Management, which credits detection and treatment of hearing loss at birth per child to saving $400,000 in special education costs by the time they graduate from high school (https://www.ncsl.org/research/health/newborn-hearing-screening-state-laws.aspx).

Earliest possible hearing detection is and should be a standard of care for infants and children, and the importance of follow up appointments also cannot be understated,” Ms. Hardy said. Perhaps the biggest challenge for professionals involved with early learning is that many children are delayed in receiving follow up appointments for hearing detection, she added. When families fail to receive a follow-up notice or opt not attend the follow-up appointment, this leaves infants that may be deaf or hard of hearing unidentified, she explained, noting that in some states, lack of consistent and stable state funding needed for effective follow-up with these children and families is a factor.

Ms. Hardy urged that anyone who knows an expectant family can tout the importance of early screenings. Even daycare workers have a responsibility to play a role in early hearing detection, she noted.

Although speech language pathologists routinely advocate for early intervention, “it is never too late to work on skills that will assist children in their everyday lives,” she advised.

The authors had no relevant financial disclosures. The study was funded in part by the Disability Research and Dissemination Center via cooperative agreements with the Centers for Disease Control and Prevention.

SOURCE: Meinzen-Derr J et al. Pediatrics. 2020 October. doi: 10.1542/peds.2020-0557.

Each year on Oct. 10, the world takes a moment to commemorate the significance of mental health and its impact on an individual’s life. This year, as we continue to reflect beyond World Mental Health Day, we see the world in a different light. Creating awareness for mental health issues and expanding access to psychiatric services has now become more essential than ever before.

The year 2020 will forever be known as the beginning of the “COVID era” as, unfortunately, the whole world as we know it adapts and reconstructs amid the rise of this global pandemic. This era has brought with it a wave of unemployment, social isolation, economic disaster, death, and disability. It is inevitable that such changes have brought forth perpetual fear and uncertainty, which have taken their toll not only on individuals’ physical health but largely on their mental health as well.

Factors that perpetuate deteriorating mental health include unemployment, poverty, isolation, fear and loss of loved ones – all of which have been further exacerbated globally, thanks to the current pandemic. According to the World Health Organization (WHO), 450 million people in the world suffer from mental illness, and one in four individuals are affected by mental illness in some stage of their lives. This means that mental illness accounts for 13% of the total global burden of disease.

The past few months have been particularly challenging for health care workers around the globe. These challenges include providing care in difficult circumstances, going to work afraid of bringing COVID-19 home, and vulnerability toward becoming mentally and physically ill. An immense sense of responsibility toward patients with mental illness, coupled with continuous fear of becoming infected with this novel virus, has made managing the mental health of our patients all the more challenging.

As a psychiatrist (A.A.M.), I have noticed a massive increase in both the incidence and prevalence of mental illness. Emergency departments are full of patients presenting with suicidal attempts/ideation. Substance abuse has increased in greater magnitude, and outpatients are presenting with escalating numbers of depression and anxiety. Relapse of symptoms among stable patients has been another major problem. Incidents of domestic violence, road rage, and impaired driving secondary to alcoholism leading to psychiatric consultations have also risen drastically.

Mental health units in hospitals are tremendously busy with scarce availability of beds. The increase in waiting times for allocation of beds has also become a major concern globally.

Governments have allocated more funds and are actively attempting to mobilize resources in the developed world. However, adapting to the circumstances has proven to be far more challenging in many regions of the developing world. To avoid personal contacts in health settings, governments have allowed virtual consultations, which has proven to be a highly commendable decision. The use of telephone and video consultations has allowed physicians, particularly psychiatrists, to continue to provide health care to their patients while maintaining social distance. Crisis services have also become far more active, which can help in alleviating mental health emergencies to a great extent.

International crisis is possible

According to the director of the World Federation for Mental Health, citing the report of World Economic Forum, mental health problems could cost the global economy up to $16 trillion between 2010 and 2030, and if this matter is not addressed, it could potentially lead to an international mental health crisis. If the pandemic continues to create such a large impact for a prolonged period of time, the state of mental health globally will continue to be a major concern.

