User login
Anorexia nervosa in adolescent patients: What pediatricians need to know
Eating disorders are among the most prevalent, disabling, and potentially fatal psychiatric illnesses, and the COVID-19 pandemic has exacerbated their burden, with a 15.3% increase in incidence in 2020 compared with previous years.1 This increase was almost solely among adolescent girls with anorexia nervosa (AN), which is often insidious in onset and more difficult to treat as it advances. Adolescents with AN are most likely to present to their pediatricians, so awareness and early recognition of the symptoms is critical. Pediatricians are also an integral part of the treatment team in AN and can offer monitoring for serious complications, alongside valuable guidance to parents, who are central to treatment and the reestablishment of healthy eating habits in their children. Here we will review the epidemiology, diagnosis, and treatment of anorexia, with an emphasis on what pediatricians need to know to screen and to facilitate treatment.
Epidemiology
AN is marked by a fear of gaining weight or behaviors that interfere with weight gain and a self-evaluation unduly influenced by weight and body shape. Youth with AN often deny the seriousness of their malnutrition, although that is not required for diagnosis. AN can be of a restrictive or binge-purge subtype, and amenorrhea is no longer a requirement for diagnosis. There is not a specific weight or body mass index cutoff for the diagnosis, but the severity of AN is determined by the BMI percentile normed to age and sex. The average age of onset is 18, and the prepandemic prevalence of AN was about 1% of the population. It affects about 10 times as many females as males. It is quite rare prior to puberty, affecting about 0.01% of that age group. There is a heritable component, with a fivefold relative risk in youth with a parent with AN, and twin studies suggest heritability rates as high as 75%. Youth with rigid cognitive styles appear more vulnerable, as do those who participate in activities such as ballet, gymnastics, modeling, and wrestling because of the role of appearance and weight in performance. More than half of patients with AN will have another psychiatric illness, most commonly anxiety disorders, depression, or obsessive-compulsive disorder. AN becomes chronic in up to 15% of sufferers and the mortality rate is close to 10%, with approximately half dying from medical complications and half dying by suicide.
Screening
Parents and pediatricians are usually the first to notice that a child has started to lose weight or is falling off the growth curve. But weight changes usually emerge after feelings of preoccupation with weight, body shape, and body satisfaction. If parents report escalating pickiness around food, increased or compulsive exercise, persistent self-consciousness and self-criticism around weight and body shape, it is worth starting with screening questions.
If you notice preoccupation or anxiety around being weighed, even if the weight or growth curve are still normal, it is worthwhile to screen. Screening questions, such as the SCOFF questionnaire with five simple questions, can be very sensitive for both AN and bulimia nervosa.2 There are also many validated screening instruments, such as the Eating Disorder Inventory or Eating Attitudes Test (for adolescents) and the Kids Eating Disorder Survey and the Child Eating Attitudes Test (for younger children), that are short self-reports that you can have your patients fill out when you have a higher index of suspicion. Weight loss or growth failure without a preoccupation around weight or appearance needs a thorough a medical workup, and could be a function of other psychiatric problems, such as depression.
If a child screens positive for an eating disorder, your full physical examination, growth curves, and longitudinal growth charts are critical for diagnosis. Percentile BMIs must be used, given the inaccuracy of standard BMI calculations in this age group. (Centers for Disease Control and Prevention age and sex growth charts include methods for this calculation). Laboratory assessment, including metabolic, kidney, pancreatic, and thyroid function, and an EKG can illuminate if there are consequences of restricting or purging. Of course, you want to evaluate for significant medical symptoms, including bradycardia, orthostasis, and hypokalemia. These medical symptoms are not limited to the severely underweight and merit referral to an emergency department and possible medical admission.
Then, a referral to a clinician who is expert in the assessment and treatment of eating disorders is needed. This may be a child psychiatrist, psychologist, or a colleague pediatrician with this specialization. It is also very important to begin the conversation with the family to introduce your concerns, describe what you have noticed, and discuss the need for further assessment and possibly treatment.
Be mindful that discussing this in front of your patient may heighten the patient’s anxiety or distress. Be prepared to offer support and understanding for your patient’s anxiety, while steadfastly providing absolute clarity for the parents about the necessity of further evaluation and treatment. Many parents will be concerned and ready to do whatever is needed to get their child’s eating and growth back on track. But some parents may have more difficulty. They may have their own history with an eating disorder. They may be avoiding a sense of shame or alarm. They may be eager to avoid adding to their child’s stress. They may be tired of engaging in power struggles with the child. They may be proud of their ambitious, accomplished young athlete. Their trust in you makes you uniquely positioned to complicate their thinking. And treatment will hinge on them, so this is a critical bridge to care.
Beyond telling parents that they will need to bring more structure and supervision to mealtimes to begin addressing their child’s nutrition, you might offer guidance on other strategies. Empower parents to limit their child’s use of social media sites such as Instagram, YouTube, and TikTok, where they may be immersed in comparing themselves to idealized (and airbrushed) influencers. Empower them to make their child’s participation in beloved sports contingent on eating meals together and completely or on a stabilized weight (as will be common in treatment). Remind them that there are no bad foods, that the goal is health, and that they are not in a power struggle with their child, but instead allied with their child to treat AN. Remind them to also look for chances to have fun with their child, to help everyone remember what matters.
Treatment
Family-based therapy (FBT) is the first-line treatment of shorter-duration AN in children and adolescents. It focuses on the parents, helping them to calmly and effectively manage their child’s eating behaviors until their weight and behaviors have normalized. As a patient’s nutritional status improves, so does cognitive function, emotional flexibility, and mood. Individual therapy and psychopharmacologic treatment can be very effective for comorbid anxiety, mood, attentional, and thought disorders. Family-based work does include the child and is often done in group-based settings with clinicians from multiple disciplines. Dietitians provide education and guidance about healthy nutrition to the child and parents. Therapists may work with the child, parents, or full family to focus on behavior modification and managing distress. Most academic medical centers provide access to FBT, but there are many regions with no providers of this evidence-based treatment. One of the silver linings of the COVID-19 pandemic is that several online services have emerged offering FBT, working with families to manage mealtimes and treatment entirely at home.3 Pediatricians provide regular medical checks to measure progress and help with decisions about when it is safe to permit exercise or advance privileges and independence around eating. Some pediatricians have discovered a deep interest in this area of pediatrics and built their practices on it. Given the surge in prevalence of AN and the needs for adolescent mental health services, we hope more will do so.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
References
1. Taquet M et al. Br J Psychiatry. 2022;220:262-4.
2. Morgan JF et al. West J Med. 2000 Mar;172(3):164-5.
3. Matheson BE et al. Int J Eat Disord. 2020 Jul;53(7):1142-54.
Eating disorders are among the most prevalent, disabling, and potentially fatal psychiatric illnesses, and the COVID-19 pandemic has exacerbated their burden, with a 15.3% increase in incidence in 2020 compared with previous years.1 This increase was almost solely among adolescent girls with anorexia nervosa (AN), which is often insidious in onset and more difficult to treat as it advances. Adolescents with AN are most likely to present to their pediatricians, so awareness and early recognition of the symptoms is critical. Pediatricians are also an integral part of the treatment team in AN and can offer monitoring for serious complications, alongside valuable guidance to parents, who are central to treatment and the reestablishment of healthy eating habits in their children. Here we will review the epidemiology, diagnosis, and treatment of anorexia, with an emphasis on what pediatricians need to know to screen and to facilitate treatment.
Epidemiology
AN is marked by a fear of gaining weight or behaviors that interfere with weight gain and a self-evaluation unduly influenced by weight and body shape. Youth with AN often deny the seriousness of their malnutrition, although that is not required for diagnosis. AN can be of a restrictive or binge-purge subtype, and amenorrhea is no longer a requirement for diagnosis. There is not a specific weight or body mass index cutoff for the diagnosis, but the severity of AN is determined by the BMI percentile normed to age and sex. The average age of onset is 18, and the prepandemic prevalence of AN was about 1% of the population. It affects about 10 times as many females as males. It is quite rare prior to puberty, affecting about 0.01% of that age group. There is a heritable component, with a fivefold relative risk in youth with a parent with AN, and twin studies suggest heritability rates as high as 75%. Youth with rigid cognitive styles appear more vulnerable, as do those who participate in activities such as ballet, gymnastics, modeling, and wrestling because of the role of appearance and weight in performance. More than half of patients with AN will have another psychiatric illness, most commonly anxiety disorders, depression, or obsessive-compulsive disorder. AN becomes chronic in up to 15% of sufferers and the mortality rate is close to 10%, with approximately half dying from medical complications and half dying by suicide.
Screening
Parents and pediatricians are usually the first to notice that a child has started to lose weight or is falling off the growth curve. But weight changes usually emerge after feelings of preoccupation with weight, body shape, and body satisfaction. If parents report escalating pickiness around food, increased or compulsive exercise, persistent self-consciousness and self-criticism around weight and body shape, it is worth starting with screening questions.
If you notice preoccupation or anxiety around being weighed, even if the weight or growth curve are still normal, it is worthwhile to screen. Screening questions, such as the SCOFF questionnaire with five simple questions, can be very sensitive for both AN and bulimia nervosa.2 There are also many validated screening instruments, such as the Eating Disorder Inventory or Eating Attitudes Test (for adolescents) and the Kids Eating Disorder Survey and the Child Eating Attitudes Test (for younger children), that are short self-reports that you can have your patients fill out when you have a higher index of suspicion. Weight loss or growth failure without a preoccupation around weight or appearance needs a thorough a medical workup, and could be a function of other psychiatric problems, such as depression.
If a child screens positive for an eating disorder, your full physical examination, growth curves, and longitudinal growth charts are critical for diagnosis. Percentile BMIs must be used, given the inaccuracy of standard BMI calculations in this age group. (Centers for Disease Control and Prevention age and sex growth charts include methods for this calculation). Laboratory assessment, including metabolic, kidney, pancreatic, and thyroid function, and an EKG can illuminate if there are consequences of restricting or purging. Of course, you want to evaluate for significant medical symptoms, including bradycardia, orthostasis, and hypokalemia. These medical symptoms are not limited to the severely underweight and merit referral to an emergency department and possible medical admission.
Then, a referral to a clinician who is expert in the assessment and treatment of eating disorders is needed. This may be a child psychiatrist, psychologist, or a colleague pediatrician with this specialization. It is also very important to begin the conversation with the family to introduce your concerns, describe what you have noticed, and discuss the need for further assessment and possibly treatment.
Be mindful that discussing this in front of your patient may heighten the patient’s anxiety or distress. Be prepared to offer support and understanding for your patient’s anxiety, while steadfastly providing absolute clarity for the parents about the necessity of further evaluation and treatment. Many parents will be concerned and ready to do whatever is needed to get their child’s eating and growth back on track. But some parents may have more difficulty. They may have their own history with an eating disorder. They may be avoiding a sense of shame or alarm. They may be eager to avoid adding to their child’s stress. They may be tired of engaging in power struggles with the child. They may be proud of their ambitious, accomplished young athlete. Their trust in you makes you uniquely positioned to complicate their thinking. And treatment will hinge on them, so this is a critical bridge to care.
Beyond telling parents that they will need to bring more structure and supervision to mealtimes to begin addressing their child’s nutrition, you might offer guidance on other strategies. Empower parents to limit their child’s use of social media sites such as Instagram, YouTube, and TikTok, where they may be immersed in comparing themselves to idealized (and airbrushed) influencers. Empower them to make their child’s participation in beloved sports contingent on eating meals together and completely or on a stabilized weight (as will be common in treatment). Remind them that there are no bad foods, that the goal is health, and that they are not in a power struggle with their child, but instead allied with their child to treat AN. Remind them to also look for chances to have fun with their child, to help everyone remember what matters.
Treatment
Family-based therapy (FBT) is the first-line treatment of shorter-duration AN in children and adolescents. It focuses on the parents, helping them to calmly and effectively manage their child’s eating behaviors until their weight and behaviors have normalized. As a patient’s nutritional status improves, so does cognitive function, emotional flexibility, and mood. Individual therapy and psychopharmacologic treatment can be very effective for comorbid anxiety, mood, attentional, and thought disorders. Family-based work does include the child and is often done in group-based settings with clinicians from multiple disciplines. Dietitians provide education and guidance about healthy nutrition to the child and parents. Therapists may work with the child, parents, or full family to focus on behavior modification and managing distress. Most academic medical centers provide access to FBT, but there are many regions with no providers of this evidence-based treatment. One of the silver linings of the COVID-19 pandemic is that several online services have emerged offering FBT, working with families to manage mealtimes and treatment entirely at home.3 Pediatricians provide regular medical checks to measure progress and help with decisions about when it is safe to permit exercise or advance privileges and independence around eating. Some pediatricians have discovered a deep interest in this area of pediatrics and built their practices on it. Given the surge in prevalence of AN and the needs for adolescent mental health services, we hope more will do so.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
References
1. Taquet M et al. Br J Psychiatry. 2022;220:262-4.
2. Morgan JF et al. West J Med. 2000 Mar;172(3):164-5.
3. Matheson BE et al. Int J Eat Disord. 2020 Jul;53(7):1142-54.
Eating disorders are among the most prevalent, disabling, and potentially fatal psychiatric illnesses, and the COVID-19 pandemic has exacerbated their burden, with a 15.3% increase in incidence in 2020 compared with previous years.1 This increase was almost solely among adolescent girls with anorexia nervosa (AN), which is often insidious in onset and more difficult to treat as it advances. Adolescents with AN are most likely to present to their pediatricians, so awareness and early recognition of the symptoms is critical. Pediatricians are also an integral part of the treatment team in AN and can offer monitoring for serious complications, alongside valuable guidance to parents, who are central to treatment and the reestablishment of healthy eating habits in their children. Here we will review the epidemiology, diagnosis, and treatment of anorexia, with an emphasis on what pediatricians need to know to screen and to facilitate treatment.
Epidemiology
AN is marked by a fear of gaining weight or behaviors that interfere with weight gain and a self-evaluation unduly influenced by weight and body shape. Youth with AN often deny the seriousness of their malnutrition, although that is not required for diagnosis. AN can be of a restrictive or binge-purge subtype, and amenorrhea is no longer a requirement for diagnosis. There is not a specific weight or body mass index cutoff for the diagnosis, but the severity of AN is determined by the BMI percentile normed to age and sex. The average age of onset is 18, and the prepandemic prevalence of AN was about 1% of the population. It affects about 10 times as many females as males. It is quite rare prior to puberty, affecting about 0.01% of that age group. There is a heritable component, with a fivefold relative risk in youth with a parent with AN, and twin studies suggest heritability rates as high as 75%. Youth with rigid cognitive styles appear more vulnerable, as do those who participate in activities such as ballet, gymnastics, modeling, and wrestling because of the role of appearance and weight in performance. More than half of patients with AN will have another psychiatric illness, most commonly anxiety disorders, depression, or obsessive-compulsive disorder. AN becomes chronic in up to 15% of sufferers and the mortality rate is close to 10%, with approximately half dying from medical complications and half dying by suicide.
Screening
Parents and pediatricians are usually the first to notice that a child has started to lose weight or is falling off the growth curve. But weight changes usually emerge after feelings of preoccupation with weight, body shape, and body satisfaction. If parents report escalating pickiness around food, increased or compulsive exercise, persistent self-consciousness and self-criticism around weight and body shape, it is worth starting with screening questions.
If you notice preoccupation or anxiety around being weighed, even if the weight or growth curve are still normal, it is worthwhile to screen. Screening questions, such as the SCOFF questionnaire with five simple questions, can be very sensitive for both AN and bulimia nervosa.2 There are also many validated screening instruments, such as the Eating Disorder Inventory or Eating Attitudes Test (for adolescents) and the Kids Eating Disorder Survey and the Child Eating Attitudes Test (for younger children), that are short self-reports that you can have your patients fill out when you have a higher index of suspicion. Weight loss or growth failure without a preoccupation around weight or appearance needs a thorough a medical workup, and could be a function of other psychiatric problems, such as depression.
If a child screens positive for an eating disorder, your full physical examination, growth curves, and longitudinal growth charts are critical for diagnosis. Percentile BMIs must be used, given the inaccuracy of standard BMI calculations in this age group. (Centers for Disease Control and Prevention age and sex growth charts include methods for this calculation). Laboratory assessment, including metabolic, kidney, pancreatic, and thyroid function, and an EKG can illuminate if there are consequences of restricting or purging. Of course, you want to evaluate for significant medical symptoms, including bradycardia, orthostasis, and hypokalemia. These medical symptoms are not limited to the severely underweight and merit referral to an emergency department and possible medical admission.
Then, a referral to a clinician who is expert in the assessment and treatment of eating disorders is needed. This may be a child psychiatrist, psychologist, or a colleague pediatrician with this specialization. It is also very important to begin the conversation with the family to introduce your concerns, describe what you have noticed, and discuss the need for further assessment and possibly treatment.
Be mindful that discussing this in front of your patient may heighten the patient’s anxiety or distress. Be prepared to offer support and understanding for your patient’s anxiety, while steadfastly providing absolute clarity for the parents about the necessity of further evaluation and treatment. Many parents will be concerned and ready to do whatever is needed to get their child’s eating and growth back on track. But some parents may have more difficulty. They may have their own history with an eating disorder. They may be avoiding a sense of shame or alarm. They may be eager to avoid adding to their child’s stress. They may be tired of engaging in power struggles with the child. They may be proud of their ambitious, accomplished young athlete. Their trust in you makes you uniquely positioned to complicate their thinking. And treatment will hinge on them, so this is a critical bridge to care.
Beyond telling parents that they will need to bring more structure and supervision to mealtimes to begin addressing their child’s nutrition, you might offer guidance on other strategies. Empower parents to limit their child’s use of social media sites such as Instagram, YouTube, and TikTok, where they may be immersed in comparing themselves to idealized (and airbrushed) influencers. Empower them to make their child’s participation in beloved sports contingent on eating meals together and completely or on a stabilized weight (as will be common in treatment). Remind them that there are no bad foods, that the goal is health, and that they are not in a power struggle with their child, but instead allied with their child to treat AN. Remind them to also look for chances to have fun with their child, to help everyone remember what matters.
Treatment
Family-based therapy (FBT) is the first-line treatment of shorter-duration AN in children and adolescents. It focuses on the parents, helping them to calmly and effectively manage their child’s eating behaviors until their weight and behaviors have normalized. As a patient’s nutritional status improves, so does cognitive function, emotional flexibility, and mood. Individual therapy and psychopharmacologic treatment can be very effective for comorbid anxiety, mood, attentional, and thought disorders. Family-based work does include the child and is often done in group-based settings with clinicians from multiple disciplines. Dietitians provide education and guidance about healthy nutrition to the child and parents. Therapists may work with the child, parents, or full family to focus on behavior modification and managing distress. Most academic medical centers provide access to FBT, but there are many regions with no providers of this evidence-based treatment. One of the silver linings of the COVID-19 pandemic is that several online services have emerged offering FBT, working with families to manage mealtimes and treatment entirely at home.3 Pediatricians provide regular medical checks to measure progress and help with decisions about when it is safe to permit exercise or advance privileges and independence around eating. Some pediatricians have discovered a deep interest in this area of pediatrics and built their practices on it. Given the surge in prevalence of AN and the needs for adolescent mental health services, we hope more will do so.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
References
1. Taquet M et al. Br J Psychiatry. 2022;220:262-4.
2. Morgan JF et al. West J Med. 2000 Mar;172(3):164-5.
3. Matheson BE et al. Int J Eat Disord. 2020 Jul;53(7):1142-54.
What can be new about developmental milestones?
The American Academy of Pediatrics, with funding from the Centers for Disease Control and Prevention, studied the CDC’s “Learn the Signs. Act Early” developmental surveillance milestones for children 0-5 years to update the milestones based on published studies. The goal was to improve this tool for developmental surveillance and use by the public. Developmental surveillance is not just observing a child at a check-up but rather “is a longitudinal process that involves eliciting concerns, taking a developmental history based on milestone attainment, observing milestones and other behaviors, examining the child, and applying clinical judgment during health supervision visits (HSVs).”1
While the milestones we were trained on were a good start and highlighted the developmental progression central to pediatrics, they were not based on norms or cut scores indicating significant developmental risk unless taught from a validated tool. The CDC was concerned that their public handouts and apps were based on median ages (middle number of the entire range) of attainment not the mode (most common) or even average ages. That means that about half of all typically developing children would “not have attained” that skill at the age noted, potentially evoking unnecessary concern for parents and a “wait-and-see” message from a knowledgeable provider who realized the statistical meaning and the broad range of normal. Another potential problem with using milestones set at the median age is that parents, especially those with several children or experienced friends, may see the provider as an alarmist when they have seen great variation in children who later were normal. This reaction can dampen provider willingness to discuss development or even to screen with validated tools. We have learned the hard way from COVID-19 that it is difficult to convey concepts of risk effectively both balancing fear and stimulating action.
The AAP experts reviewed the English literature for data-based milestones, finding 34 articles, 10 of which had an opinion for at least one milestone. If this sounds like a very small number, you are correct. You may not realize that almost all screening and diagnostic tools have been based on data collected by Gesell in 1928!2 While most of health care has changed since then, which milestones are measured in infants has not.
The biggest change from this review was deciding to use as milestones skills reported for 75% of children at each age of typical HSVs, adding ones for 15 and 30 months. The implication is that children not attaining these milestones are all at risk and deserving of more careful history, examination, and administration of a validated screening tool; not true when based on median data. Of the 94 existing CDC milestones retained after the review, one-third were moved to a different age with 21 of 31 assigned to an older age. Domains of functioning for the milestones were consolidated into social emotional, cognitive, language/communication, and motor, to help parents learn to distinguish these areas, and, although many milestones reflect several domains, each was included only once to reduce confusion.
Psychosocial assessment is recommended by the AAP and Bright Futures at every HSV but the fewest milestones with normative data were identified for this domain, often self-help rather than social engagement or emotion regulation skills. The cross-cultural study cited for many of the new milestones was reassuring overall in that the median ages for 67%-88% of milestones in most domains were equivalent across the four countries sampled, but only 22% of self-help skills were equivalent.3 This should remind us that parenting has more influence over psychosocial skills than other domains. Psychosocial and behavioral functioning, especially emotional regulation, also deserve “surveillance” as they have enormous impact on life outcomes but need to be measured and supported differently. Routine use of validated tools such as the Early Childhood Screening Assessment or the Ages & Stages Questionnaires: Social-Emotional for these domains are also needed.
Normal variations in temperament and patterns of attachment can affect many milestones including courage for walking, exploration, social engagement, and prosocial behaviors or self-control for social situations, attention, range of affect, and cooperation. All of these skills are among the 42 total (14 new) social-emotional milestones for 0- to 5-year-olds. Variations in these functions are at the root of the most common “challenging behaviors” in our studies in primary care. They are also the most vulnerable to suboptimal parent-child relationships, adverse childhood experiences, and social determinants of health.
As primary care providers, we not only need to detect children at risk for developmental problems but also promote and celebrate developmental progress. I hope that changing the threshold for concern to 75% will allow for a more positive review with the family (as fewer will be flagged as at risk) and chance to congratulate parents on all that is going well. But I also hope the change will not make us overlook parenting challenges, often from the psychosocial milestones most amenable to our guidance and support.
