Commentary

If you ask a primary care pediatrician who has been practicing for more than 2 decades, she will tell you that her practice has tilted steeply toward complaints with a more developmental and behavioral flavor. In the lead article of the April 2015 Pediatrics (“Are We on the Right Track? Examining the Role of Developmental Behavioral Pediatrics”) Dr. Ruth E.K. Stein, a recent recipient of the C. Anderson Aldrich Award given by the American Academy of Pediatrics section on children with developmental and behavioral pediatrics, questions whether we, both general pediatricians and specialists in developmental and behavioral pediatrics, are on the right path in addressing this shifting mix in our patient populations.

Dr. Stein observes that while she and other pioneers in the creation of her specialty began as general pediatricians, today physicians typically enter developmental and behavioral fellowship programs without the benefit of practicing the runny nose–earache–diaper rash kind of pediatrics that many of us enjoy. She worries that from this early branching point in training, developmental and behavioral specialists have become “sequestered and siloed – increasingly seen only as people who take care of children who have special needs.” The problem is that, as Dr. Stein wisely observes, developmental and behavioral issues “are the core constructs of pediatrics and its backbone and that they must be incorporated into every primary care and specialty encounter and included in every educational experience.”

Dr. Stein continues her essay by proposing a handful of strategies for bridging the gap between developmental and behavioral specialists and general pediatricians, and strengthening the training of house officers, which currently requires only a pitifully inadequate month devoted to developmental and behavioral issues. While it is hard to argue with Dr. Stein’s suggestions, they only nibble around the edges of the real problem.

If one really believes as she and I do, that behavior and development must be considered in every patient encounter and educational experience, then the solution lies in changing how we teach medicine from the very beginning instead of waiting until postgraduate education. Everyone mouths the importance of the mind-body connection, but it is often just so much hot air. The relationship between behavior and development, and what Dr. Stein refers to as “biomedical” conditions, exists in every patient. It is often said it is the fact that our patients are growing and developing that keeps pediatrics apart from the rest of medicine. But the same process of change over time occurs in adults as well; we call it aging instead of development. Understanding where our patients are positioned on this trajectory from birth to death is critical in helping us understand what is troubling them, and how best to help them manage their concerns.

For pediatricians, our preverbal patients’ behavior is often the only way we have of knowing there is a problem. Behavior can be their unspoken chief complaint. The failure by a physician to interpret her patient’s behavior as either a result or the cause of the problem can lead to an unfortunate outcome.

This means, as we teach aspiring doctors the art of medicine, we must make it clear that the patient’s behavior and stage of development must be considered equally with the more traditional biomedical etiologies, not as an afterthought. For example, any discussion of nonacute recurrent abdominal pain in children that fails to acknowledge from the outset that most of these patients will not have an abnormality detectable by lab work and imaging studies is doing the young physician and his patients a disservice. I am suggesting that we adopt a more patient-centered rather than a disease-centered approach to training all physicians.

While every patient must be viewed in the proper behavioral and developmental context, there are those in whom a behavior problem dominates. Given the patient mix that the new millennium pediatrician is going to face, 1 month in postgraduate training is clearly insufficient. One cannot begin to learn even the rudiments of managing common problems such as attention-deficit/hyperactivity disorder, disordered sleep, temper tantrums, and school refusal in 30 days. Finding room in a training program to give behavioral and developmental problems more than a quick nod is going to require some rethinking of how we train pediatricians. It may be that training programs will need to selectively trim back some programs that may be of only limited long-term use to most general office-based pediatricians and offer them as electives. For example, how many of us still practice the kind of neonatology we were exposed to in the special care nursery? These are not easy decisions, but as Dr. Reid has suggested, we need to reconsider whether we are on the right track.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at pdnews@frontlinemedcom.com.

If you ask a primary care pediatrician who has been practicing for more than 2 decades, she will tell you that her practice has tilted steeply toward complaints with a more developmental and behavioral flavor. In the lead article of the April 2015 Pediatrics (“Are We on the Right Track? Examining the Role of Developmental Behavioral Pediatrics”) Dr. Ruth E.K. Stein, a recent recipient of the C. Anderson Aldrich Award given by the American Academy of Pediatrics section on children with developmental and behavioral pediatrics, questions whether we, both general pediatricians and specialists in developmental and behavioral pediatrics, are on the right path in addressing this shifting mix in our patient populations.

Dr. Stein observes that while she and other pioneers in the creation of her specialty began as general pediatricians, today physicians typically enter developmental and behavioral fellowship programs without the benefit of practicing the runny nose–earache–diaper rash kind of pediatrics that many of us enjoy. She worries that from this early branching point in training, developmental and behavioral specialists have become “sequestered and siloed – increasingly seen only as people who take care of children who have special needs.” The problem is that, as Dr. Stein wisely observes, developmental and behavioral issues “are the core constructs of pediatrics and its backbone and that they must be incorporated into every primary care and specialty encounter and included in every educational experience.”