Universal effort is imperative to strengthen the mental health service and increase our ability to provide care for vulnerable individuals. This can be achieved through collaboration with other stakeholders, the allied health sector, the WHO, and the World Bank. The efforts should be directed toward the availability of funds, mobilizing and enhancing resources and training health care and crisis workers. This focus should not only be for developed countries but also for developing countries alike because we are all suffering from the impacts of this global crisis together.

It is important to raise awareness and support one another now more than ever before as we strive to improve and strengthen our mental health on this World Mental Health Day.
 

Dr. Muhammad is clinical professor of psychiatry at McMaster University, Hamilton, Ont. Ms. Amin is a 5th-year MBBS student at St. George’s University Hospital in London.

Each year on Oct. 10, the world takes a moment to commemorate the significance of mental health and its impact on an individual’s life. This year, as we continue to reflect beyond World Mental Health Day, we see the world in a different light. Creating awareness for mental health issues and expanding access to psychiatric services has now become more essential than ever before.

The year 2020 will forever be known as the beginning of the “COVID era” as, unfortunately, the whole world as we know it adapts and reconstructs amid the rise of this global pandemic. This era has brought with it a wave of unemployment, social isolation, economic disaster, death, and disability. It is inevitable that such changes have brought forth perpetual fear and uncertainty, which have taken their toll not only on individuals’ physical health but largely on their mental health as well.

Factors that perpetuate deteriorating mental health include unemployment, poverty, isolation, fear and loss of loved ones – all of which have been further exacerbated globally, thanks to the current pandemic. According to the World Health Organization (WHO), 450 million people in the world suffer from mental illness, and one in four individuals are affected by mental illness in some stage of their lives. This means that mental illness accounts for 13% of the total global burden of disease.

The past few months have been particularly challenging for health care workers around the globe. These challenges include providing care in difficult circumstances, going to work afraid of bringing COVID-19 home, and vulnerability toward becoming mentally and physically ill. An immense sense of responsibility toward patients with mental illness, coupled with continuous fear of becoming infected with this novel virus, has made managing the mental health of our patients all the more challenging.

As a psychiatrist (A.A.M.), I have noticed a massive increase in both the incidence and prevalence of mental illness. Emergency departments are full of patients presenting with suicidal attempts/ideation. Substance abuse has increased in greater magnitude, and outpatients are presenting with escalating numbers of depression and anxiety. Relapse of symptoms among stable patients has been another major problem. Incidents of domestic violence, road rage, and impaired driving secondary to alcoholism leading to psychiatric consultations have also risen drastically.

Mental health units in hospitals are tremendously busy with scarce availability of beds. The increase in waiting times for allocation of beds has also become a major concern globally.

Governments have allocated more funds and are actively attempting to mobilize resources in the developed world. However, adapting to the circumstances has proven to be far more challenging in many regions of the developing world. To avoid personal contacts in health settings, governments have allowed virtual consultations, which has proven to be a highly commendable decision. The use of telephone and video consultations has allowed physicians, particularly psychiatrists, to continue to provide health care to their patients while maintaining social distance. Crisis services have also become far more active, which can help in alleviating mental health emergencies to a great extent.

International crisis is possible

According to the director of the World Federation for Mental Health, citing the report of World Economic Forum, mental health problems could cost the global economy up to $16 trillion between 2010 and 2030, and if this matter is not addressed, it could potentially lead to an international mental health crisis. If the pandemic continues to create such a large impact for a prolonged period of time, the state of mental health globally will continue to be a major concern.

Universal effort is imperative to strengthen the mental health service and increase our ability to provide care for vulnerable individuals. This can be achieved through collaboration with other stakeholders, the allied health sector, the WHO, and the World Bank. The efforts should be directed toward the availability of funds, mobilizing and enhancing resources and training health care and crisis workers. This focus should not only be for developed countries but also for developing countries alike because we are all suffering from the impacts of this global crisis together.