Early identification is mainly important to obtain the early intervention shown to improve outcomes. However, less than 25% of children with delays or disabilities receive early intervention before age 3 and most with emotional, behavioral, and developmental conditions, other than autism spectrum disorder, not before age 5. Since early intervention services are freely available in all states, we also need to do better at getting children to this care.
Let’s reconsider the process of developmental surveillance in this light of delayed referral: “Eliciting concerns” is key as parents have been shown to be usually correct in their worries. Listening to how they express the concerns can help you connect their specific issues when discussing reasons for referral. While most parent “recall of past milestones” is not accurate, current milestones reported are; thus, the need to have the new more accurate norms for all ages for comparison. When we make observations of a child’s abilities and behaviors ourselves we may not only pick up on issues missed by the parent, but will be more convincing in conveying the need for referral when indicated. When we “examine” the child we can use our professional skills to determine the very important risk factor of the quality of how a skill is performed, not just that it is. The recommended “use of validated screening tools” when the new milestones are not met give us an objective tool to share with parents, more confidence in when referral is warranted, which we will convey to parents (and perhaps skeptical relatives), and baseline documentation from which we can “track” referrals, progress, and, hopefully, better outcomes.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. Email her at pdnews@mdedge.com.
References
1. Zubler JM et al. Pediatrics. 2022;149(3):e2021052138.
2. Gessell A et al. Macmillan: New York, 1928.
3. Ertem IO et al. Lancet Glob Health. 2018 Mar;6(3):e279-91.
The American Academy of Pediatrics, with funding from the Centers for Disease Control and Prevention, studied the CDC’s “Learn the Signs. Act Early” developmental surveillance milestones for children 0-5 years to update the milestones based on published studies. The goal was to improve this tool for developmental surveillance and use by the public. Developmental surveillance is not just observing a child at a check-up but rather “is a longitudinal process that involves eliciting concerns, taking a developmental history based on milestone attainment, observing milestones and other behaviors, examining the child, and applying clinical judgment during health supervision visits (HSVs).”1
While the milestones we were trained on were a good start and highlighted the developmental progression central to pediatrics, they were not based on norms or cut scores indicating significant developmental risk unless taught from a validated tool. The CDC was concerned that their public handouts and apps were based on median ages (middle number of the entire range) of attainment not the mode (most common) or even average ages. That means that about half of all typically developing children would “not have attained” that skill at the age noted, potentially evoking unnecessary concern for parents and a “wait-and-see” message from a knowledgeable provider who realized the statistical meaning and the broad range of normal. Another potential problem with using milestones set at the median age is that parents, especially those with several children or experienced friends, may see the provider as an alarmist when they have seen great variation in children who later were normal. This reaction can dampen provider willingness to discuss development or even to screen with validated tools. We have learned the hard way from COVID-19 that it is difficult to convey concepts of risk effectively both balancing fear and stimulating action.
The AAP experts reviewed the English literature for data-based milestones, finding 34 articles, 10 of which had an opinion for at least one milestone. If this sounds like a very small number, you are correct. You may not realize that almost all screening and diagnostic tools have been based on data collected by Gesell in 1928!2 While most of health care has changed since then, which milestones are measured in infants has not.
The biggest change from this review was deciding to use as milestones skills reported for 75% of children at each age of typical HSVs, adding ones for 15 and 30 months. The implication is that children not attaining these milestones are all at risk and deserving of more careful history, examination, and administration of a validated screening tool; not true when based on median data. Of the 94 existing CDC milestones retained after the review, one-third were moved to a different age with 21 of 31 assigned to an older age. Domains of functioning for the milestones were consolidated into social emotional, cognitive, language/communication, and motor, to help parents learn to distinguish these areas, and, although many milestones reflect several domains, each was included only once to reduce confusion.
Psychosocial assessment is recommended by the AAP and Bright Futures at every HSV but the fewest milestones with normative data were identified for this domain, often self-help rather than social engagement or emotion regulation skills. The cross-cultural study cited for many of the new milestones was reassuring overall in that the median ages for 67%-88% of milestones in most domains were equivalent across the four countries sampled, but only 22% of self-help skills were equivalent.3 This should remind us that parenting has more influence over psychosocial skills than other domains. Psychosocial and behavioral functioning, especially emotional regulation, also deserve “surveillance” as they have enormous impact on life outcomes but need to be measured and supported differently. Routine use of validated tools such as the Early Childhood Screening Assessment or the Ages & Stages Questionnaires: Social-Emotional for these domains are also needed.
Normal variations in temperament and patterns of attachment can affect many milestones including courage for walking, exploration, social engagement, and prosocial behaviors or self-control for social situations, attention, range of affect, and cooperation. All of these skills are among the 42 total (14 new) social-emotional milestones for 0- to 5-year-olds. Variations in these functions are at the root of the most common “challenging behaviors” in our studies in primary care. They are also the most vulnerable to suboptimal parent-child relationships, adverse childhood experiences, and social determinants of health.
As primary care providers, we not only need to detect children at risk for developmental problems but also promote and celebrate developmental progress. I hope that changing the threshold for concern to 75% will allow for a more positive review with the family (as fewer will be flagged as at risk) and chance to congratulate parents on all that is going well. But I also hope the change will not make us overlook parenting challenges, often from the psychosocial milestones most amenable to our guidance and support.
Early identification is mainly important to obtain the early intervention shown to improve outcomes. However, less than 25% of children with delays or disabilities receive early intervention before age 3 and most with emotional, behavioral, and developmental conditions, other than autism spectrum disorder, not before age 5. Since early intervention services are freely available in all states, we also need to do better at getting children to this care.
Let’s reconsider the process of developmental surveillance in this light of delayed referral: “Eliciting concerns” is key as parents have been shown to be usually correct in their worries. Listening to how they express the concerns can help you connect their specific issues when discussing reasons for referral. While most parent “recall of past milestones” is not accurate, current milestones reported are; thus, the need to have the new more accurate norms for all ages for comparison. When we make observations of a child’s abilities and behaviors ourselves we may not only pick up on issues missed by the parent, but will be more convincing in conveying the need for referral when indicated. When we “examine” the child we can use our professional skills to determine the very important risk factor of the quality of how a skill is performed, not just that it is. The recommended “use of validated screening tools” when the new milestones are not met give us an objective tool to share with parents, more confidence in when referral is warranted, which we will convey to parents (and perhaps skeptical relatives), and baseline documentation from which we can “track” referrals, progress, and, hopefully, better outcomes.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. Email her at pdnews@mdedge.com.
References
1. Zubler JM et al. Pediatrics. 2022;149(3):e2021052138.
2. Gessell A et al. Macmillan: New York, 1928.
3. Ertem IO et al. Lancet Glob Health. 2018 Mar;6(3):e279-91.
The American Academy of Pediatrics, with funding from the Centers for Disease Control and Prevention, studied the CDC’s “Learn the Signs. Act Early” developmental surveillance milestones for children 0-5 years to update the milestones based on published studies. The goal was to improve this tool for developmental surveillance and use by the public. Developmental surveillance is not just observing a child at a check-up but rather “is a longitudinal process that involves eliciting concerns, taking a developmental history based on milestone attainment, observing milestones and other behaviors, examining the child, and applying clinical judgment during health supervision visits (HSVs).”1
While the milestones we were trained on were a good start and highlighted the developmental progression central to pediatrics, they were not based on norms or cut scores indicating significant developmental risk unless taught from a validated tool. The CDC was concerned that their public handouts and apps were based on median ages (middle number of the entire range) of attainment not the mode (most common) or even average ages. That means that about half of all typically developing children would “not have attained” that skill at the age noted, potentially evoking unnecessary concern for parents and a “wait-and-see” message from a knowledgeable provider who realized the statistical meaning and the broad range of normal. Another potential problem with using milestones set at the median age is that parents, especially those with several children or experienced friends, may see the provider as an alarmist when they have seen great variation in children who later were normal. This reaction can dampen provider willingness to discuss development or even to screen with validated tools. We have learned the hard way from COVID-19 that it is difficult to convey concepts of risk effectively both balancing fear and stimulating action.
The AAP experts reviewed the English literature for data-based milestones, finding 34 articles, 10 of which had an opinion for at least one milestone. If this sounds like a very small number, you are correct. You may not realize that almost all screening and diagnostic tools have been based on data collected by Gesell in 1928!2 While most of health care has changed since then, which milestones are measured in infants has not.
The biggest change from this review was deciding to use as milestones skills reported for 75% of children at each age of typical HSVs, adding ones for 15 and 30 months. The implication is that children not attaining these milestones are all at risk and deserving of more careful history, examination, and administration of a validated screening tool; not true when based on median data. Of the 94 existing CDC milestones retained after the review, one-third were moved to a different age with 21 of 31 assigned to an older age. Domains of functioning for the milestones were consolidated into social emotional, cognitive, language/communication, and motor, to help parents learn to distinguish these areas, and, although many milestones reflect several domains, each was included only once to reduce confusion.
Psychosocial assessment is recommended by the AAP and Bright Futures at every HSV but the fewest milestones with normative data were identified for this domain, often self-help rather than social engagement or emotion regulation skills. The cross-cultural study cited for many of the new milestones was reassuring overall in that the median ages for 67%-88% of milestones in most domains were equivalent across the four countries sampled, but only 22% of self-help skills were equivalent.3 This should remind us that parenting has more influence over psychosocial skills than other domains. Psychosocial and behavioral functioning, especially emotional regulation, also deserve “surveillance” as they have enormous impact on life outcomes but need to be measured and supported differently. Routine use of validated tools such as the Early Childhood Screening Assessment or the Ages & Stages Questionnaires: Social-Emotional for these domains are also needed.
Normal variations in temperament and patterns of attachment can affect many milestones including courage for walking, exploration, social engagement, and prosocial behaviors or self-control for social situations, attention, range of affect, and cooperation. All of these skills are among the 42 total (14 new) social-emotional milestones for 0- to 5-year-olds. Variations in these functions are at the root of the most common “challenging behaviors” in our studies in primary care. They are also the most vulnerable to suboptimal parent-child relationships, adverse childhood experiences, and social determinants of health.
As primary care providers, we not only need to detect children at risk for developmental problems but also promote and celebrate developmental progress. I hope that changing the threshold for concern to 75% will allow for a more positive review with the family (as fewer will be flagged as at risk) and chance to congratulate parents on all that is going well. But I also hope the change will not make us overlook parenting challenges, often from the psychosocial milestones most amenable to our guidance and support.
Early identification is mainly important to obtain the early intervention shown to improve outcomes. However, less than 25% of children with delays or disabilities receive early intervention before age 3 and most with emotional, behavioral, and developmental conditions, other than autism spectrum disorder, not before age 5. Since early intervention services are freely available in all states, we also need to do better at getting children to this care.
Let’s reconsider the process of developmental surveillance in this light of delayed referral: “Eliciting concerns” is key as parents have been shown to be usually correct in their worries. Listening to how they express the concerns can help you connect their specific issues when discussing reasons for referral. While most parent “recall of past milestones” is not accurate, current milestones reported are; thus, the need to have the new more accurate norms for all ages for comparison. When we make observations of a child’s abilities and behaviors ourselves we may not only pick up on issues missed by the parent, but will be more convincing in conveying the need for referral when indicated. When we “examine” the child we can use our professional skills to determine the very important risk factor of the quality of how a skill is performed, not just that it is. The recommended “use of validated screening tools” when the new milestones are not met give us an objective tool to share with parents, more confidence in when referral is warranted, which we will convey to parents (and perhaps skeptical relatives), and baseline documentation from which we can “track” referrals, progress, and, hopefully, better outcomes.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. Email her at pdnews@mdedge.com.
References
1. Zubler JM et al. Pediatrics. 2022;149(3):e2021052138.
2. Gessell A et al. Macmillan: New York, 1928.
3. Ertem IO et al. Lancet Glob Health. 2018 Mar;6(3):e279-91.
Diagnosing adolescent ADHD
Pediatricians are increasingly expert in the assessment and treatment of attention-deficit/hyperactivity disorder. But what do you do when adolescents present to your office saying they think they have ADHD? While ADHD is a common and treatable disorder of youth, it is important to take special care when assessing an adolescent. Difficulties with attention and concentration are common symptoms for many different challenges of adolescence, and for ADHD to be the underlying cause, those symptoms must have started prior to adolescence (according to DSM-5, prior to the age of 12). When your adolescent patients or their parents come to your office complaining of inattention, it is important to consider the full range of possible explanations.
Sleep
We have written in this column previously about the challenges that adolescents face in getting adequate sleep consistently. Teenagers, on average, need more than 9 hours of sleep nightly and American teenagers get fewer than 6. This mismatch is because of physiologic shifts that move their natural sleep onset time significantly later, while school still starts early. It’s often compounded by other demands on their time, including homework, extracurricular activities, and the gravitational pull of social connections. Independent teenagers make their own decisions about how to manage their time and may feel sleep is optional, or manage their fatigue with naps and caffeine, both of which will further compromise the quality and efficiency of sleep.
Chronic sleep deprivation will present with difficulties with focus, attention, memory, and cognitive performance. Treatment of this problem with stimulants is likely to make the underlying poor sleep habits even worse. When your patient presents complaining of difficulty concentrating and worsening school performance, be sure to start with a thorough sleep history, and always provide guidance about the body’s need for sleep and healthy sleep habits.
Anxiety
Anxiety disorders are the most common psychiatric illnesses of youth, with estimates of as many as 30% of children and adolescents experiencing one. The true prevalence of ADHD is estimated to be about 4% of the population. Whether social phobia, generalized anxiety disorder, or even posttraumatic stress disorder, anxiety disorders interfere with attention as ruminative worry tends to distract those experiencing it. It can also affect attention and focus indirectly by interfering with restful sleep. Anxiety disorders can be difficult to identify, as the sufferers typically internalize their symptoms. But inquire about specific worries (such as speaking in front of others, meeting new people, or an illness or accident striking themselves or a loved one) and how much time they take up. Explore if worries fill their thoughts during quiet or downtime, and explore more about their worries. You may use a screening instrument such as the Pediatric Symptom Checklist or the SCARED, both of which will indicate a likely problem with anxiety. While it is possible to have comorbid ADHD with an anxiety disorder, the anxiety disorder will likely worsen with stimulants and should be treated first. These are usually curable illnesses and you may find that remission of anxiety symptoms resolves the attentional problems.
Depression
Mood disorders are less common than anxiety disorders in youth, but far more prevalent than ADHD. And depression is usually marked by serious difficulty concentrating across settings (including for things that were previously very interesting). A sullen teenager who is deeply self-critical about school performance would benefit from exploration of associated changes in mood, interests, energy, appetite, sleep, and for feelings of worthlessness, guilt, and suicidal thoughts. The PHQ9A is a simple, free screening instrument that is reasonable to use with every sick visit (and well-check) with your adolescent patients, given the risks of undetected and untreated depression. If your patient presents complaining of poor school performance, always screen for depression. As with anxiety disorders, comorbid ADHD is possible, but it is always recommended to treat the mood disorder first and then to assess for residual ADHD symptoms once the mood disorder is in remission.
Substance abuse
Adolescence is a time of exploration, and drug and alcohol use is common. While attentional impairment will happen with intoxication, occasional or rare use should not lead to consistent impairment in school. But when parents are more worried than their children about a significant change in school performance, it is important to screen for substance abuse. A child with a secret substance use disorder will often present with behavioral changes and deteriorating school performance and might deny any drug or alcohol use to parents. Indeed, stimulants have some street value and some patients may be seeking a stimulant prescription to sell or trade for other drugs. Regular marijuana use may present with only deteriorating school performance and no irritability or other noticeable behavioral changes. Marijuana is seen as safe and even healthy by many teenagers (and even many parents), and some youth may be using it recreationally or to manage difficulties with sleep, anxiety, or mood symptoms.
But there is compelling evidence that marijuana use causes cognitive impairment, including difficulty with sustaining attention, short-term memory, and processing speed, for as long as 24 hours after use. If a teenager is using marijuana daily after school, it is certainly going to interfere, in a dose-dependent manner, with attention and cognitive function. Sustained heavy use can lead to permanent cognitive deficits. It can also trigger or worsen anxiety or mood symptoms (contrary to much popular opinion).
Gathering a thorough substance use history is essential when assessing a teenager for difficulties with focus or attention, especially when these are accompanied by change in behavior and school performance. Remember, it is critical to interview these children without their parents present to invite them to be forthcoming with you.
History
While true ADHD should have been present throughout childhood, it is possible that the symptoms have become noticeable only in adolescence. For patients with very high intelligence and lower levels of impulsivity and hyperactivity, they might easily have “flown under the radar” during their elementary and even middle school years. Their difficulties with attention and focus might become apparent only when the volume and difficulty of schoolwork both are great enough that their intelligence is not enough to get good grades. That is, their problems with executive function, prioritizing, shifting sets, and completing tasks in a timely way make it impossible to keep up good grades when the work gets harder.
Your history should reveal a long history of dreaminess or distractibility, a tendency to lose and forget things, and the other symptoms of inattention. Did they often seem to not be listening when they were younger? Forget to hand in homework? Leave chores unfinished? Leave messes behind everywhere they went? These will not be definitive, but they do reassure that symptoms may have been present for a long time, even if school performance was considered fine until the workload got too large. If such problems were not present before puberty, consider whether a subtle learning disability could be impairing them as they face more challenging academic subjects.
If you have ruled out anxiety, mood, and substance use concerns, and helped them to address a sleep deficit, then you can proceed. It is worthwhile to get Vanderbilt Assessments as you would for a younger child. If they meet criteria, discuss the risks and benefits of medication, executive skills coaching, and environmental adjustments (extra time for tests, a less stimulating environment) that can help them explore academic challenges without the discouragement that ADHD can bring.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
Pediatricians are increasingly expert in the assessment and treatment of attention-deficit/hyperactivity disorder. But what do you do when adolescents present to your office saying they think they have ADHD? While ADHD is a common and treatable disorder of youth, it is important to take special care when assessing an adolescent. Difficulties with attention and concentration are common symptoms for many different challenges of adolescence, and for ADHD to be the underlying cause, those symptoms must have started prior to adolescence (according to DSM-5, prior to the age of 12). When your adolescent patients or their parents come to your office complaining of inattention, it is important to consider the full range of possible explanations.
Sleep
We have written in this column previously about the challenges that adolescents face in getting adequate sleep consistently. Teenagers, on average, need more than 9 hours of sleep nightly and American teenagers get fewer than 6. This mismatch is because of physiologic shifts that move their natural sleep onset time significantly later, while school still starts early. It’s often compounded by other demands on their time, including homework, extracurricular activities, and the gravitational pull of social connections. Independent teenagers make their own decisions about how to manage their time and may feel sleep is optional, or manage their fatigue with naps and caffeine, both of which will further compromise the quality and efficiency of sleep.
Chronic sleep deprivation will present with difficulties with focus, attention, memory, and cognitive performance. Treatment of this problem with stimulants is likely to make the underlying poor sleep habits even worse. When your patient presents complaining of difficulty concentrating and worsening school performance, be sure to start with a thorough sleep history, and always provide guidance about the body’s need for sleep and healthy sleep habits.
Anxiety
Anxiety disorders are the most common psychiatric illnesses of youth, with estimates of as many as 30% of children and adolescents experiencing one. The true prevalence of ADHD is estimated to be about 4% of the population. Whether social phobia, generalized anxiety disorder, or even posttraumatic stress disorder, anxiety disorders interfere with attention as ruminative worry tends to distract those experiencing it. It can also affect attention and focus indirectly by interfering with restful sleep. Anxiety disorders can be difficult to identify, as the sufferers typically internalize their symptoms. But inquire about specific worries (such as speaking in front of others, meeting new people, or an illness or accident striking themselves or a loved one) and how much time they take up. Explore if worries fill their thoughts during quiet or downtime, and explore more about their worries. You may use a screening instrument such as the Pediatric Symptom Checklist or the SCARED, both of which will indicate a likely problem with anxiety. While it is possible to have comorbid ADHD with an anxiety disorder, the anxiety disorder will likely worsen with stimulants and should be treated first. These are usually curable illnesses and you may find that remission of anxiety symptoms resolves the attentional problems.
Depression
Mood disorders are less common than anxiety disorders in youth, but far more prevalent than ADHD. And depression is usually marked by serious difficulty concentrating across settings (including for things that were previously very interesting). A sullen teenager who is deeply self-critical about school performance would benefit from exploration of associated changes in mood, interests, energy, appetite, sleep, and for feelings of worthlessness, guilt, and suicidal thoughts. The PHQ9A is a simple, free screening instrument that is reasonable to use with every sick visit (and well-check) with your adolescent patients, given the risks of undetected and untreated depression. If your patient presents complaining of poor school performance, always screen for depression. As with anxiety disorders, comorbid ADHD is possible, but it is always recommended to treat the mood disorder first and then to assess for residual ADHD symptoms once the mood disorder is in remission.
Substance abuse
Adolescence is a time of exploration, and drug and alcohol use is common. While attentional impairment will happen with intoxication, occasional or rare use should not lead to consistent impairment in school. But when parents are more worried than their children about a significant change in school performance, it is important to screen for substance abuse. A child with a secret substance use disorder will often present with behavioral changes and deteriorating school performance and might deny any drug or alcohol use to parents. Indeed, stimulants have some street value and some patients may be seeking a stimulant prescription to sell or trade for other drugs. Regular marijuana use may present with only deteriorating school performance and no irritability or other noticeable behavioral changes. Marijuana is seen as safe and even healthy by many teenagers (and even many parents), and some youth may be using it recreationally or to manage difficulties with sleep, anxiety, or mood symptoms.
But there is compelling evidence that marijuana use causes cognitive impairment, including difficulty with sustaining attention, short-term memory, and processing speed, for as long as 24 hours after use. If a teenager is using marijuana daily after school, it is certainly going to interfere, in a dose-dependent manner, with attention and cognitive function. Sustained heavy use can lead to permanent cognitive deficits. It can also trigger or worsen anxiety or mood symptoms (contrary to much popular opinion).
Gathering a thorough substance use history is essential when assessing a teenager for difficulties with focus or attention, especially when these are accompanied by change in behavior and school performance. Remember, it is critical to interview these children without their parents present to invite them to be forthcoming with you.
History
While true ADHD should have been present throughout childhood, it is possible that the symptoms have become noticeable only in adolescence. For patients with very high intelligence and lower levels of impulsivity and hyperactivity, they might easily have “flown under the radar” during their elementary and even middle school years. Their difficulties with attention and focus might become apparent only when the volume and difficulty of schoolwork both are great enough that their intelligence is not enough to get good grades. That is, their problems with executive function, prioritizing, shifting sets, and completing tasks in a timely way make it impossible to keep up good grades when the work gets harder.
Your history should reveal a long history of dreaminess or distractibility, a tendency to lose and forget things, and the other symptoms of inattention. Did they often seem to not be listening when they were younger? Forget to hand in homework? Leave chores unfinished? Leave messes behind everywhere they went? These will not be definitive, but they do reassure that symptoms may have been present for a long time, even if school performance was considered fine until the workload got too large. If such problems were not present before puberty, consider whether a subtle learning disability could be impairing them as they face more challenging academic subjects.