Dr. Stein continues her essay by proposing a handful of strategies for bridging the gap between developmental and behavioral specialists and general pediatricians, and strengthening the training of house officers, which currently requires only a pitifully inadequate month devoted to developmental and behavioral issues. While it is hard to argue with Dr. Stein’s suggestions, they only nibble around the edges of the real problem.

If one really believes as she and I do, that behavior and development must be considered in every patient encounter and educational experience, then the solution lies in changing how we teach medicine from the very beginning instead of waiting until postgraduate education. Everyone mouths the importance of the mind-body connection, but it is often just so much hot air. The relationship between behavior and development, and what Dr. Stein refers to as “biomedical” conditions, exists in every patient. It is often said it is the fact that our patients are growing and developing that keeps pediatrics apart from the rest of medicine. But the same process of change over time occurs in adults as well; we call it aging instead of development. Understanding where our patients are positioned on this trajectory from birth to death is critical in helping us understand what is troubling them, and how best to help them manage their concerns.

For pediatricians, our preverbal patients’ behavior is often the only way we have of knowing there is a problem. Behavior can be their unspoken chief complaint. The failure by a physician to interpret her patient’s behavior as either a result or the cause of the problem can lead to an unfortunate outcome.

This means, as we teach aspiring doctors the art of medicine, we must make it clear that the patient’s behavior and stage of development must be considered equally with the more traditional biomedical etiologies, not as an afterthought. For example, any discussion of nonacute recurrent abdominal pain in children that fails to acknowledge from the outset that most of these patients will not have an abnormality detectable by lab work and imaging studies is doing the young physician and his patients a disservice. I am suggesting that we adopt a more patient-centered rather than a disease-centered approach to training all physicians.

While every patient must be viewed in the proper behavioral and developmental context, there are those in whom a behavior problem dominates. Given the patient mix that the new millennium pediatrician is going to face, 1 month in postgraduate training is clearly insufficient. One cannot begin to learn even the rudiments of managing common problems such as attention-deficit/hyperactivity disorder, disordered sleep, temper tantrums, and school refusal in 30 days. Finding room in a training program to give behavioral and developmental problems more than a quick nod is going to require some rethinking of how we train pediatricians. It may be that training programs will need to selectively trim back some programs that may be of only limited long-term use to most general office-based pediatricians and offer them as electives. For example, how many of us still practice the kind of neonatology we were exposed to in the special care nursery? These are not easy decisions, but as Dr. Reid has suggested, we need to reconsider whether we are on the right track.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at pdnews@frontlinemedcom.com.

If you ask a primary care pediatrician who has been practicing for more than 2 decades, she will tell you that her practice has tilted steeply toward complaints with a more developmental and behavioral flavor. In the lead article of the April 2015 Pediatrics (“Are We on the Right Track? Examining the Role of Developmental Behavioral Pediatrics”) Dr. Ruth E.K. Stein, a recent recipient of the C. Anderson Aldrich Award given by the American Academy of Pediatrics section on children with developmental and behavioral pediatrics, questions whether we, both general pediatricians and specialists in developmental and behavioral pediatrics, are on the right path in addressing this shifting mix in our patient populations.

Dr. Stein observes that while she and other pioneers in the creation of her specialty began as general pediatricians, today physicians typically enter developmental and behavioral fellowship programs without the benefit of practicing the runny nose–earache–diaper rash kind of pediatrics that many of us enjoy. She worries that from this early branching point in training, developmental and behavioral specialists have become “sequestered and siloed – increasingly seen only as people who take care of children who have special needs.” The problem is that, as Dr. Stein wisely observes, developmental and behavioral issues “are the core constructs of pediatrics and its backbone and that they must be incorporated into every primary care and specialty encounter and included in every educational experience.”

Dr. Stein continues her essay by proposing a handful of strategies for bridging the gap between developmental and behavioral specialists and general pediatricians, and strengthening the training of house officers, which currently requires only a pitifully inadequate month devoted to developmental and behavioral issues. While it is hard to argue with Dr. Stein’s suggestions, they only nibble around the edges of the real problem.

If one really believes as she and I do, that behavior and development must be considered in every patient encounter and educational experience, then the solution lies in changing how we teach medicine from the very beginning instead of waiting until postgraduate education. Everyone mouths the importance of the mind-body connection, but it is often just so much hot air. The relationship between behavior and development, and what Dr. Stein refers to as “biomedical” conditions, exists in every patient. It is often said it is the fact that our patients are growing and developing that keeps pediatrics apart from the rest of medicine. But the same process of change over time occurs in adults as well; we call it aging instead of development. Understanding where our patients are positioned on this trajectory from birth to death is critical in helping us understand what is troubling them, and how best to help them manage their concerns.