It is important to raise awareness and support one another now more than ever before as we strive to improve and strengthen our mental health on this World Mental Health Day.
 

Dr. Muhammad is clinical professor of psychiatry at McMaster University, Hamilton, Ont. Ms. Amin is a 5th-year MBBS student at St. George’s University Hospital in London.

Each year on Oct. 10, the world takes a moment to commemorate the significance of mental health and its impact on an individual’s life. This year, as we continue to reflect beyond World Mental Health Day, we see the world in a different light. Creating awareness for mental health issues and expanding access to psychiatric services has now become more essential than ever before.

The year 2020 will forever be known as the beginning of the “COVID era” as, unfortunately, the whole world as we know it adapts and reconstructs amid the rise of this global pandemic. This era has brought with it a wave of unemployment, social isolation, economic disaster, death, and disability. It is inevitable that such changes have brought forth perpetual fear and uncertainty, which have taken their toll not only on individuals’ physical health but largely on their mental health as well.

Factors that perpetuate deteriorating mental health include unemployment, poverty, isolation, fear and loss of loved ones – all of which have been further exacerbated globally, thanks to the current pandemic. According to the World Health Organization (WHO), 450 million people in the world suffer from mental illness, and one in four individuals are affected by mental illness in some stage of their lives. This means that mental illness accounts for 13% of the total global burden of disease.

The past few months have been particularly challenging for health care workers around the globe. These challenges include providing care in difficult circumstances, going to work afraid of bringing COVID-19 home, and vulnerability toward becoming mentally and physically ill. An immense sense of responsibility toward patients with mental illness, coupled with continuous fear of becoming infected with this novel virus, has made managing the mental health of our patients all the more challenging.

As a psychiatrist (A.A.M.), I have noticed a massive increase in both the incidence and prevalence of mental illness. Emergency departments are full of patients presenting with suicidal attempts/ideation. Substance abuse has increased in greater magnitude, and outpatients are presenting with escalating numbers of depression and anxiety. Relapse of symptoms among stable patients has been another major problem. Incidents of domestic violence, road rage, and impaired driving secondary to alcoholism leading to psychiatric consultations have also risen drastically.

Mental health units in hospitals are tremendously busy with scarce availability of beds. The increase in waiting times for allocation of beds has also become a major concern globally.

Governments have allocated more funds and are actively attempting to mobilize resources in the developed world. However, adapting to the circumstances has proven to be far more challenging in many regions of the developing world. To avoid personal contacts in health settings, governments have allowed virtual consultations, which has proven to be a highly commendable decision. The use of telephone and video consultations has allowed physicians, particularly psychiatrists, to continue to provide health care to their patients while maintaining social distance. Crisis services have also become far more active, which can help in alleviating mental health emergencies to a great extent.

International crisis is possible

According to the director of the World Federation for Mental Health, citing the report of World Economic Forum, mental health problems could cost the global economy up to $16 trillion between 2010 and 2030, and if this matter is not addressed, it could potentially lead to an international mental health crisis. If the pandemic continues to create such a large impact for a prolonged period of time, the state of mental health globally will continue to be a major concern.

Universal effort is imperative to strengthen the mental health service and increase our ability to provide care for vulnerable individuals. This can be achieved through collaboration with other stakeholders, the allied health sector, the WHO, and the World Bank. The efforts should be directed toward the availability of funds, mobilizing and enhancing resources and training health care and crisis workers. This focus should not only be for developed countries but also for developing countries alike because we are all suffering from the impacts of this global crisis together.

It is important to raise awareness and support one another now more than ever before as we strive to improve and strengthen our mental health on this World Mental Health Day.
 

Dr. Muhammad is clinical professor of psychiatry at McMaster University, Hamilton, Ont. Ms. Amin is a 5th-year MBBS student at St. George’s University Hospital in London.

Increasing parental awareness of noncigarette tobacco products should be part of “tobacco anticipatory guidance and prevention support,” Tsu-Suan Wu and Benjamin W. Chaffee, DDS, PhD, of the University of California, San Francisco, advised in their study in Pediatrics.