If you have ruled out anxiety, mood, and substance use concerns, and helped them to address a sleep deficit, then you can proceed. It is worthwhile to get Vanderbilt Assessments as you would for a younger child. If they meet criteria, discuss the risks and benefits of medication, executive skills coaching, and environmental adjustments (extra time for tests, a less stimulating environment) that can help them explore academic challenges without the discouragement that ADHD can bring.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
Pediatricians are increasingly expert in the assessment and treatment of attention-deficit/hyperactivity disorder. But what do you do when adolescents present to your office saying they think they have ADHD? While ADHD is a common and treatable disorder of youth, it is important to take special care when assessing an adolescent. Difficulties with attention and concentration are common symptoms for many different challenges of adolescence, and for ADHD to be the underlying cause, those symptoms must have started prior to adolescence (according to DSM-5, prior to the age of 12). When your adolescent patients or their parents come to your office complaining of inattention, it is important to consider the full range of possible explanations.
Sleep
We have written in this column previously about the challenges that adolescents face in getting adequate sleep consistently. Teenagers, on average, need more than 9 hours of sleep nightly and American teenagers get fewer than 6. This mismatch is because of physiologic shifts that move their natural sleep onset time significantly later, while school still starts early. It’s often compounded by other demands on their time, including homework, extracurricular activities, and the gravitational pull of social connections. Independent teenagers make their own decisions about how to manage their time and may feel sleep is optional, or manage their fatigue with naps and caffeine, both of which will further compromise the quality and efficiency of sleep.
Chronic sleep deprivation will present with difficulties with focus, attention, memory, and cognitive performance. Treatment of this problem with stimulants is likely to make the underlying poor sleep habits even worse. When your patient presents complaining of difficulty concentrating and worsening school performance, be sure to start with a thorough sleep history, and always provide guidance about the body’s need for sleep and healthy sleep habits.
Anxiety
Anxiety disorders are the most common psychiatric illnesses of youth, with estimates of as many as 30% of children and adolescents experiencing one. The true prevalence of ADHD is estimated to be about 4% of the population. Whether social phobia, generalized anxiety disorder, or even posttraumatic stress disorder, anxiety disorders interfere with attention as ruminative worry tends to distract those experiencing it. It can also affect attention and focus indirectly by interfering with restful sleep. Anxiety disorders can be difficult to identify, as the sufferers typically internalize their symptoms. But inquire about specific worries (such as speaking in front of others, meeting new people, or an illness or accident striking themselves or a loved one) and how much time they take up. Explore if worries fill their thoughts during quiet or downtime, and explore more about their worries. You may use a screening instrument such as the Pediatric Symptom Checklist or the SCARED, both of which will indicate a likely problem with anxiety. While it is possible to have comorbid ADHD with an anxiety disorder, the anxiety disorder will likely worsen with stimulants and should be treated first. These are usually curable illnesses and you may find that remission of anxiety symptoms resolves the attentional problems.
Depression
Mood disorders are less common than anxiety disorders in youth, but far more prevalent than ADHD. And depression is usually marked by serious difficulty concentrating across settings (including for things that were previously very interesting). A sullen teenager who is deeply self-critical about school performance would benefit from exploration of associated changes in mood, interests, energy, appetite, sleep, and for feelings of worthlessness, guilt, and suicidal thoughts. The PHQ9A is a simple, free screening instrument that is reasonable to use with every sick visit (and well-check) with your adolescent patients, given the risks of undetected and untreated depression. If your patient presents complaining of poor school performance, always screen for depression. As with anxiety disorders, comorbid ADHD is possible, but it is always recommended to treat the mood disorder first and then to assess for residual ADHD symptoms once the mood disorder is in remission.
Substance abuse
Adolescence is a time of exploration, and drug and alcohol use is common. While attentional impairment will happen with intoxication, occasional or rare use should not lead to consistent impairment in school. But when parents are more worried than their children about a significant change in school performance, it is important to screen for substance abuse. A child with a secret substance use disorder will often present with behavioral changes and deteriorating school performance and might deny any drug or alcohol use to parents. Indeed, stimulants have some street value and some patients may be seeking a stimulant prescription to sell or trade for other drugs. Regular marijuana use may present with only deteriorating school performance and no irritability or other noticeable behavioral changes. Marijuana is seen as safe and even healthy by many teenagers (and even many parents), and some youth may be using it recreationally or to manage difficulties with sleep, anxiety, or mood symptoms.
But there is compelling evidence that marijuana use causes cognitive impairment, including difficulty with sustaining attention, short-term memory, and processing speed, for as long as 24 hours after use. If a teenager is using marijuana daily after school, it is certainly going to interfere, in a dose-dependent manner, with attention and cognitive function. Sustained heavy use can lead to permanent cognitive deficits. It can also trigger or worsen anxiety or mood symptoms (contrary to much popular opinion).
Gathering a thorough substance use history is essential when assessing a teenager for difficulties with focus or attention, especially when these are accompanied by change in behavior and school performance. Remember, it is critical to interview these children without their parents present to invite them to be forthcoming with you.
History
While true ADHD should have been present throughout childhood, it is possible that the symptoms have become noticeable only in adolescence. For patients with very high intelligence and lower levels of impulsivity and hyperactivity, they might easily have “flown under the radar” during their elementary and even middle school years. Their difficulties with attention and focus might become apparent only when the volume and difficulty of schoolwork both are great enough that their intelligence is not enough to get good grades. That is, their problems with executive function, prioritizing, shifting sets, and completing tasks in a timely way make it impossible to keep up good grades when the work gets harder.
Your history should reveal a long history of dreaminess or distractibility, a tendency to lose and forget things, and the other symptoms of inattention. Did they often seem to not be listening when they were younger? Forget to hand in homework? Leave chores unfinished? Leave messes behind everywhere they went? These will not be definitive, but they do reassure that symptoms may have been present for a long time, even if school performance was considered fine until the workload got too large. If such problems were not present before puberty, consider whether a subtle learning disability could be impairing them as they face more challenging academic subjects.
If you have ruled out anxiety, mood, and substance use concerns, and helped them to address a sleep deficit, then you can proceed. It is worthwhile to get Vanderbilt Assessments as you would for a younger child. If they meet criteria, discuss the risks and benefits of medication, executive skills coaching, and environmental adjustments (extra time for tests, a less stimulating environment) that can help them explore academic challenges without the discouragement that ADHD can bring.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
Did you know these things about nicotine? Your patients don’t
When asked, young people report that their reasons for starting smoking include rebellion, a new thing to try, and a peer social activity, among others. While you recognize these as developmentally expected drives, it is frustrating and scary that youth don’t realize how their brains are especially sensitive to permanent changes from nicotine.
Smoking even five packs of cigarettes is enough to cause addiction in youth; an influence as powerful as for cocaine or heroin. One pod of a vaping device delivers as much nicotine as one to five packs of cigarettes, depending on the strength and brand. There are no standards for this content and youth often are unaware of any nicotine and chemicals in vapes. Over 90% of adult smokers started before age 18, some as young as 6, mainly because quitting is so difficult. Cigarettes and vaping are not the only sources of nicotine used by youth; others are oral tobacco (chewing tobacco and dip), cigars, pipes, snus (between cheek and gum), hookahs, electronic devices, bidis (tobacco in a tendu leaf), kreteks (tobacco with cloves), and dissolvable tobacco products. Many youth use both cigarettes and noncigarette tobacco.
Given these predispositions, short-term COVID-19 and asthma exacerbation, and the long-lasting detriment of smoking on neurological, cardiac, pulmonary, and emotional health, actually the “leading preventable cause of death,” our job as pediatric providers is to do our best to prevent smoking/vaping or help our patients quit. But adolescent development is notoriously characterized by short-term thinking and feeling immune from long-term health consequences. So what approach has the best results? Focus on aspects of smoking important to the youth now, such as sports performance, bad breath, social stigma, insomnia, cost, lack of benefit for weight loss, and hazardous waste produced. Add to that loss of independence and being manipulated by Big Business by getting them (and targeted minorities) hooked may be salient in our discussion.
Even a brief 3-minute discussion using the AAC (Ask/Assess, Advise, Connect) format has shown effectiveness in getting teens and adults to quit smoking. Our assessment needs to include asking the extent of current use and symptoms of dependence to inform the treatment plan. We need to use their trust in us to advise that quitting is the best thing they can do for their health.
If the youth’s readiness stage is “thinking about stopping” nicotine, our motivational interview–style discussion of pros and cons could include asking “How important is it to you to stop?” and “What are some things that would help you?” If they are open to trying to stop, advise them to set a quit date within 2 weeks and suggest reducing gradually before then (and schedule follow-up). The plan needs to include dealing with the inevitable urges by finding ways to avoid current triggers to smoke (e.g., certain school bathrooms, people drinking or smoking, or stress over homework, conflict at home, etc.). Encourage exercise and meditation to distract and deal with the anxiety; asking family to quit; having a snack handy (such as sugarless gum or sunflower seeds) for when oral cravings develop; and setting rewards for early days of smoke-free success. We need to inform youth that using e-cigs actually reduces rates of success in quitting.
We need to warn youth of the withdrawal symptoms and their usual course when quitting: cravings each lasting 15-20 minutes (starting at 1/2-4 hours); restlessness, sadness, hopelessness (10 hours); irritability, trouble concentrating, insomnia, hunger and weight gain (5-10 pounds over 2 weeks, starting 24 hrs); headaches, dizziness, fatigue (starting 2 days); and anxiety (starting 3 days). There tends to be less brain fog, and less hunger after 2-4 weeks, but depression, anxiety, irritability, cough, constipation, and even suicidal thoughts may last weeks to months. Sounds nasty, right? No wonder quitting is so hard.
Support is crucial to quitting and staying off nicotine. You can provide this but, in addition to friends and family, we should connect youth to free ongoing phone counselors (1-800-QUIT-NOW or 877-44U-QUIT for Spanish), text services (text QUIT to 47848), apps (quit START), or community support.
While behavioral treatments are best for youth with minimal to mild dependence, risk of relapse is minimized with fewer withdrawal symptoms, thus the role for nicotine replacement therapy (NRT) for those with moderate to strong dependence and to help anyone ad lib with cravings. NRT is recommended by the American Academy of Pediatrics (AAP) to supplement counseling, although NRT is not Food and Drug Administration approved and requires a prescription for those under 18.
How can we determine the degree of dependence? Smoking more than 15 cigarettes per day (or vape equivalent) and inhaling even “seldom” counts as “moderate” dependence and more than 26 with difficulty refraining in several situations as “substantial” in the Fagerstrom Tolerance test. Early morning smoking is asked about, important to which NRT to use (gum or lozenge for faster onset). The Hooked on Nicotine Checklist assesses “loss of autonomy” over smoking by any “yes” item and is incorporated in the CRAFFT screen. The recommended dose of NRT and length of weaning is greater in substantial addiction versus moderate. Besides gum, lozenges, patch, inhaler, and nasal spray, you can prescribe bupropion (Wellbutrin or Zyban) or varenicline (Chantix), making note of the black box suicide warning. Combining NRTs is similarly effective compared with varenicline.
Relapse after quitting is more common than not. As for any chronic condition, in relapse we need to query adherence, and consider increasing NRT dose or wean duration, even years. Discussion should have a positive focus on “what was learned” from past attempts in making a new plan that incorporates Relevance, Risks, Rewards, Roadblocks, and Repetition.
Many youth smokers start because their parents smoke. While addressing adults may seem out of scope, we often treat parents when managing scabies, pinworms, meningococcal disease, and even depression for the benefit of the child. The AAP recommends prescribing NRT for parents, when needed.
Nicotine dependence is a chronic relapsing condition with comorbidities of substance use and psychiatric disorders that requires similar monitoring and support as for other chronic conditions we manage and is more likely to shorten lifespan than many.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. 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.
Reference
Clinical practice policy to protect children from tobacco, nicotine, and tobacco smoke, Pediatrics 2015;136(5):1008-17. doi: 10.1542/peds.2015-31088.
When asked, young people report that their reasons for starting smoking include rebellion, a new thing to try, and a peer social activity, among others. While you recognize these as developmentally expected drives, it is frustrating and scary that youth don’t realize how their brains are especially sensitive to permanent changes from nicotine.
Smoking even five packs of cigarettes is enough to cause addiction in youth; an influence as powerful as for cocaine or heroin. One pod of a vaping device delivers as much nicotine as one to five packs of cigarettes, depending on the strength and brand. There are no standards for this content and youth often are unaware of any nicotine and chemicals in vapes. Over 90% of adult smokers started before age 18, some as young as 6, mainly because quitting is so difficult. Cigarettes and vaping are not the only sources of nicotine used by youth; others are oral tobacco (chewing tobacco and dip), cigars, pipes, snus (between cheek and gum), hookahs, electronic devices, bidis (tobacco in a tendu leaf), kreteks (tobacco with cloves), and dissolvable tobacco products. Many youth use both cigarettes and noncigarette tobacco.
Given these predispositions, short-term COVID-19 and asthma exacerbation, and the long-lasting detriment of smoking on neurological, cardiac, pulmonary, and emotional health, actually the “leading preventable cause of death,” our job as pediatric providers is to do our best to prevent smoking/vaping or help our patients quit. But adolescent development is notoriously characterized by short-term thinking and feeling immune from long-term health consequences. So what approach has the best results? Focus on aspects of smoking important to the youth now, such as sports performance, bad breath, social stigma, insomnia, cost, lack of benefit for weight loss, and hazardous waste produced. Add to that loss of independence and being manipulated by Big Business by getting them (and targeted minorities) hooked may be salient in our discussion.
Even a brief 3-minute discussion using the AAC (Ask/Assess, Advise, Connect) format has shown effectiveness in getting teens and adults to quit smoking. Our assessment needs to include asking the extent of current use and symptoms of dependence to inform the treatment plan. We need to use their trust in us to advise that quitting is the best thing they can do for their health.
If the youth’s readiness stage is “thinking about stopping” nicotine, our motivational interview–style discussion of pros and cons could include asking “How important is it to you to stop?” and “What are some things that would help you?” If they are open to trying to stop, advise them to set a quit date within 2 weeks and suggest reducing gradually before then (and schedule follow-up). The plan needs to include dealing with the inevitable urges by finding ways to avoid current triggers to smoke (e.g., certain school bathrooms, people drinking or smoking, or stress over homework, conflict at home, etc.). Encourage exercise and meditation to distract and deal with the anxiety; asking family to quit; having a snack handy (such as sugarless gum or sunflower seeds) for when oral cravings develop; and setting rewards for early days of smoke-free success. We need to inform youth that using e-cigs actually reduces rates of success in quitting.
We need to warn youth of the withdrawal symptoms and their usual course when quitting: cravings each lasting 15-20 minutes (starting at 1/2-4 hours); restlessness, sadness, hopelessness (10 hours); irritability, trouble concentrating, insomnia, hunger and weight gain (5-10 pounds over 2 weeks, starting 24 hrs); headaches, dizziness, fatigue (starting 2 days); and anxiety (starting 3 days). There tends to be less brain fog, and less hunger after 2-4 weeks, but depression, anxiety, irritability, cough, constipation, and even suicidal thoughts may last weeks to months. Sounds nasty, right? No wonder quitting is so hard.
Support is crucial to quitting and staying off nicotine. You can provide this but, in addition to friends and family, we should connect youth to free ongoing phone counselors (1-800-QUIT-NOW or 877-44U-QUIT for Spanish), text services (text QUIT to 47848), apps (quit START), or community support.
While behavioral treatments are best for youth with minimal to mild dependence, risk of relapse is minimized with fewer withdrawal symptoms, thus the role for nicotine replacement therapy (NRT) for those with moderate to strong dependence and to help anyone ad lib with cravings. NRT is recommended by the American Academy of Pediatrics (AAP) to supplement counseling, although NRT is not Food and Drug Administration approved and requires a prescription for those under 18.
How can we determine the degree of dependence? Smoking more than 15 cigarettes per day (or vape equivalent) and inhaling even “seldom” counts as “moderate” dependence and more than 26 with difficulty refraining in several situations as “substantial” in the Fagerstrom Tolerance test. Early morning smoking is asked about, important to which NRT to use (gum or lozenge for faster onset). The Hooked on Nicotine Checklist assesses “loss of autonomy” over smoking by any “yes” item and is incorporated in the CRAFFT screen. The recommended dose of NRT and length of weaning is greater in substantial addiction versus moderate. Besides gum, lozenges, patch, inhaler, and nasal spray, you can prescribe bupropion (Wellbutrin or Zyban) or varenicline (Chantix), making note of the black box suicide warning. Combining NRTs is similarly effective compared with varenicline.
Relapse after quitting is more common than not. As for any chronic condition, in relapse we need to query adherence, and consider increasing NRT dose or wean duration, even years. Discussion should have a positive focus on “what was learned” from past attempts in making a new plan that incorporates Relevance, Risks, Rewards, Roadblocks, and Repetition.
Many youth smokers start because their parents smoke. While addressing adults may seem out of scope, we often treat parents when managing scabies, pinworms, meningococcal disease, and even depression for the benefit of the child. The AAP recommends prescribing NRT for parents, when needed.
Nicotine dependence is a chronic relapsing condition with comorbidities of substance use and psychiatric disorders that requires similar monitoring and support as for other chronic conditions we manage and is more likely to shorten lifespan than many.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. 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.
Reference
Clinical practice policy to protect children from tobacco, nicotine, and tobacco smoke, Pediatrics 2015;136(5):1008-17. doi: 10.1542/peds.2015-31088.
When asked, young people report that their reasons for starting smoking include rebellion, a new thing to try, and a peer social activity, among others. While you recognize these as developmentally expected drives, it is frustrating and scary that youth don’t realize how their brains are especially sensitive to permanent changes from nicotine.
Smoking even five packs of cigarettes is enough to cause addiction in youth; an influence as powerful as for cocaine or heroin. One pod of a vaping device delivers as much nicotine as one to five packs of cigarettes, depending on the strength and brand. There are no standards for this content and youth often are unaware of any nicotine and chemicals in vapes. Over 90% of adult smokers started before age 18, some as young as 6, mainly because quitting is so difficult. Cigarettes and vaping are not the only sources of nicotine used by youth; others are oral tobacco (chewing tobacco and dip), cigars, pipes, snus (between cheek and gum), hookahs, electronic devices, bidis (tobacco in a tendu leaf), kreteks (tobacco with cloves), and dissolvable tobacco products. Many youth use both cigarettes and noncigarette tobacco.
Given these predispositions, short-term COVID-19 and asthma exacerbation, and the long-lasting detriment of smoking on neurological, cardiac, pulmonary, and emotional health, actually the “leading preventable cause of death,” our job as pediatric providers is to do our best to prevent smoking/vaping or help our patients quit. But adolescent development is notoriously characterized by short-term thinking and feeling immune from long-term health consequences. So what approach has the best results? Focus on aspects of smoking important to the youth now, such as sports performance, bad breath, social stigma, insomnia, cost, lack of benefit for weight loss, and hazardous waste produced. Add to that loss of independence and being manipulated by Big Business by getting them (and targeted minorities) hooked may be salient in our discussion.
Even a brief 3-minute discussion using the AAC (Ask/Assess, Advise, Connect) format has shown effectiveness in getting teens and adults to quit smoking. Our assessment needs to include asking the extent of current use and symptoms of dependence to inform the treatment plan. We need to use their trust in us to advise that quitting is the best thing they can do for their health.
If the youth’s readiness stage is “thinking about stopping” nicotine, our motivational interview–style discussion of pros and cons could include asking “How important is it to you to stop?” and “What are some things that would help you?” If they are open to trying to stop, advise them to set a quit date within 2 weeks and suggest reducing gradually before then (and schedule follow-up). The plan needs to include dealing with the inevitable urges by finding ways to avoid current triggers to smoke (e.g., certain school bathrooms, people drinking or smoking, or stress over homework, conflict at home, etc.). Encourage exercise and meditation to distract and deal with the anxiety; asking family to quit; having a snack handy (such as sugarless gum or sunflower seeds) for when oral cravings develop; and setting rewards for early days of smoke-free success. We need to inform youth that using e-cigs actually reduces rates of success in quitting.
We need to warn youth of the withdrawal symptoms and their usual course when quitting: cravings each lasting 15-20 minutes (starting at 1/2-4 hours); restlessness, sadness, hopelessness (10 hours); irritability, trouble concentrating, insomnia, hunger and weight gain (5-10 pounds over 2 weeks, starting 24 hrs); headaches, dizziness, fatigue (starting 2 days); and anxiety (starting 3 days). There tends to be less brain fog, and less hunger after 2-4 weeks, but depression, anxiety, irritability, cough, constipation, and even suicidal thoughts may last weeks to months. Sounds nasty, right? No wonder quitting is so hard.
Support is crucial to quitting and staying off nicotine. You can provide this but, in addition to friends and family, we should connect youth to free ongoing phone counselors (1-800-QUIT-NOW or 877-44U-QUIT for Spanish), text services (text QUIT to 47848), apps (quit START), or community support.
While behavioral treatments are best for youth with minimal to mild dependence, risk of relapse is minimized with fewer withdrawal symptoms, thus the role for nicotine replacement therapy (NRT) for those with moderate to strong dependence and to help anyone ad lib with cravings. NRT is recommended by the American Academy of Pediatrics (AAP) to supplement counseling, although NRT is not Food and Drug Administration approved and requires a prescription for those under 18.
How can we determine the degree of dependence? Smoking more than 15 cigarettes per day (or vape equivalent) and inhaling even “seldom” counts as “moderate” dependence and more than 26 with difficulty refraining in several situations as “substantial” in the Fagerstrom Tolerance test. Early morning smoking is asked about, important to which NRT to use (gum or lozenge for faster onset). The Hooked on Nicotine Checklist assesses “loss of autonomy” over smoking by any “yes” item and is incorporated in the CRAFFT screen. The recommended dose of NRT and length of weaning is greater in substantial addiction versus moderate. Besides gum, lozenges, patch, inhaler, and nasal spray, you can prescribe bupropion (Wellbutrin or Zyban) or varenicline (Chantix), making note of the black box suicide warning. Combining NRTs is similarly effective compared with varenicline.
Relapse after quitting is more common than not. As for any chronic condition, in relapse we need to query adherence, and consider increasing NRT dose or wean duration, even years. Discussion should have a positive focus on “what was learned” from past attempts in making a new plan that incorporates Relevance, Risks, Rewards, Roadblocks, and Repetition.
Many youth smokers start because their parents smoke. While addressing adults may seem out of scope, we often treat parents when managing scabies, pinworms, meningococcal disease, and even depression for the benefit of the child. The AAP recommends prescribing NRT for parents, when needed.
Nicotine dependence is a chronic relapsing condition with comorbidities of substance use and psychiatric disorders that requires similar monitoring and support as for other chronic conditions we manage and is more likely to shorten lifespan than many.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. 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.