For pediatricians, our preverbal patients’ behavior is often the only way we have of knowing there is a problem. Behavior can be their unspoken chief complaint. The failure by a physician to interpret her patient’s behavior as either a result or the cause of the problem can lead to an unfortunate outcome.

This means, as we teach aspiring doctors the art of medicine, we must make it clear that the patient’s behavior and stage of development must be considered equally with the more traditional biomedical etiologies, not as an afterthought. For example, any discussion of nonacute recurrent abdominal pain in children that fails to acknowledge from the outset that most of these patients will not have an abnormality detectable by lab work and imaging studies is doing the young physician and his patients a disservice. I am suggesting that we adopt a more patient-centered rather than a disease-centered approach to training all physicians.

While every patient must be viewed in the proper behavioral and developmental context, there are those in whom a behavior problem dominates. Given the patient mix that the new millennium pediatrician is going to face, 1 month in postgraduate training is clearly insufficient. One cannot begin to learn even the rudiments of managing common problems such as attention-deficit/hyperactivity disorder, disordered sleep, temper tantrums, and school refusal in 30 days. Finding room in a training program to give behavioral and developmental problems more than a quick nod is going to require some rethinking of how we train pediatricians. It may be that training programs will need to selectively trim back some programs that may be of only limited long-term use to most general office-based pediatricians and offer them as electives. For example, how many of us still practice the kind of neonatology we were exposed to in the special care nursery? These are not easy decisions, but as Dr. Reid has suggested, we need to reconsider whether we are on the right track.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at pdnews@frontlinemedcom.com.

Well, in a remarkable moment in what is likely the most dysfunctional American government on record, all sides agreed to repeal the sustainable growth rate formula and change the way Medicare payments are done.

For the foreseeable future, this eliminates the annual game of chicken that political parties play at our expense.

For more than 10 years now, the cuts have come up, the medical journals decry them, doctors threaten to stop seeing Medicare patients, and eventually the politicians reach an agreement to stop the cuts that had grown to a high of 27.4% in 2012 ... until the next year. The classic game of political kick the can.

The dysfunctional waltz had been going on for so long that only the medical press and doctors seemed to care.

So, after years of wrapping duct tape around a leaking pipe, they called a plumber and replaced the pipe. The cost is far higher than it would have been if they’d actually addressed the problem when it started in 2003.

I’m sure the new law will have its own issues, but it stops – for now – the nightmare scenario where the cuts are allowed to go through. That would have left many of us in the difficult situation of turning away new Medicare patients. None of us wants to do that.

It’s nice to have seen the government function in the way it’s supposed to – with negotiations and compromise – rather than more threats, vitriolic posturing, and finger-pointing that have been the recent norm. Members of Congress, regrettably, don’t have their health care affected by their decisions. Regardless of age, the majority aren’t on Medicare. They’re all covered through the Federal Employees Health Benefits Program, which uses private plans. So it doesn’t directly affect them if a doctor’s office is shuttered or sick constituents can’t find someone to help them. They figure by the next election cycle they’ll be able to distract voters with some other topic.

I’m glad that reason and concern for the health care of ordinary citizens prevailed. It’s easy to play chicken when someone else’s life and livelihood are involved, and not yours. I hope this leads to greater cooperation and willingness to work together between the two sides in the future.

But I’m not optimistic.

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

Well, in a remarkable moment in what is likely the most dysfunctional American government on record, all sides agreed to repeal the sustainable growth rate formula and change the way Medicare payments are done.

For the foreseeable future, this eliminates the annual game of chicken that political parties play at our expense.

For more than 10 years now, the cuts have come up, the medical journals decry them, doctors threaten to stop seeing Medicare patients, and eventually the politicians reach an agreement to stop the cuts that had grown to a high of 27.4% in 2012 ... until the next year. The classic game of political kick the can.

The dysfunctional waltz had been going on for so long that only the medical press and doctors seemed to care.

So, after years of wrapping duct tape around a leaking pipe, they called a plumber and replaced the pipe. The cost is far higher than it would have been if they’d actually addressed the problem when it started in 2003.

I’m sure the new law will have its own issues, but it stops – for now – the nightmare scenario where the cuts are allowed to go through. That would have left many of us in the difficult situation of turning away new Medicare patients. None of us wants to do that.