Carpe89/ThinkStock

Previous studies have shown that children who grow up in a nonsmoking household are less likely to begin smoking themselves, and active parental engagement in interventions shows promise overall in protecting children from drug, alcohol, and illicit drug use. Households with rigid rules against smoking offer a deterrent for children who might otherwise be tempted, the researchers noted.

Other studies have shown that while youth smoking is on the decline, use of noncigarette products is increasing sharply. The inconspicuous appearance and attractive scents these delivery devices afford make it easier to conceal them from parents.

In the current study, using data from the Population Assessment of Tobacco and Health (PATH) Study involving 23,170 parents and youth ages 9 and up, Mr. Wu and Dr. Chaffee sought to assess to what extent parents had knowledge or suspicions of tobacco use and also to evaluate the association between youth initiating tobacco use and the establishment of household rules and engaging in regular conversation about tobacco.

Study results revealed in three of the four groups evaluated that youth were most likely to engage in using several different types of tobacco (polytobacco) products; in the fourth group, e-cigarette use was most common. Among polytobacco users, fully 77%-80% reported cigarette usage.
 

Parental knowledge and actions

Overall, Mr. Wu and Dr. Chaffee “identified substantial lapses in parents’ awareness of their children’s tobacco use.” Parents were most likely to register awareness when their children smoked cigarettes; half as many parents were aware or suspected use when noncigarette products were used.

Parents who had heightened awareness about possible tobacco usage tended to be the child’s mother, had completed lower levels of education, parented children who were older, male and non-Hispanic, and lived with a tobacco user.

Noteworthy was the growing percentage of parents who report awareness or suspicions of cigarette usage – approximately 70% – compared with previous study findings – about 40%. The researchers speculated that this increase could be directly tied to growing social concern regarding youth smoking. Unfortunately, parents will continue to be challenged to keep up with constantly changing e-cigarette designs in maintaining their awareness, Mr. Wu and Dr. Chaffee noted.

Establishing strict household rules was found to be more effective than just talking with youth about usage, which half of the youth reported their parents did. At all time points, the risk of tobacco initiation was 20%-26% lower for children who lived in a house with strict household rules forbidding any tobacco use by anyone. The researchers observed that success with the household rules method was best achieved with children at younger ages.

The study did not measure the quality or frequency of antitobacco conversations but it should not be concluded definitively that all parental communication is unhelpful, the researchers cautioned.

To their knowledge, this study is the first to analyze the effects of household antitobacco strategies on discouraging initiation the use of tobacco and other smoking products as well as assessing parental awareness surrounding tobacco usage among youth.
 

What to tell parents

In a separate interview, Kelly Curran, MD, MA, assistant professor of pediatrics at the University of Oklahoma, Oklahoma City, commented on the explosive growth of e-cigarette use in the last 7 years.

What makes e-cigs so difficult to detect is that they “can resemble common objects such as flash drives or pens, and as a result, can often be hidden or overlooked by parents,” noted Dr. Curran.

The most important message for parents from this study is that they have the potential to have a large impact in the prevention of tobacco initiation, she said. “This effort requires parents to ‘walk the walk’ instead of just ‘talking the talk.”

As the study revealed, simply talking to teens about not using tobacco products doesn’t decrease use, but “creating strict household rules around no tobacco use for all visitors and inhabitants has a significant impact in decreasing youth tobacco initiation – by nearly 25%,” she added. “When counseling patients and families about tobacco prevention, clinicians should encourage them to create a tobacco-free home.”

The study was funded by a National Institutes of Health grant and the Delta Dental Community Care Foundation. The authors have no relevant financial disclosures. Dr. Curran, who is a member of the Pediatric News editorial advisory board, said she had no relevant financial disclosures.

SOURCE: Wu T-S and Chaffee BW. Pediatrics 2020 October. doi: 10.1542/peds.2019-4034.

Increasing parental awareness of noncigarette tobacco products should be part of “tobacco anticipatory guidance and prevention support,” Tsu-Suan Wu and Benjamin W. Chaffee, DDS, PhD, of the University of California, San Francisco, advised in their study in Pediatrics.