Reference
Clinical practice policy to protect children from tobacco, nicotine, and tobacco smoke, Pediatrics 2015;136(5):1008-17. doi: 10.1542/peds.2015-31088.
Pediatric depression and parents
In October of 2021, the American Academy of Child and Adolescent Psychiatry, the American Academy of Pediatrics, and the Children’s Hospital Association jointly declared a National State of Emergency in Children’s Mental Health and called on policy makers to address a host of challenges that have impeded access to effective mental health care for youth.
In November, we wrote about how pediatricians may increase their use of screening for adolescent depression and initiate treatment when appropriate.
Now we complement that piece with guidance you may offer the parents of your depressed adolescent patients. Adolescent depression is a common pediatric disorder, especially in the COVID-19 era when so many relationships and activities have been limited or cut off. With treatment, most adolescents recover. Accepting that it may be taking longer to find a therapist, you can make treatment recommendations, support the teenager and parents, address safety concerns and, if the depression is of moderate or more serious severity, start medications. Parents are your natural partners as they are concerned about their children’s health and safety and eager for guidance on how to best support their recovery.
Adolescence is a time in which parents transition to more of a consulting than a controlling posture with their children, but illness calls for a shift toward setting rules and routines that will support health and healing. Prepare both the teenager (in a 1:1 discussion) and parents for this temporary shift, and for some teenagers, expect resistance. Depression will make the teenager more unhappy and irritable. It also causes withdrawal, by sapping energy and making one feel unwelcome at activities, believing his or her presence will be a burden to others. Treatment includes something called “behavioral activation,” or continuous nudging, to keep the patient involved in social, intellectual, and physical activities. Parents (and siblings) are the keys to this behavioral activation, whether nudging to participate in a board game or a walk. Reassure parents they should not take it personally when their teen resists, and not be discouraged if they fail sometimes. Their focus is on calmly, warmly, and repeatedly prompting their children with nudges toward these routines and activities. They should be ready to remind them why they are “nagging,” framing these efforts explicitly as supporting recovery from depression. If possible, applying these rules to everyone at home will help. They need to avoid being drawn into conflict, focusing instead on staying connected to their teens. Their task is to keep planning and cajoling, giving their children multiple opportunities to participate, pushing back against depression’s gravitational pull for total withdrawal.
Sleep
One of the most important thing parents can do for their depressed adolescents is to support their healthy restful sleep. During adolescence, the timing of sleep naturally shifts later, and the need for restful sleep increases. Working against the demands of homework, extracurricular activities, and social connections, sleep often suffers during adolescence. Further sleep disruptions, including difficulty falling asleep and frequent awakening during sleep or in the early morning, are typical of depression. Restful sleep is instrumental to recovery, and parents need to help their depressed teens set good sleep habits. This includes setting a time for bed that is realistic and consistent and turning off screens 30 minutes before lights out. A soothing, consistent bedtime routine, including a hot shower and reading in bed, is a powerful cue for sleep. Getting daily exercise and avoiding a heavy meal and caffeine in the hours before bed supports both falling and staying asleep. Having light reading near bed (magazines or comics) instead of screens can provide a way to pass 30 minutes if they wake up during the night (ideally reading out of bed), one that will not make it harder for them to go back to sleep. Finally, teens should not be allowed to spend all day in bed or nap in the afternoon. This may be the hardest task for parents, as adolescents naturally treat their beds like their center of operations and depression lowers their energy and initiative. If parents set these rules and routines for all members of the family, it can improve the chances that their depressed adolescents may begin to return to healthy sleep.
Exercise
Vigorous exercise (for 20 minutes three times weekly) is as effective as SSRIs in treating mild to moderate depression. Even in severe depression, exercise may accelerate recovery and certainly contributes to returning to restful sleep and a feeling of improved energy. Inviting their depressed teens to join them on a trip to the gym may seem like a fool’s errand to parents, but they should prioritize getting their children moving. Don’t offer choices or ask what activity they would like to do. Most invitations will be met with “no, thanks” (or probably something less polite). Instead, initiate simple activities and then cajole the children with “let’s go!” They should use loving persistence to get them out the door. Parents are the experts on their children and will know if there is an activity that they are more likely to enjoy. Make any activities group ones, easy to start and not too long. They could initiate family walks or bike rides in their neighborhood. If it helps, they can blame you, “these are doctor’s orders!” This approach of warm persistence should be applied across the board, helping their depressed teens participate in mealtimes and other activities. Prepare parents that this can feel unnatural, if they have been letting their healthy teenagers have more space and independence and less time in family activities.
Social connections
Behavioral activation includes keeping a depressed teen engaged in social activities. Friendships are a potent motivator in the lives of healthy adolescents. If depressed teens can stay connected to close friends, it is a powerful force for recovery. Find out if their friends know about their depression, whom do they trust to tell about it? Help them find comfortable language to speak about their depression with trusted friends. Parents can use their behavioral activation strategies to prompt their teenagers to participate in social activities. If texting, video chatting, or social media platforms are how they stay connected with close friends, support their use of these platforms. But be mindful that social media promotes social comparison over connection, and depression sets them up to feel less than others even without assistance. Parents should support real time with their friends in small groups, for short periods during the time of day when they have the most energy.
Safety
Suicide is the second leading cause of death for adolescents in the United States, and the rate of attempted and completed suicide in adolescents has been steadily climbing over the past decade according to the CDC. The rate is higher in older adolescents, though thankfully relatively uncommon (about 1 in 10,000 a year), and, although we know risk factors, no one has been able to predict reliably the risk for an individual teenager at a point in time. In a clinically referred sample, 85% of depressed adolescents will have suicidal ideation and 32% will make a suicide attempt. The risk is higher in those adolescents with more than one psychiatric diagnosis and with a history of impulsive behaviors, substance abuse, prior suicide attempts, and a family history of suicide. It is important that parents hear that asking about suicidal thoughts will not cause them. On the contrary, preserving open communication and a warm relationship is very protective. Adolescent suicide attempts are likely to be impulsive, so helping the family to consider ways to “put up obstacles” that would slow down any possible attempt is an effective way to improve safety. Ask your patients about suicidal thoughts, plans, and what keeps them safe. Find out if they worry about sharing these thoughts with their parents and why. Ask if there are ways their parents can check on them that “aren’t too annoying.” Determine if there are guns in the home, and if so, are they safely stored (locked, separate from ammunition)? More than 50% of completed adolescent suicides involve firearms, so this question is critical. What about access to medications that could be dangerous in overdose in your home or a relative’s home they may visit? Discussing these facts with your patients and their parents together will make it easier for them to continue the conversation outside of your office and can make an enormous difference in their recovery.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
Reference
Kovacs M et al. J Am Acad Child Adolesc Psychiatry. 1993 Jan;32(1):8-20.
In October of 2021, the American Academy of Child and Adolescent Psychiatry, the American Academy of Pediatrics, and the Children’s Hospital Association jointly declared a National State of Emergency in Children’s Mental Health and called on policy makers to address a host of challenges that have impeded access to effective mental health care for youth.
In November, we wrote about how pediatricians may increase their use of screening for adolescent depression and initiate treatment when appropriate.
Now we complement that piece with guidance you may offer the parents of your depressed adolescent patients. Adolescent depression is a common pediatric disorder, especially in the COVID-19 era when so many relationships and activities have been limited or cut off. With treatment, most adolescents recover. Accepting that it may be taking longer to find a therapist, you can make treatment recommendations, support the teenager and parents, address safety concerns and, if the depression is of moderate or more serious severity, start medications. Parents are your natural partners as they are concerned about their children’s health and safety and eager for guidance on how to best support their recovery.
Adolescence is a time in which parents transition to more of a consulting than a controlling posture with their children, but illness calls for a shift toward setting rules and routines that will support health and healing. Prepare both the teenager (in a 1:1 discussion) and parents for this temporary shift, and for some teenagers, expect resistance. Depression will make the teenager more unhappy and irritable. It also causes withdrawal, by sapping energy and making one feel unwelcome at activities, believing his or her presence will be a burden to others. Treatment includes something called “behavioral activation,” or continuous nudging, to keep the patient involved in social, intellectual, and physical activities. Parents (and siblings) are the keys to this behavioral activation, whether nudging to participate in a board game or a walk. Reassure parents they should not take it personally when their teen resists, and not be discouraged if they fail sometimes. Their focus is on calmly, warmly, and repeatedly prompting their children with nudges toward these routines and activities. They should be ready to remind them why they are “nagging,” framing these efforts explicitly as supporting recovery from depression. If possible, applying these rules to everyone at home will help. They need to avoid being drawn into conflict, focusing instead on staying connected to their teens. Their task is to keep planning and cajoling, giving their children multiple opportunities to participate, pushing back against depression’s gravitational pull for total withdrawal.
Sleep
One of the most important thing parents can do for their depressed adolescents is to support their healthy restful sleep. During adolescence, the timing of sleep naturally shifts later, and the need for restful sleep increases. Working against the demands of homework, extracurricular activities, and social connections, sleep often suffers during adolescence. Further sleep disruptions, including difficulty falling asleep and frequent awakening during sleep or in the early morning, are typical of depression. Restful sleep is instrumental to recovery, and parents need to help their depressed teens set good sleep habits. This includes setting a time for bed that is realistic and consistent and turning off screens 30 minutes before lights out. A soothing, consistent bedtime routine, including a hot shower and reading in bed, is a powerful cue for sleep. Getting daily exercise and avoiding a heavy meal and caffeine in the hours before bed supports both falling and staying asleep. Having light reading near bed (magazines or comics) instead of screens can provide a way to pass 30 minutes if they wake up during the night (ideally reading out of bed), one that will not make it harder for them to go back to sleep. Finally, teens should not be allowed to spend all day in bed or nap in the afternoon. This may be the hardest task for parents, as adolescents naturally treat their beds like their center of operations and depression lowers their energy and initiative. If parents set these rules and routines for all members of the family, it can improve the chances that their depressed adolescents may begin to return to healthy sleep.
Exercise
Vigorous exercise (for 20 minutes three times weekly) is as effective as SSRIs in treating mild to moderate depression. Even in severe depression, exercise may accelerate recovery and certainly contributes to returning to restful sleep and a feeling of improved energy. Inviting their depressed teens to join them on a trip to the gym may seem like a fool’s errand to parents, but they should prioritize getting their children moving. Don’t offer choices or ask what activity they would like to do. Most invitations will be met with “no, thanks” (or probably something less polite). Instead, initiate simple activities and then cajole the children with “let’s go!” They should use loving persistence to get them out the door. Parents are the experts on their children and will know if there is an activity that they are more likely to enjoy. Make any activities group ones, easy to start and not too long. They could initiate family walks or bike rides in their neighborhood. If it helps, they can blame you, “these are doctor’s orders!” This approach of warm persistence should be applied across the board, helping their depressed teens participate in mealtimes and other activities. Prepare parents that this can feel unnatural, if they have been letting their healthy teenagers have more space and independence and less time in family activities.
Social connections
Behavioral activation includes keeping a depressed teen engaged in social activities. Friendships are a potent motivator in the lives of healthy adolescents. If depressed teens can stay connected to close friends, it is a powerful force for recovery. Find out if their friends know about their depression, whom do they trust to tell about it? Help them find comfortable language to speak about their depression with trusted friends. Parents can use their behavioral activation strategies to prompt their teenagers to participate in social activities. If texting, video chatting, or social media platforms are how they stay connected with close friends, support their use of these platforms. But be mindful that social media promotes social comparison over connection, and depression sets them up to feel less than others even without assistance. Parents should support real time with their friends in small groups, for short periods during the time of day when they have the most energy.
Safety
Suicide is the second leading cause of death for adolescents in the United States, and the rate of attempted and completed suicide in adolescents has been steadily climbing over the past decade according to the CDC. The rate is higher in older adolescents, though thankfully relatively uncommon (about 1 in 10,000 a year), and, although we know risk factors, no one has been able to predict reliably the risk for an individual teenager at a point in time. In a clinically referred sample, 85% of depressed adolescents will have suicidal ideation and 32% will make a suicide attempt. The risk is higher in those adolescents with more than one psychiatric diagnosis and with a history of impulsive behaviors, substance abuse, prior suicide attempts, and a family history of suicide. It is important that parents hear that asking about suicidal thoughts will not cause them. On the contrary, preserving open communication and a warm relationship is very protective. Adolescent suicide attempts are likely to be impulsive, so helping the family to consider ways to “put up obstacles” that would slow down any possible attempt is an effective way to improve safety. Ask your patients about suicidal thoughts, plans, and what keeps them safe. Find out if they worry about sharing these thoughts with their parents and why. Ask if there are ways their parents can check on them that “aren’t too annoying.” Determine if there are guns in the home, and if so, are they safely stored (locked, separate from ammunition)? More than 50% of completed adolescent suicides involve firearms, so this question is critical. What about access to medications that could be dangerous in overdose in your home or a relative’s home they may visit? Discussing these facts with your patients and their parents together will make it easier for them to continue the conversation outside of your office and can make an enormous difference in their recovery.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
Reference
Kovacs M et al. J Am Acad Child Adolesc Psychiatry. 1993 Jan;32(1):8-20.
In October of 2021, the American Academy of Child and Adolescent Psychiatry, the American Academy of Pediatrics, and the Children’s Hospital Association jointly declared a National State of Emergency in Children’s Mental Health and called on policy makers to address a host of challenges that have impeded access to effective mental health care for youth.
In November, we wrote about how pediatricians may increase their use of screening for adolescent depression and initiate treatment when appropriate.
Now we complement that piece with guidance you may offer the parents of your depressed adolescent patients. Adolescent depression is a common pediatric disorder, especially in the COVID-19 era when so many relationships and activities have been limited or cut off. With treatment, most adolescents recover. Accepting that it may be taking longer to find a therapist, you can make treatment recommendations, support the teenager and parents, address safety concerns and, if the depression is of moderate or more serious severity, start medications. Parents are your natural partners as they are concerned about their children’s health and safety and eager for guidance on how to best support their recovery.
Adolescence is a time in which parents transition to more of a consulting than a controlling posture with their children, but illness calls for a shift toward setting rules and routines that will support health and healing. Prepare both the teenager (in a 1:1 discussion) and parents for this temporary shift, and for some teenagers, expect resistance. Depression will make the teenager more unhappy and irritable. It also causes withdrawal, by sapping energy and making one feel unwelcome at activities, believing his or her presence will be a burden to others. Treatment includes something called “behavioral activation,” or continuous nudging, to keep the patient involved in social, intellectual, and physical activities. Parents (and siblings) are the keys to this behavioral activation, whether nudging to participate in a board game or a walk. Reassure parents they should not take it personally when their teen resists, and not be discouraged if they fail sometimes. Their focus is on calmly, warmly, and repeatedly prompting their children with nudges toward these routines and activities. They should be ready to remind them why they are “nagging,” framing these efforts explicitly as supporting recovery from depression. If possible, applying these rules to everyone at home will help. They need to avoid being drawn into conflict, focusing instead on staying connected to their teens. Their task is to keep planning and cajoling, giving their children multiple opportunities to participate, pushing back against depression’s gravitational pull for total withdrawal.
Sleep
One of the most important thing parents can do for their depressed adolescents is to support their healthy restful sleep. During adolescence, the timing of sleep naturally shifts later, and the need for restful sleep increases. Working against the demands of homework, extracurricular activities, and social connections, sleep often suffers during adolescence. Further sleep disruptions, including difficulty falling asleep and frequent awakening during sleep or in the early morning, are typical of depression. Restful sleep is instrumental to recovery, and parents need to help their depressed teens set good sleep habits. This includes setting a time for bed that is realistic and consistent and turning off screens 30 minutes before lights out. A soothing, consistent bedtime routine, including a hot shower and reading in bed, is a powerful cue for sleep. Getting daily exercise and avoiding a heavy meal and caffeine in the hours before bed supports both falling and staying asleep. Having light reading near bed (magazines or comics) instead of screens can provide a way to pass 30 minutes if they wake up during the night (ideally reading out of bed), one that will not make it harder for them to go back to sleep. Finally, teens should not be allowed to spend all day in bed or nap in the afternoon. This may be the hardest task for parents, as adolescents naturally treat their beds like their center of operations and depression lowers their energy and initiative. If parents set these rules and routines for all members of the family, it can improve the chances that their depressed adolescents may begin to return to healthy sleep.
Exercise
Vigorous exercise (for 20 minutes three times weekly) is as effective as SSRIs in treating mild to moderate depression. Even in severe depression, exercise may accelerate recovery and certainly contributes to returning to restful sleep and a feeling of improved energy. Inviting their depressed teens to join them on a trip to the gym may seem like a fool’s errand to parents, but they should prioritize getting their children moving. Don’t offer choices or ask what activity they would like to do. Most invitations will be met with “no, thanks” (or probably something less polite). Instead, initiate simple activities and then cajole the children with “let’s go!” They should use loving persistence to get them out the door. Parents are the experts on their children and will know if there is an activity that they are more likely to enjoy. Make any activities group ones, easy to start and not too long. They could initiate family walks or bike rides in their neighborhood. If it helps, they can blame you, “these are doctor’s orders!” This approach of warm persistence should be applied across the board, helping their depressed teens participate in mealtimes and other activities. Prepare parents that this can feel unnatural, if they have been letting their healthy teenagers have more space and independence and less time in family activities.
Social connections
Behavioral activation includes keeping a depressed teen engaged in social activities. Friendships are a potent motivator in the lives of healthy adolescents. If depressed teens can stay connected to close friends, it is a powerful force for recovery. Find out if their friends know about their depression, whom do they trust to tell about it? Help them find comfortable language to speak about their depression with trusted friends. Parents can use their behavioral activation strategies to prompt their teenagers to participate in social activities. If texting, video chatting, or social media platforms are how they stay connected with close friends, support their use of these platforms. But be mindful that social media promotes social comparison over connection, and depression sets them up to feel less than others even without assistance. Parents should support real time with their friends in small groups, for short periods during the time of day when they have the most energy.
Safety
Suicide is the second leading cause of death for adolescents in the United States, and the rate of attempted and completed suicide in adolescents has been steadily climbing over the past decade according to the CDC. The rate is higher in older adolescents, though thankfully relatively uncommon (about 1 in 10,000 a year), and, although we know risk factors, no one has been able to predict reliably the risk for an individual teenager at a point in time. In a clinically referred sample, 85% of depressed adolescents will have suicidal ideation and 32% will make a suicide attempt. The risk is higher in those adolescents with more than one psychiatric diagnosis and with a history of impulsive behaviors, substance abuse, prior suicide attempts, and a family history of suicide. It is important that parents hear that asking about suicidal thoughts will not cause them. On the contrary, preserving open communication and a warm relationship is very protective. Adolescent suicide attempts are likely to be impulsive, so helping the family to consider ways to “put up obstacles” that would slow down any possible attempt is an effective way to improve safety. Ask your patients about suicidal thoughts, plans, and what keeps them safe. Find out if they worry about sharing these thoughts with their parents and why. Ask if there are ways their parents can check on them that “aren’t too annoying.” Determine if there are guns in the home, and if so, are they safely stored (locked, separate from ammunition)? More than 50% of completed adolescent suicides involve firearms, so this question is critical. What about access to medications that could be dangerous in overdose in your home or a relative’s home they may visit? Discussing these facts with your patients and their parents together will make it easier for them to continue the conversation outside of your office and can make an enormous difference in their recovery.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
Reference
Kovacs M et al. J Am Acad Child Adolesc Psychiatry. 1993 Jan;32(1):8-20.
Don’t give up on relentless youth depression
As pediatricians, we are acutely aware of the increase in depression in our teen patients. Lifetime prevalence is now approaching 20%, and we are doing our best to help.
The Guidelines for Adolescent Depression in Primary Care (GLAD-PC, 2018) has advice on screening and primary care provider (PCP) management, verifying our role in care. But GLAD-PC also advises “referral to a mental health specialist” in patient scenarios we see multiple times per week. Even when patients are willing and able to go, mental health specialists are in short supply or have months-long waiting lists. What should we do to help the more severely depressed adolescent when immediate referral is not possible? What should we expect of specialist care for what is called treatment-resistant or treatment-refractory depression (TRD)?
To know what to do for a youth with TRD, first you need to know what constitutes an adequate trial of treatment. After diagnosis of major depressive disorder (MDD) from a validated screening tool or an interview based on DSM-5 criteria and an appropriate assessment (as described in GLAD-PC), patients and parents need education on symptoms, course, prognosis including suicide risk, and treatment options. Known TRD risk factors, besides longer or greater depression severity, anhedonia, and poor global functioning, can benefit from being specifically addressed: trauma, bullying, comorbid anxiety or substance use, subsyndromal mania, insomnia, hypothyroidism, nutritional deficiencies from eating disorders, certain genetic variants, LGBTQ identification, family conflict, and parental depression. Screening and assessment for suicidal ideation/attempts is needed initially and in follow-up as MDD increases risk of suicide 30 times.
PCPs can manage mild depression with regular visits every 1-2 weeks for active support for 6-8 weeks. Advise all depressed youth on healthy eating, adequate sleep and exercise, pleasurable activities, and refraining from substance use. With a full response (50%+ reduction in symptom score from baseline), monthly monitoring for symptoms, suicidality, and stressors (phone/televisits suffice) should continue for 6-24 months as half recur. Monitoring with ratings by both youth and parent are recommended and may be required by insurers. Scores below cutoff suggest “remission,” although functioning must be considered. Youth report symptoms best but parents may better report improved functioning and affect that can precede symptom reduction.
If there is no initial response (< 25% decrease in symptom score) or a partial response (25%-49% decrease), PCPs should begin treatment as for moderate depression with either a selective serotonin reuptake inhibitor (SSRI) or psychotherapy. Use of both has the best evidence; cognitive behavior therapy (CBT) and interpersonal psychotherapy for adolescents are equally effective.
Side effects from SSRIs are almost universal with GI upset, headaches, and sexual dysfunction most common, but activation (increased agitation or irritability) may occur. Educate patients about these and encourage tolerating them as they tend to subside in weeks, allowing continuation of these most effective medicines. Activation rarely indicates true mania, which would require stopping and referral.
Moderate depression with only comorbid anxiety may be addressed by PCPs with problem-focused supportive counseling and SSRIs, but mental health consultation or referral also are appropriate. Fluoxetine starting at 5-10 mg/day has best evidence and Food and Drug Administration approval for MDD from age 8. Starting at a higher dose may increase risk of suicidal ideation. Alternatively, escitalopram is FDA approved for MDD at age 12 starting at 10 mg/day, although meta-analyses do not distinguish effectiveness within the SSRI class. Although benefit usually appears within 2 weeks, a trial of at least 4 weeks should be used to assess effect.
If after 4 weeks, the SSRI is tolerated but has little or no response, reassess the diagnosis, try a different SSRI, e.g. sertraline, and add CBT (combined SSRI+CBT has an advantage). To switch SSRIs, reduce the first every 1-2 weeks (by 10-20 mg for fluoxetine; 5-10 for escitalopram) to reduce side effects. If overlapping, the replacement SSRI may start midway in the wean at low dose with patients educated about serotonin syndrome. If instead there was a partial response to the initial SSRI, progressively increase the dose (by 10 mg for fluoxetine or 5 mg for escitalopram monthly) as indicated by symptom change up to the maximum (60-80 mg fluoxetine or 20 mg escitalopram), if needed, and maintain for another 4 weeks. Alternatively, or in addition, start psychotherapy or ask to change current therapy, as therapy focus makes a difference in effect. Initial CBT focus on anxiety acts fastest when anxiety is comorbid.