Carpe89/ThinkStock

Previous studies have shown that children who grow up in a nonsmoking household are less likely to begin smoking themselves, and active parental engagement in interventions shows promise overall in protecting children from drug, alcohol, and illicit drug use. Households with rigid rules against smoking offer a deterrent for children who might otherwise be tempted, the researchers noted.

Other studies have shown that while youth smoking is on the decline, use of noncigarette products is increasing sharply. The inconspicuous appearance and attractive scents these delivery devices afford make it easier to conceal them from parents.

In the current study, using data from the Population Assessment of Tobacco and Health (PATH) Study involving 23,170 parents and youth ages 9 and up, Mr. Wu and Dr. Chaffee sought to assess to what extent parents had knowledge or suspicions of tobacco use and also to evaluate the association between youth initiating tobacco use and the establishment of household rules and engaging in regular conversation about tobacco.

Study results revealed in three of the four groups evaluated that youth were most likely to engage in using several different types of tobacco (polytobacco) products; in the fourth group, e-cigarette use was most common. Among polytobacco users, fully 77%-80% reported cigarette usage.
 

Parental knowledge and actions

Overall, Mr. Wu and Dr. Chaffee “identified substantial lapses in parents’ awareness of their children’s tobacco use.” Parents were most likely to register awareness when their children smoked cigarettes; half as many parents were aware or suspected use when noncigarette products were used.

Parents who had heightened awareness about possible tobacco usage tended to be the child’s mother, had completed lower levels of education, parented children who were older, male and non-Hispanic, and lived with a tobacco user.

Noteworthy was the growing percentage of parents who report awareness or suspicions of cigarette usage – approximately 70% – compared with previous study findings – about 40%. The researchers speculated that this increase could be directly tied to growing social concern regarding youth smoking. Unfortunately, parents will continue to be challenged to keep up with constantly changing e-cigarette designs in maintaining their awareness, Mr. Wu and Dr. Chaffee noted.

Establishing strict household rules was found to be more effective than just talking with youth about usage, which half of the youth reported their parents did. At all time points, the risk of tobacco initiation was 20%-26% lower for children who lived in a house with strict household rules forbidding any tobacco use by anyone. The researchers observed that success with the household rules method was best achieved with children at younger ages.

The study did not measure the quality or frequency of antitobacco conversations but it should not be concluded definitively that all parental communication is unhelpful, the researchers cautioned.

To their knowledge, this study is the first to analyze the effects of household antitobacco strategies on discouraging initiation the use of tobacco and other smoking products as well as assessing parental awareness surrounding tobacco usage among youth.
 

What to tell parents

In a separate interview, Kelly Curran, MD, MA, assistant professor of pediatrics at the University of Oklahoma, Oklahoma City, commented on the explosive growth of e-cigarette use in the last 7 years.

What makes e-cigs so difficult to detect is that they “can resemble common objects such as flash drives or pens, and as a result, can often be hidden or overlooked by parents,” noted Dr. Curran.

The most important message for parents from this study is that they have the potential to have a large impact in the prevention of tobacco initiation, she said. “This effort requires parents to ‘walk the walk’ instead of just ‘talking the talk.”

As the study revealed, simply talking to teens about not using tobacco products doesn’t decrease use, but “creating strict household rules around no tobacco use for all visitors and inhabitants has a significant impact in decreasing youth tobacco initiation – by nearly 25%,” she added. “When counseling patients and families about tobacco prevention, clinicians should encourage them to create a tobacco-free home.”

The study was funded by a National Institutes of Health grant and the Delta Dental Community Care Foundation. The authors have no relevant financial disclosures. Dr. Curran, who is a member of the Pediatric News editorial advisory board, said she had no relevant financial disclosures.

SOURCE: Wu T-S and Chaffee BW. Pediatrics 2020 October. doi: 10.1542/peds.2019-4034.

Increasing parental awareness of noncigarette tobacco products should be part of “tobacco anticipatory guidance and prevention support,” Tsu-Suan Wu and Benjamin W. Chaffee, DDS, PhD, of the University of California, San Francisco, advised in their study in Pediatrics.

Carpe89/ThinkStock

Previous studies have shown that children who grow up in a nonsmoking household are less likely to begin smoking themselves, and active parental engagement in interventions shows promise overall in protecting children from drug, alcohol, and illicit drug use. Households with rigid rules against smoking offer a deterrent for children who might otherwise be tempted, the researchers noted.

Other studies have shown that while youth smoking is on the decline, use of noncigarette products is increasing sharply. The inconspicuous appearance and attractive scents these delivery devices afford make it easier to conceal them from parents.

In the current study, using data from the Population Assessment of Tobacco and Health (PATH) Study involving 23,170 parents and youth ages 9 and up, Mr. Wu and Dr. Chaffee sought to assess to what extent parents had knowledge or suspicions of tobacco use and also to evaluate the association between youth initiating tobacco use and the establishment of household rules and engaging in regular conversation about tobacco.

Study results revealed in three of the four groups evaluated that youth were most likely to engage in using several different types of tobacco (polytobacco) products; in the fourth group, e-cigarette use was most common. Among polytobacco users, fully 77%-80% reported cigarette usage.
 

Parental knowledge and actions

Overall, Mr. Wu and Dr. Chaffee “identified substantial lapses in parents’ awareness of their children’s tobacco use.” Parents were most likely to register awareness when their children smoked cigarettes; half as many parents were aware or suspected use when noncigarette products were used.

Parents who had heightened awareness about possible tobacco usage tended to be the child’s mother, had completed lower levels of education, parented children who were older, male and non-Hispanic, and lived with a tobacco user.

Noteworthy was the growing percentage of parents who report awareness or suspicions of cigarette usage – approximately 70% – compared with previous study findings – about 40%. The researchers speculated that this increase could be directly tied to growing social concern regarding youth smoking. Unfortunately, parents will continue to be challenged to keep up with constantly changing e-cigarette designs in maintaining their awareness, Mr. Wu and Dr. Chaffee noted.

Establishing strict household rules was found to be more effective than just talking with youth about usage, which half of the youth reported their parents did. At all time points, the risk of tobacco initiation was 20%-26% lower for children who lived in a house with strict household rules forbidding any tobacco use by anyone. The researchers observed that success with the household rules method was best achieved with children at younger ages.

The study did not measure the quality or frequency of antitobacco conversations but it should not be concluded definitively that all parental communication is unhelpful, the researchers cautioned.

To their knowledge, this study is the first to analyze the effects of household antitobacco strategies on discouraging initiation the use of tobacco and other smoking products as well as assessing parental awareness surrounding tobacco usage among youth.
 

What to tell parents

In a separate interview, Kelly Curran, MD, MA, assistant professor of pediatrics at the University of Oklahoma, Oklahoma City, commented on the explosive growth of e-cigarette use in the last 7 years.

What makes e-cigs so difficult to detect is that they “can resemble common objects such as flash drives or pens, and as a result, can often be hidden or overlooked by parents,” noted Dr. Curran.

The most important message for parents from this study is that they have the potential to have a large impact in the prevention of tobacco initiation, she said. “This effort requires parents to ‘walk the walk’ instead of just ‘talking the talk.”

As the study revealed, simply talking to teens about not using tobacco products doesn’t decrease use, but “creating strict household rules around no tobacco use for all visitors and inhabitants has a significant impact in decreasing youth tobacco initiation – by nearly 25%,” she added. “When counseling patients and families about tobacco prevention, clinicians should encourage them to create a tobacco-free home.”

The study was funded by a National Institutes of Health grant and the Delta Dental Community Care Foundation. The authors have no relevant financial disclosures. Dr. Curran, who is a member of the Pediatric News editorial advisory board, said she had no relevant financial disclosures.

SOURCE: Wu T-S and Chaffee BW. Pediatrics 2020 October. doi: 10.1542/peds.2019-4034.