Once a regimen produces a response, maintain it for 16-20 weeks, the longer for more severe depression. Although three-fourths of mildly to moderately depressed youth are late responders, emerging near 6 weeks, a rapid initial response is associated with better outcome. The recommended 8 weeks on a final tolerated dose constituting an adequate trial before changing may be shortened to 6 weeks in severe unremitting cases. Youth not remitting by 12 weeks should be offered alternative treatment. Referral is recommended for moderately severe depression with comorbidity or severe depression but also for unresponsive moderate depression or by family or clinician preference.
Treatment-resistant depression is defined as “clinically impairing depression symptoms despite an adequate trial of an evidence-based psychotherapy and an antidepressant with grade A evidence (fluoxetine, escitalopram, or sertraline),” sequentially or together; treatment-refractory depression comprises the above with failure on at least two antidepressants, with at least one being grade A. Unfortunately, TRD occurs in 30%-40% of children and remission is only 30%. Low adherence based on pill counts (> 30% missed) or with therapy (fewer than nine visits) should be considered in treatment failures.
With manageable factors addressed, the next step for TRD is treatment augmentation. The best evidence-based augmentation for TRD is CBT; 55% of those receiving CBT responded within 12 weeks. TRD augmentations and interventions with evidence in adults have either no evidence of effect in children (SNRIs, lithium), no randomized controlled trials, or support only from small suggestive studies, e.g., antipsychotics, 16 g/day omega-3 fatty acid supplementation, folic acid supplementation, repetitive transcranial magnetic stimulation, electroconvulsive therapy, or ketamine. Prompt referral to a child psychiatrist is essential for youth classified as TRD as earlier more aggressive treatment may avoid the long-term morbidity of chronic depression.
Fortunately, a meta-analysis of studies showed that PCP medication management visits with monitoring could improve outcomes, even for TRD.
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.
Reference
Dwyer J et al. Annual research review: Defining and treating pediatric treatment-resistant depression. J Child Psychol Psychiatry. 2020 March;61(3):312-32.
As pediatricians, we are acutely aware of the increase in depression in our teen patients. Lifetime prevalence is now approaching 20%, and we are doing our best to help.
The Guidelines for Adolescent Depression in Primary Care (GLAD-PC, 2018) has advice on screening and primary care provider (PCP) management, verifying our role in care. But GLAD-PC also advises “referral to a mental health specialist” in patient scenarios we see multiple times per week. Even when patients are willing and able to go, mental health specialists are in short supply or have months-long waiting lists. What should we do to help the more severely depressed adolescent when immediate referral is not possible? What should we expect of specialist care for what is called treatment-resistant or treatment-refractory depression (TRD)?
To know what to do for a youth with TRD, first you need to know what constitutes an adequate trial of treatment. After diagnosis of major depressive disorder (MDD) from a validated screening tool or an interview based on DSM-5 criteria and an appropriate assessment (as described in GLAD-PC), patients and parents need education on symptoms, course, prognosis including suicide risk, and treatment options. Known TRD risk factors, besides longer or greater depression severity, anhedonia, and poor global functioning, can benefit from being specifically addressed: trauma, bullying, comorbid anxiety or substance use, subsyndromal mania, insomnia, hypothyroidism, nutritional deficiencies from eating disorders, certain genetic variants, LGBTQ identification, family conflict, and parental depression. Screening and assessment for suicidal ideation/attempts is needed initially and in follow-up as MDD increases risk of suicide 30 times.
PCPs can manage mild depression with regular visits every 1-2 weeks for active support for 6-8 weeks. Advise all depressed youth on healthy eating, adequate sleep and exercise, pleasurable activities, and refraining from substance use. With a full response (50%+ reduction in symptom score from baseline), monthly monitoring for symptoms, suicidality, and stressors (phone/televisits suffice) should continue for 6-24 months as half recur. Monitoring with ratings by both youth and parent are recommended and may be required by insurers. Scores below cutoff suggest “remission,” although functioning must be considered. Youth report symptoms best but parents may better report improved functioning and affect that can precede symptom reduction.
If there is no initial response (< 25% decrease in symptom score) or a partial response (25%-49% decrease), PCPs should begin treatment as for moderate depression with either a selective serotonin reuptake inhibitor (SSRI) or psychotherapy. Use of both has the best evidence; cognitive behavior therapy (CBT) and interpersonal psychotherapy for adolescents are equally effective.
Side effects from SSRIs are almost universal with GI upset, headaches, and sexual dysfunction most common, but activation (increased agitation or irritability) may occur. Educate patients about these and encourage tolerating them as they tend to subside in weeks, allowing continuation of these most effective medicines. Activation rarely indicates true mania, which would require stopping and referral.
Moderate depression with only comorbid anxiety may be addressed by PCPs with problem-focused supportive counseling and SSRIs, but mental health consultation or referral also are appropriate. Fluoxetine starting at 5-10 mg/day has best evidence and Food and Drug Administration approval for MDD from age 8. Starting at a higher dose may increase risk of suicidal ideation. Alternatively, escitalopram is FDA approved for MDD at age 12 starting at 10 mg/day, although meta-analyses do not distinguish effectiveness within the SSRI class. Although benefit usually appears within 2 weeks, a trial of at least 4 weeks should be used to assess effect.
If after 4 weeks, the SSRI is tolerated but has little or no response, reassess the diagnosis, try a different SSRI, e.g. sertraline, and add CBT (combined SSRI+CBT has an advantage). To switch SSRIs, reduce the first every 1-2 weeks (by 10-20 mg for fluoxetine; 5-10 for escitalopram) to reduce side effects. If overlapping, the replacement SSRI may start midway in the wean at low dose with patients educated about serotonin syndrome. If instead there was a partial response to the initial SSRI, progressively increase the dose (by 10 mg for fluoxetine or 5 mg for escitalopram monthly) as indicated by symptom change up to the maximum (60-80 mg fluoxetine or 20 mg escitalopram), if needed, and maintain for another 4 weeks. Alternatively, or in addition, start psychotherapy or ask to change current therapy, as therapy focus makes a difference in effect. Initial CBT focus on anxiety acts fastest when anxiety is comorbid.
Once a regimen produces a response, maintain it for 16-20 weeks, the longer for more severe depression. Although three-fourths of mildly to moderately depressed youth are late responders, emerging near 6 weeks, a rapid initial response is associated with better outcome. The recommended 8 weeks on a final tolerated dose constituting an adequate trial before changing may be shortened to 6 weeks in severe unremitting cases. Youth not remitting by 12 weeks should be offered alternative treatment. Referral is recommended for moderately severe depression with comorbidity or severe depression but also for unresponsive moderate depression or by family or clinician preference.
Treatment-resistant depression is defined as “clinically impairing depression symptoms despite an adequate trial of an evidence-based psychotherapy and an antidepressant with grade A evidence (fluoxetine, escitalopram, or sertraline),” sequentially or together; treatment-refractory depression comprises the above with failure on at least two antidepressants, with at least one being grade A. Unfortunately, TRD occurs in 30%-40% of children and remission is only 30%. Low adherence based on pill counts (> 30% missed) or with therapy (fewer than nine visits) should be considered in treatment failures.
With manageable factors addressed, the next step for TRD is treatment augmentation. The best evidence-based augmentation for TRD is CBT; 55% of those receiving CBT responded within 12 weeks. TRD augmentations and interventions with evidence in adults have either no evidence of effect in children (SNRIs, lithium), no randomized controlled trials, or support only from small suggestive studies, e.g., antipsychotics, 16 g/day omega-3 fatty acid supplementation, folic acid supplementation, repetitive transcranial magnetic stimulation, electroconvulsive therapy, or ketamine. Prompt referral to a child psychiatrist is essential for youth classified as TRD as earlier more aggressive treatment may avoid the long-term morbidity of chronic depression.
Fortunately, a meta-analysis of studies showed that PCP medication management visits with monitoring could improve outcomes, even for TRD.
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.
Reference
Dwyer J et al. Annual research review: Defining and treating pediatric treatment-resistant depression. J Child Psychol Psychiatry. 2020 March;61(3):312-32.
As pediatricians, we are acutely aware of the increase in depression in our teen patients. Lifetime prevalence is now approaching 20%, and we are doing our best to help.
The Guidelines for Adolescent Depression in Primary Care (GLAD-PC, 2018) has advice on screening and primary care provider (PCP) management, verifying our role in care. But GLAD-PC also advises “referral to a mental health specialist” in patient scenarios we see multiple times per week. Even when patients are willing and able to go, mental health specialists are in short supply or have months-long waiting lists. What should we do to help the more severely depressed adolescent when immediate referral is not possible? What should we expect of specialist care for what is called treatment-resistant or treatment-refractory depression (TRD)?
To know what to do for a youth with TRD, first you need to know what constitutes an adequate trial of treatment. After diagnosis of major depressive disorder (MDD) from a validated screening tool or an interview based on DSM-5 criteria and an appropriate assessment (as described in GLAD-PC), patients and parents need education on symptoms, course, prognosis including suicide risk, and treatment options. Known TRD risk factors, besides longer or greater depression severity, anhedonia, and poor global functioning, can benefit from being specifically addressed: trauma, bullying, comorbid anxiety or substance use, subsyndromal mania, insomnia, hypothyroidism, nutritional deficiencies from eating disorders, certain genetic variants, LGBTQ identification, family conflict, and parental depression. Screening and assessment for suicidal ideation/attempts is needed initially and in follow-up as MDD increases risk of suicide 30 times.
PCPs can manage mild depression with regular visits every 1-2 weeks for active support for 6-8 weeks. Advise all depressed youth on healthy eating, adequate sleep and exercise, pleasurable activities, and refraining from substance use. With a full response (50%+ reduction in symptom score from baseline), monthly monitoring for symptoms, suicidality, and stressors (phone/televisits suffice) should continue for 6-24 months as half recur. Monitoring with ratings by both youth and parent are recommended and may be required by insurers. Scores below cutoff suggest “remission,” although functioning must be considered. Youth report symptoms best but parents may better report improved functioning and affect that can precede symptom reduction.
If there is no initial response (< 25% decrease in symptom score) or a partial response (25%-49% decrease), PCPs should begin treatment as for moderate depression with either a selective serotonin reuptake inhibitor (SSRI) or psychotherapy. Use of both has the best evidence; cognitive behavior therapy (CBT) and interpersonal psychotherapy for adolescents are equally effective.
Side effects from SSRIs are almost universal with GI upset, headaches, and sexual dysfunction most common, but activation (increased agitation or irritability) may occur. Educate patients about these and encourage tolerating them as they tend to subside in weeks, allowing continuation of these most effective medicines. Activation rarely indicates true mania, which would require stopping and referral.
Moderate depression with only comorbid anxiety may be addressed by PCPs with problem-focused supportive counseling and SSRIs, but mental health consultation or referral also are appropriate. Fluoxetine starting at 5-10 mg/day has best evidence and Food and Drug Administration approval for MDD from age 8. Starting at a higher dose may increase risk of suicidal ideation. Alternatively, escitalopram is FDA approved for MDD at age 12 starting at 10 mg/day, although meta-analyses do not distinguish effectiveness within the SSRI class. Although benefit usually appears within 2 weeks, a trial of at least 4 weeks should be used to assess effect.
If after 4 weeks, the SSRI is tolerated but has little or no response, reassess the diagnosis, try a different SSRI, e.g. sertraline, and add CBT (combined SSRI+CBT has an advantage). To switch SSRIs, reduce the first every 1-2 weeks (by 10-20 mg for fluoxetine; 5-10 for escitalopram) to reduce side effects. If overlapping, the replacement SSRI may start midway in the wean at low dose with patients educated about serotonin syndrome. If instead there was a partial response to the initial SSRI, progressively increase the dose (by 10 mg for fluoxetine or 5 mg for escitalopram monthly) as indicated by symptom change up to the maximum (60-80 mg fluoxetine or 20 mg escitalopram), if needed, and maintain for another 4 weeks. Alternatively, or in addition, start psychotherapy or ask to change current therapy, as therapy focus makes a difference in effect. Initial CBT focus on anxiety acts fastest when anxiety is comorbid.
Once a regimen produces a response, maintain it for 16-20 weeks, the longer for more severe depression. Although three-fourths of mildly to moderately depressed youth are late responders, emerging near 6 weeks, a rapid initial response is associated with better outcome. The recommended 8 weeks on a final tolerated dose constituting an adequate trial before changing may be shortened to 6 weeks in severe unremitting cases. Youth not remitting by 12 weeks should be offered alternative treatment. Referral is recommended for moderately severe depression with comorbidity or severe depression but also for unresponsive moderate depression or by family or clinician preference.
Treatment-resistant depression is defined as “clinically impairing depression symptoms despite an adequate trial of an evidence-based psychotherapy and an antidepressant with grade A evidence (fluoxetine, escitalopram, or sertraline),” sequentially or together; treatment-refractory depression comprises the above with failure on at least two antidepressants, with at least one being grade A. Unfortunately, TRD occurs in 30%-40% of children and remission is only 30%. Low adherence based on pill counts (> 30% missed) or with therapy (fewer than nine visits) should be considered in treatment failures.
With manageable factors addressed, the next step for TRD is treatment augmentation. The best evidence-based augmentation for TRD is CBT; 55% of those receiving CBT responded within 12 weeks. TRD augmentations and interventions with evidence in adults have either no evidence of effect in children (SNRIs, lithium), no randomized controlled trials, or support only from small suggestive studies, e.g., antipsychotics, 16 g/day omega-3 fatty acid supplementation, folic acid supplementation, repetitive transcranial magnetic stimulation, electroconvulsive therapy, or ketamine. Prompt referral to a child psychiatrist is essential for youth classified as TRD as earlier more aggressive treatment may avoid the long-term morbidity of chronic depression.
Fortunately, a meta-analysis of studies showed that PCP medication management visits with monitoring could improve outcomes, even for TRD.
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.
Reference
Dwyer J et al. Annual research review: Defining and treating pediatric treatment-resistant depression. J Child Psychol Psychiatry. 2020 March;61(3):312-32.
A pediatrician’s guide to screening for and treating depression
On Oct. 19, the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association jointly declared a “national emergency in children’s mental health,” calling upon policy makers to take actions that could help address “soaring rates” of anxiety and depression.
Knowing that increasing the work force or creating new programs will come slowly if at all, they called for the integration of mental health care into primary care pediatrics and efforts to reduce the risk of suicide in children and adolescents.
Our clinical experience suggests that adolescent depression, which can lead to profoundly impaired function, impaired development, and even suicide, is a major concern in your practice. We hope to do our part by reviewing the screening, diagnosis, and management of depression that can reasonably happen in the pediatrician’s office.
Depression
Depression affects as many as 20% of adolescents, with girls experiencing major depressive disorder (MDD) twice as often as boys. The incidence of depression increases fourfold after puberty, and there is substantial evidence, but no clear cause, that it has increased by nearly 50% over the past decade, rising from a rate of 8% of U.S. adolescents in 2007 to 13% in 2017.1 In that same time period, the rate of completed suicides among U.S. youth aged 10-24 increased 57.4%, after being stable for the prior decade.2 Adolescent depression is also linked to increased substance use and high-risk behaviors such as drunk driving. In 2020, mental health–related emergency department visits by adolescents aged 12-17 increased by 31%. Visits for suicide attempts among adolescent girls in 2021 jumped by 51% from 2019.3 Clearly, MDD in adolescence is a common, potentially life-threatening problem
.
Screening and assessment
At annual checkups with patients 12 and older or at sick visits of patients with emotional, sleep, or vague somatic concerns, it should be standard practice to screen for depression. The Patient Health Questionnaire 9 modified for Adolescents (PHQ9-A) is a reliable, validated, and free screening instrument that your patients can fill out in the waiting room. (The PHQ9 can be used for your patients who are 18 and older.) It takes only 5 minutes to complete and is very easy to score. It establishes whether your patient meets DSM-5 criteria for MDD, and the degree of severity (5-9 is mild, 10-14 is moderate, 15-19 is moderately severe, and 20-27 is severe). It also screens for thoughts about suicide and past suicide attempts. You might add the more comprehensive parent-completed Pediatric Symptom Checklist, which includes a depression screen.4
These screening instruments can be completed electronically prior to or at the visit and should have a preamble explaining why depression screening is relevant. If screening is positive, interview your adolescent patients alone. This will give you the time to gather more detail about how impaired their function is at school, with friends, and in family relationships. Have they been missing school? Have their grades changed? Are they failing to hand in homework? Have they withdrawn from sports or activities? Are they less likely to hang out with friends? Do they participate in family activities? Have others noticed any changes? You should also check for associated anxiety symptoms (ruminative worries, panic attacks) and drug and alcohol use. Of course, you should ask about any suicidal thoughts (from vague morbid thoughts to specific plans, with intent and factors that have prevented them) and actual attempts. Remember, asking about suicidal thoughts and attempts will not cause or worsen them. On the contrary, your patients may feel shame, but will be relieved to not be alone with these thoughts. And this knowledge will be essential as you decide what to do next. When you meet with the parents, ask them about a family history of depression or suicide attempts, and then offer supportive interventions.
Supportive interventions
For all adolescents with depression, supportive interventions are helpful, and for those with mild symptoms, they are often adequate treatment. This begins with education for your patient and their parents about depression. It is an illness, not a problem of character or discipline. Advise your patients that adequate, restful sleep every night is critical to recovery. Regular exercise (daily is best, but at least three times weekly for 30 minutes) is often effective in mild to moderate depression. Patience and compassion for feelings of sadness, irritability, or disinterest are important at home, and maintaining connections with those people who offer support (friends, coaches, parents, etc.) is essential. They should also be told that “depression lies.” Feelings of guilt and self-reproach are a normal part of the illness, not facts. Organizations such as the National Alliance on Mental Illness (NAMI) and the American Academy of Child and Adolescent Psychiatry (AACAP) offer written materials through their websites that are very helpful educational resources. Connect them with sources of counseling support (through school, for example). For those with mild, brief, and uncomplicated depression, supportive interventions alone should offer relief within 4-6 weeks. It is hard to predict the trajectory of depression, so follow-up visits are relevant to determine if they are improving or worsening.
Psychotherapy
For your patients with moderate depression, or with hopelessness or suicidality, a referral for evidence-based psychotherapy is indicated. Both cognitive behavioral therapy and interpersonal therapy have demonstrated efficacy in treating depression in adolescents. If there is a history of trauma or high family conflict, supportive psychotherapy that will enhance communication skills within the family is very important to recovery. Identify various sources for high-quality psychotherapy services (individual, family, and group) in your community. While this may sound easier said than done, online services such as Psychology Today’s therapist locator can help. If your local university has a graduate program in social work or psychology, connect with them as they may have easier access to high-quality services through their training programs. If there is a group practice of therapists in your community, invite them to meet with your team to learn about whether they use evidence-based therapies and can support families as well as individual youth.
Pharmacologic options
For those adolescents with moderate to severe depression, psychotherapy alone is usually inadequate. Indeed, they may be so impaired that they simply cannot meaningfully engage in the work of psychotherapy. These patients require psychopharmacologic treatment first. First-line treatment is with selective serotonin reuptake inhibitors (SSRIs) (both fluoxetine and escitalopram are approved for use in adolescent depression). While many pediatricians remain reluctant about initiating SSRI treatment of depression since the Food and Drug Administration’s 2004 boxed warning was issued, the risks of untreated severe depression are more marked than are the risks of SSRI treatment. As prescription rates dipped in the following decade, rates of suicide attempts in adolescents with severe depression climbed. Subsequent research on the nature of the risk of “increased suicidality” indicated it is substantially lower than originally thought.
The AAP’s Guidelines for Adolescent Depression in Primary Care offer reassuring guidance: They recommend that pediatricians initiate treatment at a very low dose of SSRI (5 mg of fluoxetine, 12.5 mg of sertraline, or 5 mg of escitalopram) and aim to get to a therapeutic dose within 4 weeks.5 Educate the patient and parent about likely side effects (gastrointestinal upset, sleep disruption, akathisia or restlessness, and activation), which indicate the dose should be held steady until the side effects subside. Patients should be seen weekly until they get to a therapeutic dose, then biweekly to monitor for response. At these regular check-ins, the PHQ9A can follow symptom severity. You should monitor changes in function and for any change in suicidal thoughts. If your patient does not respond with at least energy improvement within 4 weeks, you should cross-taper to a different SSRI.
Managing risk
Suicidal thoughts are a common symptom of depression and an important marker of severity. Adolescents have more limited impulse control than do adults, elevating their risk for impulsively acting on these thoughts. Adolescents who are using alcohol or other substances, or who have a history of impulsivity, are at higher risk. Further compounding the degree of risk are a history of suicide attempts, impulsive aggression or psychotic symptoms, or a family history of completed suicide. In managing risk, it is critical that you assess and discuss these risk factors and discuss the need to have a safety plan.
This planning should include both patient and parent. Help the parent to identify lethal means at home (guns, rope, medications, and knives or box cutters) and make plans to secure or remove them. It includes helping your patient list those strategies that can be helpful if they are feeling more distressed (distracting with music or television, exercise, or connecting with select friends). A safety plan is not a promise or a contract to not do something, rather it is a practical set of strategies the patient and family can employ if they are feeling worse. It depends on the adolescent having a secure, trusting connection with the adults at home and with your office.
If your patient fails to improve, if the diagnosis appears complicated, or if you feel the patient is not safe, you should refer to child psychiatry or, if needed, a local emergency department. If you cannot find access to a psychiatrist, start with your state’s child psychiatric consultation hotline for access to telephone support: www.nncpap.org.
Although the suggestions outlined above are grounded in evidence and need, treating moderate to severe depression is likely a new challenge for many pediatricians. Managing the risk of suicide can be stressful, without a doubt. In our own work as child psychiatrists, we recognize that there is no single, reliable method to predict suicide and therefore no specific approach to ensuring prevention. We appreciate this burden of worry when treating a severely depressed adolescent, and follow the rule, “never worry alone” – share your concerns with parents and/or a mental health consultant (hopefully co-located in your office), or obtain a second opinion, even consult a child psychiatrist on a hotline. Offering supportive care for those with mild depression can prevent it from becoming severe, and beginning treatment for those with severe depression can make a profound difference in the course of a young person’s illness.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
References
1. Pew Research Center. National Survey on Drug Use and Health (2017).
2. Curtin SC. Natl Vital Stat Rep. 2020 Sep;69(11):1-10.
3. Yard E et al. MMWR Morb Mortal Wkly Rep. 2021 Jun 18;70(24):888-94.
4. Jellinek M et al. J Pediatr. 2021 Jun;233:220-6.e1.
5. Zuckerbrot RA et al. Pediatrics. 2018 Mar;141(3):e20174081.
On Oct. 19, the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association jointly declared a “national emergency in children’s mental health,” calling upon policy makers to take actions that could help address “soaring rates” of anxiety and depression.
Knowing that increasing the work force or creating new programs will come slowly if at all, they called for the integration of mental health care into primary care pediatrics and efforts to reduce the risk of suicide in children and adolescents.
Our clinical experience suggests that adolescent depression, which can lead to profoundly impaired function, impaired development, and even suicide, is a major concern in your practice. We hope to do our part by reviewing the screening, diagnosis, and management of depression that can reasonably happen in the pediatrician’s office.
Depression
Depression affects as many as 20% of adolescents, with girls experiencing major depressive disorder (MDD) twice as often as boys. The incidence of depression increases fourfold after puberty, and there is substantial evidence, but no clear cause, that it has increased by nearly 50% over the past decade, rising from a rate of 8% of U.S. adolescents in 2007 to 13% in 2017.1 In that same time period, the rate of completed suicides among U.S. youth aged 10-24 increased 57.4%, after being stable for the prior decade.2 Adolescent depression is also linked to increased substance use and high-risk behaviors such as drunk driving. In 2020, mental health–related emergency department visits by adolescents aged 12-17 increased by 31%. Visits for suicide attempts among adolescent girls in 2021 jumped by 51% from 2019.3 Clearly, MDD in adolescence is a common, potentially life-threatening problem
.
Screening and assessment
At annual checkups with patients 12 and older or at sick visits of patients with emotional, sleep, or vague somatic concerns, it should be standard practice to screen for depression. The Patient Health Questionnaire 9 modified for Adolescents (PHQ9-A) is a reliable, validated, and free screening instrument that your patients can fill out in the waiting room. (The PHQ9 can be used for your patients who are 18 and older.) It takes only 5 minutes to complete and is very easy to score. It establishes whether your patient meets DSM-5 criteria for MDD, and the degree of severity (5-9 is mild, 10-14 is moderate, 15-19 is moderately severe, and 20-27 is severe). It also screens for thoughts about suicide and past suicide attempts. You might add the more comprehensive parent-completed Pediatric Symptom Checklist, which includes a depression screen.4
These screening instruments can be completed electronically prior to or at the visit and should have a preamble explaining why depression screening is relevant. If screening is positive, interview your adolescent patients alone. This will give you the time to gather more detail about how impaired their function is at school, with friends, and in family relationships. Have they been missing school? Have their grades changed? Are they failing to hand in homework? Have they withdrawn from sports or activities? Are they less likely to hang out with friends? Do they participate in family activities? Have others noticed any changes? You should also check for associated anxiety symptoms (ruminative worries, panic attacks) and drug and alcohol use. Of course, you should ask about any suicidal thoughts (from vague morbid thoughts to specific plans, with intent and factors that have prevented them) and actual attempts. Remember, asking about suicidal thoughts and attempts will not cause or worsen them. On the contrary, your patients may feel shame, but will be relieved to not be alone with these thoughts. And this knowledge will be essential as you decide what to do next. When you meet with the parents, ask them about a family history of depression or suicide attempts, and then offer supportive interventions.
Supportive interventions
For all adolescents with depression, supportive interventions are helpful, and for those with mild symptoms, they are often adequate treatment. This begins with education for your patient and their parents about depression. It is an illness, not a problem of character or discipline. Advise your patients that adequate, restful sleep every night is critical to recovery. Regular exercise (daily is best, but at least three times weekly for 30 minutes) is often effective in mild to moderate depression. Patience and compassion for feelings of sadness, irritability, or disinterest are important at home, and maintaining connections with those people who offer support (friends, coaches, parents, etc.) is essential. They should also be told that “depression lies.” Feelings of guilt and self-reproach are a normal part of the illness, not facts. Organizations such as the National Alliance on Mental Illness (NAMI) and the American Academy of Child and Adolescent Psychiatry (AACAP) offer written materials through their websites that are very helpful educational resources. Connect them with sources of counseling support (through school, for example). For those with mild, brief, and uncomplicated depression, supportive interventions alone should offer relief within 4-6 weeks. It is hard to predict the trajectory of depression, so follow-up visits are relevant to determine if they are improving or worsening.
Psychotherapy
For your patients with moderate depression, or with hopelessness or suicidality, a referral for evidence-based psychotherapy is indicated. Both cognitive behavioral therapy and interpersonal therapy have demonstrated efficacy in treating depression in adolescents. If there is a history of trauma or high family conflict, supportive psychotherapy that will enhance communication skills within the family is very important to recovery. Identify various sources for high-quality psychotherapy services (individual, family, and group) in your community. While this may sound easier said than done, online services such as Psychology Today’s therapist locator can help. If your local university has a graduate program in social work or psychology, connect with them as they may have easier access to high-quality services through their training programs. If there is a group practice of therapists in your community, invite them to meet with your team to learn about whether they use evidence-based therapies and can support families as well as individual youth.
Pharmacologic options
For those adolescents with moderate to severe depression, psychotherapy alone is usually inadequate. Indeed, they may be so impaired that they simply cannot meaningfully engage in the work of psychotherapy. These patients require psychopharmacologic treatment first. First-line treatment is with selective serotonin reuptake inhibitors (SSRIs) (both fluoxetine and escitalopram are approved for use in adolescent depression). While many pediatricians remain reluctant about initiating SSRI treatment of depression since the Food and Drug Administration’s 2004 boxed warning was issued, the risks of untreated severe depression are more marked than are the risks of SSRI treatment. As prescription rates dipped in the following decade, rates of suicide attempts in adolescents with severe depression climbed. Subsequent research on the nature of the risk of “increased suicidality” indicated it is substantially lower than originally thought.
The AAP’s Guidelines for Adolescent Depression in Primary Care offer reassuring guidance: They recommend that pediatricians initiate treatment at a very low dose of SSRI (5 mg of fluoxetine, 12.5 mg of sertraline, or 5 mg of escitalopram) and aim to get to a therapeutic dose within 4 weeks.5 Educate the patient and parent about likely side effects (gastrointestinal upset, sleep disruption, akathisia or restlessness, and activation), which indicate the dose should be held steady until the side effects subside. Patients should be seen weekly until they get to a therapeutic dose, then biweekly to monitor for response. At these regular check-ins, the PHQ9A can follow symptom severity. You should monitor changes in function and for any change in suicidal thoughts. If your patient does not respond with at least energy improvement within 4 weeks, you should cross-taper to a different SSRI.
Managing risk
Suicidal thoughts are a common symptom of depression and an important marker of severity. Adolescents have more limited impulse control than do adults, elevating their risk for impulsively acting on these thoughts. Adolescents who are using alcohol or other substances, or who have a history of impulsivity, are at higher risk. Further compounding the degree of risk are a history of suicide attempts, impulsive aggression or psychotic symptoms, or a family history of completed suicide. In managing risk, it is critical that you assess and discuss these risk factors and discuss the need to have a safety plan.
This planning should include both patient and parent. Help the parent to identify lethal means at home (guns, rope, medications, and knives or box cutters) and make plans to secure or remove them. It includes helping your patient list those strategies that can be helpful if they are feeling more distressed (distracting with music or television, exercise, or connecting with select friends). A safety plan is not a promise or a contract to not do something, rather it is a practical set of strategies the patient and family can employ if they are feeling worse. It depends on the adolescent having a secure, trusting connection with the adults at home and with your office.
If your patient fails to improve, if the diagnosis appears complicated, or if you feel the patient is not safe, you should refer to child psychiatry or, if needed, a local emergency department. If you cannot find access to a psychiatrist, start with your state’s child psychiatric consultation hotline for access to telephone support: www.nncpap.org.
Although the suggestions outlined above are grounded in evidence and need, treating moderate to severe depression is likely a new challenge for many pediatricians. Managing the risk of suicide can be stressful, without a doubt. In our own work as child psychiatrists, we recognize that there is no single, reliable method to predict suicide and therefore no specific approach to ensuring prevention. We appreciate this burden of worry when treating a severely depressed adolescent, and follow the rule, “never worry alone” – share your concerns with parents and/or a mental health consultant (hopefully co-located in your office), or obtain a second opinion, even consult a child psychiatrist on a hotline. Offering supportive care for those with mild depression can prevent it from becoming severe, and beginning treatment for those with severe depression can make a profound difference in the course of a young person’s illness.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
References
1. Pew Research Center. National Survey on Drug Use and Health (2017).
2. Curtin SC. Natl Vital Stat Rep. 2020 Sep;69(11):1-10.
3. Yard E et al. MMWR Morb Mortal Wkly Rep. 2021 Jun 18;70(24):888-94.
4. Jellinek M et al. J Pediatr. 2021 Jun;233:220-6.e1.
5. Zuckerbrot RA et al. Pediatrics. 2018 Mar;141(3):e20174081.
On Oct. 19, the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association jointly declared a “national emergency in children’s mental health,” calling upon policy makers to take actions that could help address “soaring rates” of anxiety and depression.
Knowing that increasing the work force or creating new programs will come slowly if at all, they called for the integration of mental health care into primary care pediatrics and efforts to reduce the risk of suicide in children and adolescents.
Our clinical experience suggests that adolescent depression, which can lead to profoundly impaired function, impaired development, and even suicide, is a major concern in your practice. We hope to do our part by reviewing the screening, diagnosis, and management of depression that can reasonably happen in the pediatrician’s office.
Depression
Depression affects as many as 20% of adolescents, with girls experiencing major depressive disorder (MDD) twice as often as boys. The incidence of depression increases fourfold after puberty, and there is substantial evidence, but no clear cause, that it has increased by nearly 50% over the past decade, rising from a rate of 8% of U.S. adolescents in 2007 to 13% in 2017.1 In that same time period, the rate of completed suicides among U.S. youth aged 10-24 increased 57.4%, after being stable for the prior decade.2 Adolescent depression is also linked to increased substance use and high-risk behaviors such as drunk driving. In 2020, mental health–related emergency department visits by adolescents aged 12-17 increased by 31%. Visits for suicide attempts among adolescent girls in 2021 jumped by 51% from 2019.3 Clearly, MDD in adolescence is a common, potentially life-threatening problem
.
Screening and assessment
At annual checkups with patients 12 and older or at sick visits of patients with emotional, sleep, or vague somatic concerns, it should be standard practice to screen for depression. The Patient Health Questionnaire 9 modified for Adolescents (PHQ9-A) is a reliable, validated, and free screening instrument that your patients can fill out in the waiting room. (The PHQ9 can be used for your patients who are 18 and older.) It takes only 5 minutes to complete and is very easy to score. It establishes whether your patient meets DSM-5 criteria for MDD, and the degree of severity (5-9 is mild, 10-14 is moderate, 15-19 is moderately severe, and 20-27 is severe). It also screens for thoughts about suicide and past suicide attempts. You might add the more comprehensive parent-completed Pediatric Symptom Checklist, which includes a depression screen.4
These screening instruments can be completed electronically prior to or at the visit and should have a preamble explaining why depression screening is relevant. If screening is positive, interview your adolescent patients alone. This will give you the time to gather more detail about how impaired their function is at school, with friends, and in family relationships. Have they been missing school? Have their grades changed? Are they failing to hand in homework? Have they withdrawn from sports or activities? Are they less likely to hang out with friends? Do they participate in family activities? Have others noticed any changes? You should also check for associated anxiety symptoms (ruminative worries, panic attacks) and drug and alcohol use. Of course, you should ask about any suicidal thoughts (from vague morbid thoughts to specific plans, with intent and factors that have prevented them) and actual attempts. Remember, asking about suicidal thoughts and attempts will not cause or worsen them. On the contrary, your patients may feel shame, but will be relieved to not be alone with these thoughts. And this knowledge will be essential as you decide what to do next. When you meet with the parents, ask them about a family history of depression or suicide attempts, and then offer supportive interventions.
Supportive interventions
For all adolescents with depression, supportive interventions are helpful, and for those with mild symptoms, they are often adequate treatment. This begins with education for your patient and their parents about depression. It is an illness, not a problem of character or discipline. Advise your patients that adequate, restful sleep every night is critical to recovery. Regular exercise (daily is best, but at least three times weekly for 30 minutes) is often effective in mild to moderate depression. Patience and compassion for feelings of sadness, irritability, or disinterest are important at home, and maintaining connections with those people who offer support (friends, coaches, parents, etc.) is essential. They should also be told that “depression lies.” Feelings of guilt and self-reproach are a normal part of the illness, not facts. Organizations such as the National Alliance on Mental Illness (NAMI) and the American Academy of Child and Adolescent Psychiatry (AACAP) offer written materials through their websites that are very helpful educational resources. Connect them with sources of counseling support (through school, for example). For those with mild, brief, and uncomplicated depression, supportive interventions alone should offer relief within 4-6 weeks. It is hard to predict the trajectory of depression, so follow-up visits are relevant to determine if they are improving or worsening.
Psychotherapy
For your patients with moderate depression, or with hopelessness or suicidality, a referral for evidence-based psychotherapy is indicated. Both cognitive behavioral therapy and interpersonal therapy have demonstrated efficacy in treating depression in adolescents. If there is a history of trauma or high family conflict, supportive psychotherapy that will enhance communication skills within the family is very important to recovery. Identify various sources for high-quality psychotherapy services (individual, family, and group) in your community. While this may sound easier said than done, online services such as Psychology Today’s therapist locator can help. If your local university has a graduate program in social work or psychology, connect with them as they may have easier access to high-quality services through their training programs. If there is a group practice of therapists in your community, invite them to meet with your team to learn about whether they use evidence-based therapies and can support families as well as individual youth.
Pharmacologic options
For those adolescents with moderate to severe depression, psychotherapy alone is usually inadequate. Indeed, they may be so impaired that they simply cannot meaningfully engage in the work of psychotherapy. These patients require psychopharmacologic treatment first. First-line treatment is with selective serotonin reuptake inhibitors (SSRIs) (both fluoxetine and escitalopram are approved for use in adolescent depression). While many pediatricians remain reluctant about initiating SSRI treatment of depression since the Food and Drug Administration’s 2004 boxed warning was issued, the risks of untreated severe depression are more marked than are the risks of SSRI treatment. As prescription rates dipped in the following decade, rates of suicide attempts in adolescents with severe depression climbed. Subsequent research on the nature of the risk of “increased suicidality” indicated it is substantially lower than originally thought.
The AAP’s Guidelines for Adolescent Depression in Primary Care offer reassuring guidance: They recommend that pediatricians initiate treatment at a very low dose of SSRI (5 mg of fluoxetine, 12.5 mg of sertraline, or 5 mg of escitalopram) and aim to get to a therapeutic dose within 4 weeks.5 Educate the patient and parent about likely side effects (gastrointestinal upset, sleep disruption, akathisia or restlessness, and activation), which indicate the dose should be held steady until the side effects subside. Patients should be seen weekly until they get to a therapeutic dose, then biweekly to monitor for response. At these regular check-ins, the PHQ9A can follow symptom severity. You should monitor changes in function and for any change in suicidal thoughts. If your patient does not respond with at least energy improvement within 4 weeks, you should cross-taper to a different SSRI.
Managing risk
Suicidal thoughts are a common symptom of depression and an important marker of severity. Adolescents have more limited impulse control than do adults, elevating their risk for impulsively acting on these thoughts. Adolescents who are using alcohol or other substances, or who have a history of impulsivity, are at higher risk. Further compounding the degree of risk are a history of suicide attempts, impulsive aggression or psychotic symptoms, or a family history of completed suicide. In managing risk, it is critical that you assess and discuss these risk factors and discuss the need to have a safety plan.
This planning should include both patient and parent. Help the parent to identify lethal means at home (guns, rope, medications, and knives or box cutters) and make plans to secure or remove them. It includes helping your patient list those strategies that can be helpful if they are feeling more distressed (distracting with music or television, exercise, or connecting with select friends). A safety plan is not a promise or a contract to not do something, rather it is a practical set of strategies the patient and family can employ if they are feeling worse. It depends on the adolescent having a secure, trusting connection with the adults at home and with your office.
If your patient fails to improve, if the diagnosis appears complicated, or if you feel the patient is not safe, you should refer to child psychiatry or, if needed, a local emergency department. If you cannot find access to a psychiatrist, start with your state’s child psychiatric consultation hotline for access to telephone support: www.nncpap.org.
Although the suggestions outlined above are grounded in evidence and need, treating moderate to severe depression is likely a new challenge for many pediatricians. Managing the risk of suicide can be stressful, without a doubt. In our own work as child psychiatrists, we recognize that there is no single, reliable method to predict suicide and therefore no specific approach to ensuring prevention. We appreciate this burden of worry when treating a severely depressed adolescent, and follow the rule, “never worry alone” – share your concerns with parents and/or a mental health consultant (hopefully co-located in your office), or obtain a second opinion, even consult a child psychiatrist on a hotline. Offering supportive care for those with mild depression can prevent it from becoming severe, and beginning treatment for those with severe depression can make a profound difference in the course of a young person’s illness.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
References
1. Pew Research Center. National Survey on Drug Use and Health (2017).
2. Curtin SC. Natl Vital Stat Rep. 2020 Sep;69(11):1-10.
3. Yard E et al. MMWR Morb Mortal Wkly Rep. 2021 Jun 18;70(24):888-94.
4. Jellinek M et al. J Pediatr. 2021 Jun;233:220-6.e1.
5. Zuckerbrot RA et al. Pediatrics. 2018 Mar;141(3):e20174081.
Sorting out the meaning of misbehavior: The invisible culprit
You have probably heard that determining the A(ntecedent)s, B(ehavior)s, and C(onsequence)s of a behavior is basic to counseling about oppositionality or aggression. But sorting out the As is especially important to going beyond disciplining a misbehavior to building insight for both parents and children.
Antecedents are of two types: triggers such as actions, words, or feelings that happen just before the behavior, and “setting events” that can occur intermittently hours or even days beforehand and lower the threshold for a trigger to cause a child to act out. Lack of sleep, hunger, or fatigue are common setting events that parents recognize and take into account as in “Oh, he missed his nap” to excuse a tantrum in younger children, but is less often considered or excused in older children in whom self-regulation is expected. Often, behavioral specialists in schools are asked to observe a child to identify the triggers and create a “functional behavioral assessment” based on what is observed.
While a functional behavioral assessment requires observations, invisible antecedents to consider include internal thoughts and feelings (meaning). A child feeling shame from a failed math test the day before may be on edge, then, when called on, may uncharacteristically talk back. The child may regard punishment for this “justified” response as unfair, accelerating anger. Feelings of shame or humiliation for failing one’s own standards (or perceived expectations of others the child cares about) are major setups for eliciting defiance.
Even more subtle are meanings the child creates for situations and people, whether real or imagined. A child’s behavior has meaning for the child and the family and can be initiated or maintained by that meaning. For example, a child may “live down” to what the family thinks of him/her; if you think I am bad, I will act badly.
Children may feel guilty about some real or imagined offense, such as divorce or death they think may be their fault, and act up with the family to elicit punishment as payment. When children feel conflicted in a relationship, such as a late adolescent feeling dependent on their mother when their age expectation is independence, they may act up expecting to be ejected from home when they are unable to gather the courage to voluntarily leave. This acting out may also occur with nonconflicted adults, who are actually safer targets. For example, school is often a safer place to express anger through aggression or bullying than home, the real source of the feelings, because family is the “lifeboat” of food and shelter they dare not upset.
Conflicted relationships may be present in blended families, especially if the ex speaks negatively about the other parent. The child of divorce, feeling himself composed of parts of each parent, has diminished self-esteem and anger on behalf of that side being put down. Marital conflict may set children up to feel they have to take sides to angrily defend the parent of like-gender by being oppositional to the other.
Just as we ponder whether the color blue looks the same to someone else, neurologically based differences in perception may make a child misinterpret or act inflexibly or explode in situations that seem normal to adults. While people joke about “being a little OCD,” for some children the distress caused by a change in routine, a messy room, a delayed bus, or loud music is enough to disrupt their functioning and coping enough to explode. Such hypersensitivity can be part of autism or obsessive compulsive disorder or a subthreshold variant. Children vary by age and individually in their ability to understand language, especially sarcastic humor, and often misinterpret it as insulting, threatening, or scary and act accordingly. While most common in children with autism, those with a language learning disability, intellectual disability, or who have English as a second language, or are anxious or vigilant may also take sarcasm the wrong way. Anxious children also may react aggressively from a “hostile bias attribution” of expecting the worst from others.
Another possible meaning of a behavior is that it is being used by the child to manage their feelings. I have found it useful to remind depressed children and parents that it “feels better to be mad than sad” as a reason for irritability. Anger can also push away a person whose otherwise sympathetic approach might release a collapse into tears the child can’t tolerate or would find embarrassing.
The meaning of a child’s misbehavior also resides in the minds of the adults. In addition to all the categories of meaning just described, a parent may be reminded by the child of someone else for whom the adult has strong or conflicted feelings (“projection”) such as a now-hated ex, a sibling of whom the adult is jealous, or a bully from childhood, thus eliciting a reaction falsely triggered by that connection rather than the actual child. Asking parents whom the child “takes after” may elicit such parental projections based on appearance, behavior, or temperament. Helping them pick a feature of the child to focus on to differentiate him/her can serve as an anchor to remind them to control these reactions. Other useful questions to detect meanings of behavior might include asking the child “What’s up with that?” or “What did that make you think/feel?” We can ask parents “How is that for you?” or “What do you think things will be like in 10 years?” to determine despair, mood disorders, or family discord contributing to maladaptive responses possibly maintaining unwanted behaviors.
Throughout life, putting feelings into words is the main way meanings that are contributing to misbehaviors or parenting dysfunction can be uncovered and shifted. For this, the child or adult must feel emotionally safe to talk with a person who conveys curiosity rather than judgment. Helping families explain that divorce is not the child’s fault; admit they also make mistakes; rebuild conflicted relationships through play or talking; identify hypersensitivities or triggers to avoid; and express confidence that the child is a good person, still young, and sure to do better over time, are all things we pediatricians can do to help sort out the meanings of behaviors.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. 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.
You have probably heard that determining the A(ntecedent)s, B(ehavior)s, and C(onsequence)s of a behavior is basic to counseling about oppositionality or aggression. But sorting out the As is especially important to going beyond disciplining a misbehavior to building insight for both parents and children.
Antecedents are of two types: triggers such as actions, words, or feelings that happen just before the behavior, and “setting events” that can occur intermittently hours or even days beforehand and lower the threshold for a trigger to cause a child to act out. Lack of sleep, hunger, or fatigue are common setting events that parents recognize and take into account as in “Oh, he missed his nap” to excuse a tantrum in younger children, but is less often considered or excused in older children in whom self-regulation is expected. Often, behavioral specialists in schools are asked to observe a child to identify the triggers and create a “functional behavioral assessment” based on what is observed.
While a functional behavioral assessment requires observations, invisible antecedents to consider include internal thoughts and feelings (meaning). A child feeling shame from a failed math test the day before may be on edge, then, when called on, may uncharacteristically talk back. The child may regard punishment for this “justified” response as unfair, accelerating anger. Feelings of shame or humiliation for failing one’s own standards (or perceived expectations of others the child cares about) are major setups for eliciting defiance.
Even more subtle are meanings the child creates for situations and people, whether real or imagined. A child’s behavior has meaning for the child and the family and can be initiated or maintained by that meaning. For example, a child may “live down” to what the family thinks of him/her; if you think I am bad, I will act badly.
Children may feel guilty about some real or imagined offense, such as divorce or death they think may be their fault, and act up with the family to elicit punishment as payment. When children feel conflicted in a relationship, such as a late adolescent feeling dependent on their mother when their age expectation is independence, they may act up expecting to be ejected from home when they are unable to gather the courage to voluntarily leave. This acting out may also occur with nonconflicted adults, who are actually safer targets. For example, school is often a safer place to express anger through aggression or bullying than home, the real source of the feelings, because family is the “lifeboat” of food and shelter they dare not upset.
Conflicted relationships may be present in blended families, especially if the ex speaks negatively about the other parent. The child of divorce, feeling himself composed of parts of each parent, has diminished self-esteem and anger on behalf of that side being put down. Marital conflict may set children up to feel they have to take sides to angrily defend the parent of like-gender by being oppositional to the other.
Just as we ponder whether the color blue looks the same to someone else, neurologically based differences in perception may make a child misinterpret or act inflexibly or explode in situations that seem normal to adults. While people joke about “being a little OCD,” for some children the distress caused by a change in routine, a messy room, a delayed bus, or loud music is enough to disrupt their functioning and coping enough to explode. Such hypersensitivity can be part of autism or obsessive compulsive disorder or a subthreshold variant. Children vary by age and individually in their ability to understand language, especially sarcastic humor, and often misinterpret it as insulting, threatening, or scary and act accordingly. While most common in children with autism, those with a language learning disability, intellectual disability, or who have English as a second language, or are anxious or vigilant may also take sarcasm the wrong way. Anxious children also may react aggressively from a “hostile bias attribution” of expecting the worst from others.
Another possible meaning of a behavior is that it is being used by the child to manage their feelings. I have found it useful to remind depressed children and parents that it “feels better to be mad than sad” as a reason for irritability. Anger can also push away a person whose otherwise sympathetic approach might release a collapse into tears the child can’t tolerate or would find embarrassing.
The meaning of a child’s misbehavior also resides in the minds of the adults. In addition to all the categories of meaning just described, a parent may be reminded by the child of someone else for whom the adult has strong or conflicted feelings (“projection”) such as a now-hated ex, a sibling of whom the adult is jealous, or a bully from childhood, thus eliciting a reaction falsely triggered by that connection rather than the actual child. Asking parents whom the child “takes after” may elicit such parental projections based on appearance, behavior, or temperament. Helping them pick a feature of the child to focus on to differentiate him/her can serve as an anchor to remind them to control these reactions. Other useful questions to detect meanings of behavior might include asking the child “What’s up with that?” or “What did that make you think/feel?” We can ask parents “How is that for you?” or “What do you think things will be like in 10 years?” to determine despair, mood disorders, or family discord contributing to maladaptive responses possibly maintaining unwanted behaviors.
Throughout life, putting feelings into words is the main way meanings that are contributing to misbehaviors or parenting dysfunction can be uncovered and shifted. For this, the child or adult must feel emotionally safe to talk with a person who conveys curiosity rather than judgment. Helping families explain that divorce is not the child’s fault; admit they also make mistakes; rebuild conflicted relationships through play or talking; identify hypersensitivities or triggers to avoid; and express confidence that the child is a good person, still young, and sure to do better over time, are all things we pediatricians can do to help sort out the meanings of behaviors.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. 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.
You have probably heard that determining the A(ntecedent)s, B(ehavior)s, and C(onsequence)s of a behavior is basic to counseling about oppositionality or aggression. But sorting out the As is especially important to going beyond disciplining a misbehavior to building insight for both parents and children.
Antecedents are of two types: triggers such as actions, words, or feelings that happen just before the behavior, and “setting events” that can occur intermittently hours or even days beforehand and lower the threshold for a trigger to cause a child to act out. Lack of sleep, hunger, or fatigue are common setting events that parents recognize and take into account as in “Oh, he missed his nap” to excuse a tantrum in younger children, but is less often considered or excused in older children in whom self-regulation is expected. Often, behavioral specialists in schools are asked to observe a child to identify the triggers and create a “functional behavioral assessment” based on what is observed.
While a functional behavioral assessment requires observations, invisible antecedents to consider include internal thoughts and feelings (meaning). A child feeling shame from a failed math test the day before may be on edge, then, when called on, may uncharacteristically talk back. The child may regard punishment for this “justified” response as unfair, accelerating anger. Feelings of shame or humiliation for failing one’s own standards (or perceived expectations of others the child cares about) are major setups for eliciting defiance.
Even more subtle are meanings the child creates for situations and people, whether real or imagined. A child’s behavior has meaning for the child and the family and can be initiated or maintained by that meaning. For example, a child may “live down” to what the family thinks of him/her; if you think I am bad, I will act badly.
Children may feel guilty about some real or imagined offense, such as divorce or death they think may be their fault, and act up with the family to elicit punishment as payment. When children feel conflicted in a relationship, such as a late adolescent feeling dependent on their mother when their age expectation is independence, they may act up expecting to be ejected from home when they are unable to gather the courage to voluntarily leave. This acting out may also occur with nonconflicted adults, who are actually safer targets. For example, school is often a safer place to express anger through aggression or bullying than home, the real source of the feelings, because family is the “lifeboat” of food and shelter they dare not upset.
Conflicted relationships may be present in blended families, especially if the ex speaks negatively about the other parent. The child of divorce, feeling himself composed of parts of each parent, has diminished self-esteem and anger on behalf of that side being put down. Marital conflict may set children up to feel they have to take sides to angrily defend the parent of like-gender by being oppositional to the other.
Just as we ponder whether the color blue looks the same to someone else, neurologically based differences in perception may make a child misinterpret or act inflexibly or explode in situations that seem normal to adults. While people joke about “being a little OCD,” for some children the distress caused by a change in routine, a messy room, a delayed bus, or loud music is enough to disrupt their functioning and coping enough to explode. Such hypersensitivity can be part of autism or obsessive compulsive disorder or a subthreshold variant. Children vary by age and individually in their ability to understand language, especially sarcastic humor, and often misinterpret it as insulting, threatening, or scary and act accordingly. While most common in children with autism, those with a language learning disability, intellectual disability, or who have English as a second language, or are anxious or vigilant may also take sarcasm the wrong way. Anxious children also may react aggressively from a “hostile bias attribution” of expecting the worst from others.
Another possible meaning of a behavior is that it is being used by the child to manage their feelings. I have found it useful to remind depressed children and parents that it “feels better to be mad than sad” as a reason for irritability. Anger can also push away a person whose otherwise sympathetic approach might release a collapse into tears the child can’t tolerate or would find embarrassing.
The meaning of a child’s misbehavior also resides in the minds of the adults. In addition to all the categories of meaning just described, a parent may be reminded by the child of someone else for whom the adult has strong or conflicted feelings (“projection”) such as a now-hated ex, a sibling of whom the adult is jealous, or a bully from childhood, thus eliciting a reaction falsely triggered by that connection rather than the actual child. Asking parents whom the child “takes after” may elicit such parental projections based on appearance, behavior, or temperament. Helping them pick a feature of the child to focus on to differentiate him/her can serve as an anchor to remind them to control these reactions. Other useful questions to detect meanings of behavior might include asking the child “What’s up with that?” or “What did that make you think/feel?” We can ask parents “How is that for you?” or “What do you think things will be like in 10 years?” to determine despair, mood disorders, or family discord contributing to maladaptive responses possibly maintaining unwanted behaviors.
Throughout life, putting feelings into words is the main way meanings that are contributing to misbehaviors or parenting dysfunction can be uncovered and shifted. For this, the child or adult must feel emotionally safe to talk with a person who conveys curiosity rather than judgment. Helping families explain that divorce is not the child’s fault; admit they also make mistakes; rebuild conflicted relationships through play or talking; identify hypersensitivities or triggers to avoid; and express confidence that the child is a good person, still young, and sure to do better over time, are all things we pediatricians can do to help sort out the meanings of behaviors.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. 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.
Marijuana and LSD guidance for pediatricians
Seeking novelty is central to adolescence; experimentation is how they explore their identity, exert independence, and establish deep and connected relationships outside of the family. Research over the past 2 decades has demonstrated the neurobiological changes that underpin this increase in sensation seeking. Most adolescents are very good at assessing risk but are willing to tolerate higher levels of risk than adults in the pursuit of novelty.1 If their knowledge base is limited or inaccurate, as is often the case with drugs and alcohol, accepting higher risk becomes more dangerous. Adolescents are more likely to trust their peers than their parents, but their pediatricians still have authority and credibility.
While there is ample credible information online (from the National Institute on Drug Abuse and the Substance Abuse and Mental Health Services Administration’s excellent websites, which can be recommended to teens), marijuana and hallucinogens (LSD and psilocybin) bear special discussion here because of changing legality and their potential medical utility. There is an emerging impression of safety with both; however, policy changes and for-profit marketing may not reflect the actual scientific evidence. You have the opportunity and authority to complicate your patient’s thinking by discussing the evidence supporting their medical utility, and the emerging evidence that both types of drugs may pose special risks for their developing brains.
By June 2021, marijuana was legal for recreational use in 19 states; Washington, D.C.; and Guam, and for “medical use” in 36 states and four territories. Entrepreneurs and activists have made spectacular claims that marijuana is effective for the treatment of everything from insomnia to PTSD, but the reality is less impressive. Of course, marijuana remains a schedule I drug under the federal Controlled Substances Act (1970), which has made it difficult for researchers to perform randomized controlled studies concerning treatment or risks.
However, there are a growing number of randomized controlled trials with synthetic cannabinoids (dronabinol and nabilone) and a (legal) drug derived from cannabis (cannabidiol or CBD, as distinct from the other active ingredient, tetrahydrocannabinol). There is Food and Drug Administration approval for CBD for the treatment of epilepsy in Lennox-Gastaut or Dravet syndrome in patients aged 2 years or younger, and for the synthetic agents for the treatment of chemotherapy-related nausea and vomiting in cancer patients and for the treatment of weight loss and muscle wasting related to HIV/AIDS. That’s it. There is some evidence that these agents may be effective for the treatment of muscle spasticity in multiple sclerosis, chronic pain of many etiologies, Tourette syndrome, insomnia related to multiple sclerosis and chronic pain, and possibly PTSD. But there have been multiple studies that have failed to demonstrate efficacy (or have demonstrated exacerbation) for a host of other medical and psychiatric problems.
While the evidence for marijuana’s medicinal uses is modest, there is substantial evidence that its use in adolescence carries risks. It is an addictive substance and regular use is associated with sustained modest cognitive impairment (a loss of up to eight IQ points in the clinically dependent) and higher rates of anxiety and depressive disorders. As with other substances, use before the age of 18 substantially raises the risk (as much as sevenfold) of developing addiction than the same rate of use in adulthood. The rate of schizophrenia in adolescents with heavy marijuana use is between six and seven times greater than in the general population, whereas similar adult use does not have this association.2,3 Studies in rats have demonstrated that use during adolescence delays and permanently changes the maturation of the prefrontal cortex, an area of the brain that is essential for complex decision-making, sustaining attention, abstract reasoning, and impulse control.4 While we do not fully understand the exact nature of these changes, there is good reason to believe that regular marijuana use in adolescence leads to disruption of critical brain development and cognitive or even psychotic consequences. It is worth noting that the potency of many commercially available marijuana products is much higher than those that were studied, raising the risk and uncertainty further.
Hallucinogens, or “psychedelics” (from Greek for “mind manifesting”) are a class that includes LSD and psilocybin (a chemical found in over 200 species of mushrooms). They precipitate visual and auditory “hallucinations,” a loss of sense of self, and a sense of awe that may be transcendent or frightening. While psilocybin was used by many indigenous cultures in religious ceremonies, LSD was synthesized by a chemist at Sandoz in 1938 and made widely available for study until it was classified as a schedule I drug by the 1970 Controlled Substances Act. They are not addictive. Early research demonstrated promise in the treatment of alcohol dependence and several psychiatric conditions (including other addictions and treatment-resistant depression). Research resumed in 2018, demonstrating promise in the treatment of depression related to terminal illness. Research has also concerned the nature of consciousness and spiritual experiences. Hallucinogens have become popular in certain fields (high tech) as a means of optimizing creativity and performance (“microdosing”). There is modest evidence that use in people with a family history of psychotic illness may precipitate sustained psychotic symptoms. Regular use may further increase the risk of persistent psychosis and adolescent users of multiple substances are at high risk for regular hallucinogen use. Adolescents may think that ketamine, phencyclidine , and 3,4-methylenedioxymethamphetamine are also in this category, although they are different and considerably more risky drugs. Overall, these agents show therapeutic promise, but unless your young patients are facing depression related to a terminal illness and until we learn more from studies, the potential risk to their developing brains outweighs any potential benefits.
Aware of this information, you are ready to ask your adolescent patients about their drug and alcohol use and knowledge. Using phrases like “when did you first try ...” can increase the likelihood that your patients will be forthright with you. Or start by asking about what their friends are trying and talking about. Be curious about any drug and alcohol use at home. Find out what they are curious about, whom they trust, and where they get their information. Then you can offer your information about the dramatic changes happening in their brains (just like the rest of their bodies) and the special risks of drug use during this window of brain development. Acknowledge that the risks of marijuana use in adults may very well be lower than the risks of regular alcohol use but remind them about how their brains are different than those of adults. Delaying use until they are 18 (or ideally in their mid-20s when most brain development is complete), can dramatically lower these risks. For adolescents with a family history of addiction, psychosis, or mood and anxiety disorders, discuss the additional risks that drugs may present to them. And for those adolescents who acknowledge very early (before 13) or heavy use, be curious with them about whether they might be trying to “feel better” and not just “feel good.” Screen them for depression, suicidality, and anxiety disorders. Those underlying problems are treatable, but their course will only worsen with drug and alcohol use. You are in a unique position to help your adolescent patients make wise and well-informed choices and to get them assistance if they need it.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
References
1. Romer D. Dev Psychobiol. 2010 Apr;52(3):263-76.
2. Szczepanski SM and Knight TR. Neuron. 2014;83:1002-18.
3. Renard J et al. Front Psychiatry. 2018;9:281.
4. Shen H. Proc Natl Acad Sci U S A. 2020 Jan 7;117(1):7-11.
Seeking novelty is central to adolescence; experimentation is how they explore their identity, exert independence, and establish deep and connected relationships outside of the family. Research over the past 2 decades has demonstrated the neurobiological changes that underpin this increase in sensation seeking. Most adolescents are very good at assessing risk but are willing to tolerate higher levels of risk than adults in the pursuit of novelty.1 If their knowledge base is limited or inaccurate, as is often the case with drugs and alcohol, accepting higher risk becomes more dangerous. Adolescents are more likely to trust their peers than their parents, but their pediatricians still have authority and credibility.
While there is ample credible information online (from the National Institute on Drug Abuse and the Substance Abuse and Mental Health Services Administration’s excellent websites, which can be recommended to teens), marijuana and hallucinogens (LSD and psilocybin) bear special discussion here because of changing legality and their potential medical utility. There is an emerging impression of safety with both; however, policy changes and for-profit marketing may not reflect the actual scientific evidence. You have the opportunity and authority to complicate your patient’s thinking by discussing the evidence supporting their medical utility, and the emerging evidence that both types of drugs may pose special risks for their developing brains.
By June 2021, marijuana was legal for recreational use in 19 states; Washington, D.C.; and Guam, and for “medical use” in 36 states and four territories. Entrepreneurs and activists have made spectacular claims that marijuana is effective for the treatment of everything from insomnia to PTSD, but the reality is less impressive. Of course, marijuana remains a schedule I drug under the federal Controlled Substances Act (1970), which has made it difficult for researchers to perform randomized controlled studies concerning treatment or risks.
However, there are a growing number of randomized controlled trials with synthetic cannabinoids (dronabinol and nabilone) and a (legal) drug derived from cannabis (cannabidiol or CBD, as distinct from the other active ingredient, tetrahydrocannabinol). There is Food and Drug Administration approval for CBD for the treatment of epilepsy in Lennox-Gastaut or Dravet syndrome in patients aged 2 years or younger, and for the synthetic agents for the treatment of chemotherapy-related nausea and vomiting in cancer patients and for the treatment of weight loss and muscle wasting related to HIV/AIDS. That’s it. There is some evidence that these agents may be effective for the treatment of muscle spasticity in multiple sclerosis, chronic pain of many etiologies, Tourette syndrome, insomnia related to multiple sclerosis and chronic pain, and possibly PTSD. But there have been multiple studies that have failed to demonstrate efficacy (or have demonstrated exacerbation) for a host of other medical and psychiatric problems.
While the evidence for marijuana’s medicinal uses is modest, there is substantial evidence that its use in adolescence carries risks. It is an addictive substance and regular use is associated with sustained modest cognitive impairment (a loss of up to eight IQ points in the clinically dependent) and higher rates of anxiety and depressive disorders. As with other substances, use before the age of 18 substantially raises the risk (as much as sevenfold) of developing addiction than the same rate of use in adulthood. The rate of schizophrenia in adolescents with heavy marijuana use is between six and seven times greater than in the general population, whereas similar adult use does not have this association.2,3 Studies in rats have demonstrated that use during adolescence delays and permanently changes the maturation of the prefrontal cortex, an area of the brain that is essential for complex decision-making, sustaining attention, abstract reasoning, and impulse control.4 While we do not fully understand the exact nature of these changes, there is good reason to believe that regular marijuana use in adolescence leads to disruption of critical brain development and cognitive or even psychotic consequences. It is worth noting that the potency of many commercially available marijuana products is much higher than those that were studied, raising the risk and uncertainty further.
Hallucinogens, or “psychedelics” (from Greek for “mind manifesting”) are a class that includes LSD and psilocybin (a chemical found in over 200 species of mushrooms). They precipitate visual and auditory “hallucinations,” a loss of sense of self, and a sense of awe that may be transcendent or frightening. While psilocybin was used by many indigenous cultures in religious ceremonies, LSD was synthesized by a chemist at Sandoz in 1938 and made widely available for study until it was classified as a schedule I drug by the 1970 Controlled Substances Act. They are not addictive. Early research demonstrated promise in the treatment of alcohol dependence and several psychiatric conditions (including other addictions and treatment-resistant depression). Research resumed in 2018, demonstrating promise in the treatment of depression related to terminal illness. Research has also concerned the nature of consciousness and spiritual experiences. Hallucinogens have become popular in certain fields (high tech) as a means of optimizing creativity and performance (“microdosing”). There is modest evidence that use in people with a family history of psychotic illness may precipitate sustained psychotic symptoms. Regular use may further increase the risk of persistent psychosis and adolescent users of multiple substances are at high risk for regular hallucinogen use. Adolescents may think that ketamine, phencyclidine , and 3,4-methylenedioxymethamphetamine are also in this category, although they are different and considerably more risky drugs. Overall, these agents show therapeutic promise, but unless your young patients are facing depression related to a terminal illness and until we learn more from studies, the potential risk to their developing brains outweighs any potential benefits.
Aware of this information, you are ready to ask your adolescent patients about their drug and alcohol use and knowledge. Using phrases like “when did you first try ...” can increase the likelihood that your patients will be forthright with you. Or start by asking about what their friends are trying and talking about. Be curious about any drug and alcohol use at home. Find out what they are curious about, whom they trust, and where they get their information. Then you can offer your information about the dramatic changes happening in their brains (just like the rest of their bodies) and the special risks of drug use during this window of brain development. Acknowledge that the risks of marijuana use in adults may very well be lower than the risks of regular alcohol use but remind them about how their brains are different than those of adults. Delaying use until they are 18 (or ideally in their mid-20s when most brain development is complete), can dramatically lower these risks. For adolescents with a family history of addiction, psychosis, or mood and anxiety disorders, discuss the additional risks that drugs may present to them. And for those adolescents who acknowledge very early (before 13) or heavy use, be curious with them about whether they might be trying to “feel better” and not just “feel good.” Screen them for depression, suicidality, and anxiety disorders. Those underlying problems are treatable, but their course will only worsen with drug and alcohol use. You are in a unique position to help your adolescent patients make wise and well-informed choices and to get them assistance if they need it.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
References
1. Romer D. Dev Psychobiol. 2010 Apr;52(3):263-76.
2. Szczepanski SM and Knight TR. Neuron. 2014;83:1002-18.
3. Renard J et al. Front Psychiatry. 2018;9:281.
4. Shen H. Proc Natl Acad Sci U S A. 2020 Jan 7;117(1):7-11.
Seeking novelty is central to adolescence; experimentation is how they explore their identity, exert independence, and establish deep and connected relationships outside of the family. Research over the past 2 decades has demonstrated the neurobiological changes that underpin this increase in sensation seeking. Most adolescents are very good at assessing risk but are willing to tolerate higher levels of risk than adults in the pursuit of novelty.1 If their knowledge base is limited or inaccurate, as is often the case with drugs and alcohol, accepting higher risk becomes more dangerous. Adolescents are more likely to trust their peers than their parents, but their pediatricians still have authority and credibility.
While there is ample credible information online (from the National Institute on Drug Abuse and the Substance Abuse and Mental Health Services Administration’s excellent websites, which can be recommended to teens), marijuana and hallucinogens (LSD and psilocybin) bear special discussion here because of changing legality and their potential medical utility. There is an emerging impression of safety with both; however, policy changes and for-profit marketing may not reflect the actual scientific evidence. You have the opportunity and authority to complicate your patient’s thinking by discussing the evidence supporting their medical utility, and the emerging evidence that both types of drugs may pose special risks for their developing brains.
By June 2021, marijuana was legal for recreational use in 19 states; Washington, D.C.; and Guam, and for “medical use” in 36 states and four territories. Entrepreneurs and activists have made spectacular claims that marijuana is effective for the treatment of everything from insomnia to PTSD, but the reality is less impressive. Of course, marijuana remains a schedule I drug under the federal Controlled Substances Act (1970), which has made it difficult for researchers to perform randomized controlled studies concerning treatment or risks.
However, there are a growing number of randomized controlled trials with synthetic cannabinoids (dronabinol and nabilone) and a (legal) drug derived from cannabis (cannabidiol or CBD, as distinct from the other active ingredient, tetrahydrocannabinol). There is Food and Drug Administration approval for CBD for the treatment of epilepsy in Lennox-Gastaut or Dravet syndrome in patients aged 2 years or younger, and for the synthetic agents for the treatment of chemotherapy-related nausea and vomiting in cancer patients and for the treatment of weight loss and muscle wasting related to HIV/AIDS. That’s it. There is some evidence that these agents may be effective for the treatment of muscle spasticity in multiple sclerosis, chronic pain of many etiologies, Tourette syndrome, insomnia related to multiple sclerosis and chronic pain, and possibly PTSD. But there have been multiple studies that have failed to demonstrate efficacy (or have demonstrated exacerbation) for a host of other medical and psychiatric problems.
While the evidence for marijuana’s medicinal uses is modest, there is substantial evidence that its use in adolescence carries risks. It is an addictive substance and regular use is associated with sustained modest cognitive impairment (a loss of up to eight IQ points in the clinically dependent) and higher rates of anxiety and depressive disorders. As with other substances, use before the age of 18 substantially raises the risk (as much as sevenfold) of developing addiction than the same rate of use in adulthood. The rate of schizophrenia in adolescents with heavy marijuana use is between six and seven times greater than in the general population, whereas similar adult use does not have this association.2,3 Studies in rats have demonstrated that use during adolescence delays and permanently changes the maturation of the prefrontal cortex, an area of the brain that is essential for complex decision-making, sustaining attention, abstract reasoning, and impulse control.4 While we do not fully understand the exact nature of these changes, there is good reason to believe that regular marijuana use in adolescence leads to disruption of critical brain development and cognitive or even psychotic consequences. It is worth noting that the potency of many commercially available marijuana products is much higher than those that were studied, raising the risk and uncertainty further.
Hallucinogens, or “psychedelics” (from Greek for “mind manifesting”) are a class that includes LSD and psilocybin (a chemical found in over 200 species of mushrooms). They precipitate visual and auditory “hallucinations,” a loss of sense of self, and a sense of awe that may be transcendent or frightening. While psilocybin was used by many indigenous cultures in religious ceremonies, LSD was synthesized by a chemist at Sandoz in 1938 and made widely available for study until it was classified as a schedule I drug by the 1970 Controlled Substances Act. They are not addictive. Early research demonstrated promise in the treatment of alcohol dependence and several psychiatric conditions (including other addictions and treatment-resistant depression). Research resumed in 2018, demonstrating promise in the treatment of depression related to terminal illness. Research has also concerned the nature of consciousness and spiritual experiences. Hallucinogens have become popular in certain fields (high tech) as a means of optimizing creativity and performance (“microdosing”). There is modest evidence that use in people with a family history of psychotic illness may precipitate sustained psychotic symptoms. Regular use may further increase the risk of persistent psychosis and adolescent users of multiple substances are at high risk for regular hallucinogen use. Adolescents may think that ketamine, phencyclidine , and 3,4-methylenedioxymethamphetamine are also in this category, although they are different and considerably more risky drugs. Overall, these agents show therapeutic promise, but unless your young patients are facing depression related to a terminal illness and until we learn more from studies, the potential risk to their developing brains outweighs any potential benefits.
Aware of this information, you are ready to ask your adolescent patients about their drug and alcohol use and knowledge. Using phrases like “when did you first try ...” can increase the likelihood that your patients will be forthright with you. Or start by asking about what their friends are trying and talking about. Be curious about any drug and alcohol use at home. Find out what they are curious about, whom they trust, and where they get their information. Then you can offer your information about the dramatic changes happening in their brains (just like the rest of their bodies) and the special risks of drug use during this window of brain development. Acknowledge that the risks of marijuana use in adults may very well be lower than the risks of regular alcohol use but remind them about how their brains are different than those of adults. Delaying use until they are 18 (or ideally in their mid-20s when most brain development is complete), can dramatically lower these risks. For adolescents with a family history of addiction, psychosis, or mood and anxiety disorders, discuss the additional risks that drugs may present to them. And for those adolescents who acknowledge very early (before 13) or heavy use, be curious with them about whether they might be trying to “feel better” and not just “feel good.” Screen them for depression, suicidality, and anxiety disorders. Those underlying problems are treatable, but their course will only worsen with drug and alcohol use. You are in a unique position to help your adolescent patients make wise and well-informed choices and to get them assistance if they need it.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
References
1. Romer D. Dev Psychobiol. 2010 Apr;52(3):263-76.
2. Szczepanski SM and Knight TR. Neuron. 2014;83:1002-18.
3. Renard J et al. Front Psychiatry. 2018;9:281.
4. Shen H. Proc Natl Acad Sci U S A. 2020 Jan 7;117(1):7-11.
No more encopresis!
Wishful thinking. “Repeated involuntary passage of stool in the underwear after the acquisition of toileting skills (typically > 4 years of age) in the absence of overt neuromuscular anorectal dysfunction,” formerly called encopresis, certainly still exists, renamed functional fecal incontinence (FFI). You have surely cared for many children with FFI over the years, mostly the 80% retentive (constipated) type but newer information may make your management more successful!
The first step in managing FFI is detecting it. This may seem easy as we get a whiff of its presence, even if the child and parents are unaware because of habituation to the odor. Children lose sensation from rectal dilation by the stool mass and become unaware of leakage. But they also are ashamed of and deny “accidents,” hide soiled underwear, and keep distance from parents and peers. Our physical exam may reveal an abdominal mass or perianal stool. While there, check the anal wink, anus placement, lower spine integrity, and ankle reflexes for rare neurological causes. A rectal exam is not required if the story fits but, if not, may show a dilated rectal vault and hard mass. Blood work, x-ray, ultrasound, barium enemas, or manometry are rarely indicated.
Instead of counting on expressed concern, we should routinely ask children about large, painful, or infrequent poops. There are even Rome IV criteria for constipation – at least two of the following without organic pathology and with duration of at least 1 month: less than 2 defecations/week, a history of hard or painful stools, retentive posturing or excessive stool retention, large stools blocking the toilet, large rectal fecal mass, or at least 1 episode of incontinence/week. Our history should request this but parents are often unaware of their child’s patterns except for that blocked toilet!
Other actionable history includes struggles over toilet training, early anal fissure or painful stools, a history of “straining”, crying, or crossing legs (attempts to withhold), short stature and/or diarrhea (possible celiac disease), abdominal pain, poor appetite, or a diet high in milk products or low in fiber. Family history may suggest rare organic causes such as hypothyroidism, Hirschsprung disease, multiple endocrine neoplasia type 2, or celiac disease, but also constipation (in 55%). After the newborn period (imperforate anus or meconium ileus), 95% of constipation is functional.
While constipation has a worldwide prevalence of 9.5%, low exercise and low-fiber diet are particularly American. Low total food intake as a cause is uncommon in the United States but another reason to screen for food insecurity.
Patterns of behavior can predispose to constipation and FFI. For the child, oppositionality, social anxiety, depression, or eating disorders may interfere with sufficient stool frequency and relaxation needed to fully evacuate at home, daycare, or school. Query every child with ADHD about stool patterns as inattention to urge plus impatience with completing defection (and ODD) are common disorders leading to FFI. Parents who are overly demanding, intrusive, rushing, irritable, anxious, or obsessive may also make routine toileting stressful. When caregivers are neglectful, fail to maintain routines for eating, or ignore dirty diapers, toilet training is more likely to fail and constipation ensue.
Clean out and maintenance using medication are needed for FFI, but child and family behavior change are also critical; the combination has proven more successful. Both the child and parents need clear a explanation of how constipation develops from withholding, regardless of the reason (pain, anxiety, conflict, diet), leading to larger stools more difficult to pass as water is absorbed in the colon. The large mass stretches the bowel so that sensation and strength for motility is impaired and softer stool leaks by and out the rectum unbeknownst to the child. I find drawing “the rock of poop” in a dilated thin walled colon with nerves sparse and “liquid stool sneaking by” compared to a “muscular” colon with soft poop animates and objectifies this explanation. Making it clear that leaking is involuntary is key to having the parent and child directly forgive each other for prior anger, blaming, sneaking, or punishment. While the school-aged child needs to be in charge of toileting, resolving the conflict is essential.
The critical next step is cleaning out “the rocks,” which should only rarely be omitted. Polyethylene glycol (PEG, for example, Miralax) has the best evidence, tastes better (without electrolytes), and dosing 1-1.5 g/kg per day premixed in 10 mL/kg fluid of the child’s choice kept cold and swallowed within 30 minutes daily for 3-6 days until feces have no more chunks. This process disimpacts 95% of the time. Reassure parents of the long-term safety despite the warning on the label that it is intended for adult users. Lactulose or sorbitol (1 mL/kg, once or twice daily), magnesium hydroxide, bisacodyl, or senna are long second choices. Only if these fail should mineral oil 15-30 mL per year of age, up to 240 mL per day be used and then not in infants or if there is aspiration risk. While enemas (mineral oil, sodium phosphate, or saline) and p.o. PEG are equally effective, enemas are very intrusive and unnecessary. There is insufficient evidence for probiotics, prebiotics, or synbiotics.
It is crucial to be honest with the child and parents that clean out can be uncomfortable as cramping or leaking may occur. Thus, starting PEG after school on Friday and being prepared to stay home Monday (if rocks are still emerging) may be needed to avoid accidents.
After clean out, maintenance using daily PEG 0.4-0.8 g/kg per day (best) or lactulose needs to be continued for 2-6 or even 12 months to prevent relapse as the bowel recovers. Bowels need to produce 1-2 soft stools per day for 1 month before considering weaning off PEG. High-fiber (age of child plus 5-10 g/day) diet perpetually is more acceptable if we suggest Frosted Mini-Wheats, Fig Newtons, cookies or muffins baked with wheat bran, popcorn, or fruits with “p” in the name (for example, prunes, pears, apricots), Raisin Bran, or methylcellulose in juice or Popsicles, wafers (with jelly or frosting), or tablets. Infant diet can include brown sugar, or prune/apple/pear juice (Karo is no longer reliably osmotic). Diet needs to include 32-64 ounces of nonmilk fluids, although this will not serve as treatment alone. Limit cow milk to 16 oz. or consider eliminating it entirely if other treatments fail as cow milk is constipating.
Maintenance also requires coaching the child to commence “exercises” to “strengthen the bowel.” These consist of sitting with feet supported to elevate at the hip for 10 minutes by a timer after meals 2-3 times per day and pushing. Entertainment such as music, books, small toys, or a noncompetitive video game and/or rewards of cash, tokens, or treats may lighten the routine. These “exercises” need to be continued indefinitely and monitored with a stool diary. Monthly check-ins are essential to adherence and success, especially in the first 3-4 months, to address any relapses.
While constipation has consequences besides FFI: physical (abdominal pain, anal fissure, rectal prolapse, enuresis, UTI, vesicoureteral reflux, and upper urinary tract dilatation, poor appetite, or poor growth), emotional problems (lability, depression, anxiety, aggression, and low self-esteem), social problems (peer humiliation, teasing, rejection, parent upset, anger, shaming, and punishment), and school absence, we can be supportive and effective coaches for this chronic condition.
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.
Wishful thinking. “Repeated involuntary passage of stool in the underwear after the acquisition of toileting skills (typically > 4 years of age) in the absence of overt neuromuscular anorectal dysfunction,” formerly called encopresis, certainly still exists, renamed functional fecal incontinence (FFI). You have surely cared for many children with FFI over the years, mostly the 80% retentive (constipated) type but newer information may make your management more successful!
The first step in managing FFI is detecting it. This may seem easy as we get a whiff of its presence, even if the child and parents are unaware because of habituation to the odor. Children lose sensation from rectal dilation by the stool mass and become unaware of leakage. But they also are ashamed of and deny “accidents,” hide soiled underwear, and keep distance from parents and peers. Our physical exam may reveal an abdominal mass or perianal stool. While there, check the anal wink, anus placement, lower spine integrity, and ankle reflexes for rare neurological causes. A rectal exam is not required if the story fits but, if not, may show a dilated rectal vault and hard mass. Blood work, x-ray, ultrasound, barium enemas, or manometry are rarely indicated.
Instead of counting on expressed concern, we should routinely ask children about large, painful, or infrequent poops. There are even Rome IV criteria for constipation – at least two of the following without organic pathology and with duration of at least 1 month: less than 2 defecations/week, a history of hard or painful stools, retentive posturing or excessive stool retention, large stools blocking the toilet, large rectal fecal mass, or at least 1 episode of incontinence/week. Our history should request this but parents are often unaware of their child’s patterns except for that blocked toilet!
Other actionable history includes struggles over toilet training, early anal fissure or painful stools, a history of “straining”, crying, or crossing legs (attempts to withhold), short stature and/or diarrhea (possible celiac disease), abdominal pain, poor appetite, or a diet high in milk products or low in fiber. Family history may suggest rare organic causes such as hypothyroidism, Hirschsprung disease, multiple endocrine neoplasia type 2, or celiac disease, but also constipation (in 55%). After the newborn period (imperforate anus or meconium ileus), 95% of constipation is functional.
While constipation has a worldwide prevalence of 9.5%, low exercise and low-fiber diet are particularly American. Low total food intake as a cause is uncommon in the United States but another reason to screen for food insecurity.
Patterns of behavior can predispose to constipation and FFI. For the child, oppositionality, social anxiety, depression, or eating disorders may interfere with sufficient stool frequency and relaxation needed to fully evacuate at home, daycare, or school. Query every child with ADHD about stool patterns as inattention to urge plus impatience with completing defection (and ODD) are common disorders leading to FFI. Parents who are overly demanding, intrusive, rushing, irritable, anxious, or obsessive may also make routine toileting stressful. When caregivers are neglectful, fail to maintain routines for eating, or ignore dirty diapers, toilet training is more likely to fail and constipation ensue.
Clean out and maintenance using medication are needed for FFI, but child and family behavior change are also critical; the combination has proven more successful. Both the child and parents need clear a explanation of how constipation develops from withholding, regardless of the reason (pain, anxiety, conflict, diet), leading to larger stools more difficult to pass as water is absorbed in the colon. The large mass stretches the bowel so that sensation and strength for motility is impaired and softer stool leaks by and out the rectum unbeknownst to the child. I find drawing “the rock of poop” in a dilated thin walled colon with nerves sparse and “liquid stool sneaking by” compared to a “muscular” colon with soft poop animates and objectifies this explanation. Making it clear that leaking is involuntary is key to having the parent and child directly forgive each other for prior anger, blaming, sneaking, or punishment. While the school-aged child needs to be in charge of toileting, resolving the conflict is essential.
The critical next step is cleaning out “the rocks,” which should only rarely be omitted. Polyethylene glycol (PEG, for example, Miralax) has the best evidence, tastes better (without electrolytes), and dosing 1-1.5 g/kg per day premixed in 10 mL/kg fluid of the child’s choice kept cold and swallowed within 30 minutes daily for 3-6 days until feces have no more chunks. This process disimpacts 95% of the time. Reassure parents of the long-term safety despite the warning on the label that it is intended for adult users. Lactulose or sorbitol (1 mL/kg, once or twice daily), magnesium hydroxide, bisacodyl, or senna are long second choices. Only if these fail should mineral oil 15-30 mL per year of age, up to 240 mL per day be used and then not in infants or if there is aspiration risk. While enemas (mineral oil, sodium phosphate, or saline) and p.o. PEG are equally effective, enemas are very intrusive and unnecessary. There is insufficient evidence for probiotics, prebiotics, or synbiotics.
It is crucial to be honest with the child and parents that clean out can be uncomfortable as cramping or leaking may occur. Thus, starting PEG after school on Friday and being prepared to stay home Monday (if rocks are still emerging) may be needed to avoid accidents.
After clean out, maintenance using daily PEG 0.4-0.8 g/kg per day (best) or lactulose needs to be continued for 2-6 or even 12 months to prevent relapse as the bowel recovers. Bowels need to produce 1-2 soft stools per day for 1 month before considering weaning off PEG. High-fiber (age of child plus 5-10 g/day) diet perpetually is more acceptable if we suggest Frosted Mini-Wheats, Fig Newtons, cookies or muffins baked with wheat bran, popcorn, or fruits with “p” in the name (for example, prunes, pears, apricots), Raisin Bran, or methylcellulose in juice or Popsicles, wafers (with jelly or frosting), or tablets. Infant diet can include brown sugar, or prune/apple/pear juice (Karo is no longer reliably osmotic). Diet needs to include 32-64 ounces of nonmilk fluids, although this will not serve as treatment alone. Limit cow milk to 16 oz. or consider eliminating it entirely if other treatments fail as cow milk is constipating.
Maintenance also requires coaching the child to commence “exercises” to “strengthen the bowel.” These consist of sitting with feet supported to elevate at the hip for 10 minutes by a timer after meals 2-3 times per day and pushing. Entertainment such as music, books, small toys, or a noncompetitive video game and/or rewards of cash, tokens, or treats may lighten the routine. These “exercises” need to be continued indefinitely and monitored with a stool diary. Monthly check-ins are essential to adherence and success, especially in the first 3-4 months, to address any relapses.
While constipation has consequences besides FFI: physical (abdominal pain, anal fissure, rectal prolapse, enuresis, UTI, vesicoureteral reflux, and upper urinary tract dilatation, poor appetite, or poor growth), emotional problems (lability, depression, anxiety, aggression, and low self-esteem), social problems (peer humiliation, teasing, rejection, parent upset, anger, shaming, and punishment), and school absence, we can be supportive and effective coaches for this chronic condition.
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.
Wishful thinking. “Repeated involuntary passage of stool in the underwear after the acquisition of toileting skills (typically > 4 years of age) in the absence of overt neuromuscular anorectal dysfunction,” formerly called encopresis, certainly still exists, renamed functional fecal incontinence (FFI). You have surely cared for many children with FFI over the years, mostly the 80% retentive (constipated) type but newer information may make your management more successful!
The first step in managing FFI is detecting it. This may seem easy as we get a whiff of its presence, even if the child and parents are unaware because of habituation to the odor. Children lose sensation from rectal dilation by the stool mass and become unaware of leakage. But they also are ashamed of and deny “accidents,” hide soiled underwear, and keep distance from parents and peers. Our physical exam may reveal an abdominal mass or perianal stool. While there, check the anal wink, anus placement, lower spine integrity, and ankle reflexes for rare neurological causes. A rectal exam is not required if the story fits but, if not, may show a dilated rectal vault and hard mass. Blood work, x-ray, ultrasound, barium enemas, or manometry are rarely indicated.
Instead of counting on expressed concern, we should routinely ask children about large, painful, or infrequent poops. There are even Rome IV criteria for constipation – at least two of the following without organic pathology and with duration of at least 1 month: less than 2 defecations/week, a history of hard or painful stools, retentive posturing or excessive stool retention, large stools blocking the toilet, large rectal fecal mass, or at least 1 episode of incontinence/week. Our history should request this but parents are often unaware of their child’s patterns except for that blocked toilet!
Other actionable history includes struggles over toilet training, early anal fissure or painful stools, a history of “straining”, crying, or crossing legs (attempts to withhold), short stature and/or diarrhea (possible celiac disease), abdominal pain, poor appetite, or a diet high in milk products or low in fiber. Family history may suggest rare organic causes such as hypothyroidism, Hirschsprung disease, multiple endocrine neoplasia type 2, or celiac disease, but also constipation (in 55%). After the newborn period (imperforate anus or meconium ileus), 95% of constipation is functional.
While constipation has a worldwide prevalence of 9.5%, low exercise and low-fiber diet are particularly American. Low total food intake as a cause is uncommon in the United States but another reason to screen for food insecurity.
Patterns of behavior can predispose to constipation and FFI. For the child, oppositionality, social anxiety, depression, or eating disorders may interfere with sufficient stool frequency and relaxation needed to fully evacuate at home, daycare, or school. Query every child with ADHD about stool patterns as inattention to urge plus impatience with completing defection (and ODD) are common disorders leading to FFI. Parents who are overly demanding, intrusive, rushing, irritable, anxious, or obsessive may also make routine toileting stressful. When caregivers are neglectful, fail to maintain routines for eating, or ignore dirty diapers, toilet training is more likely to fail and constipation ensue.
Clean out and maintenance using medication are needed for FFI, but child and family behavior change are also critical; the combination has proven more successful. Both the child and parents need clear a explanation of how constipation develops from withholding, regardless of the reason (pain, anxiety, conflict, diet), leading to larger stools more difficult to pass as water is absorbed in the colon. The large mass stretches the bowel so that sensation and strength for motility is impaired and softer stool leaks by and out the rectum unbeknownst to the child. I find drawing “the rock of poop” in a dilated thin walled colon with nerves sparse and “liquid stool sneaking by” compared to a “muscular” colon with soft poop animates and objectifies this explanation. Making it clear that leaking is involuntary is key to having the parent and child directly forgive each other for prior anger, blaming, sneaking, or punishment. While the school-aged child needs to be in charge of toileting, resolving the conflict is essential.
The critical next step is cleaning out “the rocks,” which should only rarely be omitted. Polyethylene glycol (PEG, for example, Miralax) has the best evidence, tastes better (without electrolytes), and dosing 1-1.5 g/kg per day premixed in 10 mL/kg fluid of the child’s choice kept cold and swallowed within 30 minutes daily for 3-6 days until feces have no more chunks. This process disimpacts 95% of the time. Reassure parents of the long-term safety despite the warning on the label that it is intended for adult users. Lactulose or sorbitol (1 mL/kg, once or twice daily), magnesium hydroxide, bisacodyl, or senna are long second choices. Only if these fail should mineral oil 15-30 mL per year of age, up to 240 mL per day be used and then not in infants or if there is aspiration risk. While enemas (mineral oil, sodium phosphate, or saline) and p.o. PEG are equally effective, enemas are very intrusive and unnecessary. There is insufficient evidence for probiotics, prebiotics, or synbiotics.
It is crucial to be honest with the child and parents that clean out can be uncomfortable as cramping or leaking may occur. Thus, starting PEG after school on Friday and being prepared to stay home Monday (if rocks are still emerging) may be needed to avoid accidents.
After clean out, maintenance using daily PEG 0.4-0.8 g/kg per day (best) or lactulose needs to be continued for 2-6 or even 12 months to prevent relapse as the bowel recovers. Bowels need to produce 1-2 soft stools per day for 1 month before considering weaning off PEG. High-fiber (age of child plus 5-10 g/day) diet perpetually is more acceptable if we suggest Frosted Mini-Wheats, Fig Newtons, cookies or muffins baked with wheat bran, popcorn, or fruits with “p” in the name (for example, prunes, pears, apricots), Raisin Bran, or methylcellulose in juice or Popsicles, wafers (with jelly or frosting), or tablets. Infant diet can include brown sugar, or prune/apple/pear juice (Karo is no longer reliably osmotic). Diet needs to include 32-64 ounces of nonmilk fluids, although this will not serve as treatment alone. Limit cow milk to 16 oz. or consider eliminating it entirely if other treatments fail as cow milk is constipating.
Maintenance also requires coaching the child to commence “exercises” to “strengthen the bowel.” These consist of sitting with feet supported to elevate at the hip for 10 minutes by a timer after meals 2-3 times per day and pushing. Entertainment such as music, books, small toys, or a noncompetitive video game and/or rewards of cash, tokens, or treats may lighten the routine. These “exercises” need to be continued indefinitely and monitored with a stool diary. Monthly check-ins are essential to adherence and success, especially in the first 3-4 months, to address any relapses.
While constipation has consequences besides FFI: physical (abdominal pain, anal fissure, rectal prolapse, enuresis, UTI, vesicoureteral reflux, and upper urinary tract dilatation, poor appetite, or poor growth), emotional problems (lability, depression, anxiety, aggression, and low self-esteem), social problems (peer humiliation, teasing, rejection, parent upset, anger, shaming, and punishment), and school absence, we can be supportive and effective coaches for this chronic condition.
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.