It’s nice to have seen the government function in the way it’s supposed to – with negotiations and compromise – rather than more threats, vitriolic posturing, and finger-pointing that have been the recent norm. Members of Congress, regrettably, don’t have their health care affected by their decisions. Regardless of age, the majority aren’t on Medicare. They’re all covered through the Federal Employees Health Benefits Program, which uses private plans. So it doesn’t directly affect them if a doctor’s office is shuttered or sick constituents can’t find someone to help them. They figure by the next election cycle they’ll be able to distract voters with some other topic.

I’m glad that reason and concern for the health care of ordinary citizens prevailed. It’s easy to play chicken when someone else’s life and livelihood are involved, and not yours. I hope this leads to greater cooperation and willingness to work together between the two sides in the future.

But I’m not optimistic.

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

Well, in a remarkable moment in what is likely the most dysfunctional American government on record, all sides agreed to repeal the sustainable growth rate formula and change the way Medicare payments are done.

For the foreseeable future, this eliminates the annual game of chicken that political parties play at our expense.

For more than 10 years now, the cuts have come up, the medical journals decry them, doctors threaten to stop seeing Medicare patients, and eventually the politicians reach an agreement to stop the cuts that had grown to a high of 27.4% in 2012 ... until the next year. The classic game of political kick the can.

The dysfunctional waltz had been going on for so long that only the medical press and doctors seemed to care.

So, after years of wrapping duct tape around a leaking pipe, they called a plumber and replaced the pipe. The cost is far higher than it would have been if they’d actually addressed the problem when it started in 2003.

I’m sure the new law will have its own issues, but it stops – for now – the nightmare scenario where the cuts are allowed to go through. That would have left many of us in the difficult situation of turning away new Medicare patients. None of us wants to do that.

It’s nice to have seen the government function in the way it’s supposed to – with negotiations and compromise – rather than more threats, vitriolic posturing, and finger-pointing that have been the recent norm. Members of Congress, regrettably, don’t have their health care affected by their decisions. Regardless of age, the majority aren’t on Medicare. They’re all covered through the Federal Employees Health Benefits Program, which uses private plans. So it doesn’t directly affect them if a doctor’s office is shuttered or sick constituents can’t find someone to help them. They figure by the next election cycle they’ll be able to distract voters with some other topic.

I’m glad that reason and concern for the health care of ordinary citizens prevailed. It’s easy to play chicken when someone else’s life and livelihood are involved, and not yours. I hope this leads to greater cooperation and willingness to work together between the two sides in the future.

But I’m not optimistic.

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

“Bath salts” is a dangerous illicit drug that teens may be using. It hit the U.S. scene in 2010 after being a big hit in Europe. It’s called “bath salts” because it resembled Epsom salt, but shares no chemical properties with it.

Because it was called bath salts, it initially evaded the Food and Drug Administration, and was sold at gas stations and clubs marked “not for human consumption,” which earned it its name as the “legal high.” Bath salts are creatively packaged in containers that are colorful and attractive, and have aliases such as “plant food,” “Ivory Wave,” “Purple Wave,” “Bloom,” “Cloud Nine,” or “Vanilla Sky,” according to the National Institute on Drug Abuse.

Shortly after the drug’s debut, emergency departments were seeing several hundreds of people with amphetamine-like intoxication and “naked rages.” In 2012, when it became known that these substances were being use as illicit drugs, they were made illegal, but the problem now is there are many derivatives of this drug and their use is becoming more widespread.

Mephedrone is one of the possible active ingredients, and it is derived from the synthetic cathinone, similar to cathinone found naturally in the khat plant (Catha edulis). It stimulates the adrenergic receptors to release dopamine and norepinephrine, and block their reuptake, which makes them act like a stimulant on the nervous system. The result is agitation, hyperalertness, hypertension, tachycardia, diaphoresis, and elevated temperatures to 106<scaps>˚ </scaps>F. The term “naked rage” came into use because users would become overheated and angry, and would rip off their clothes as they raged.

Other synthetic canthinones being used as drugs of abuse include butylone, dimethylcathinone, ethcathinone, ethylone, 3- and 4-fluoromethcathinone, mephedrone, methedrone, methylenedioxypyrovalerone (MDPV), methylone, and pyrovalerone (J. Med. Toxicol. 2012;8:33-42).

MDPV raises dopamine levels in the brain as does cocaine, but is at least 10 times as potent, according to the National Institute on Drug Abuse.

Bath salts can be administered by snorting, ingesting, smoking, or injecting. Necrotizing fasciitis has been associated with its use. Most patients present with elevated temperatures, hypertension, palpitations, and delirium. Hydration and sedation are usually required, and patients usually need to be restrained to prevent them from hurting themselves further. Psychiatric symptoms may include paranoia, hallucinations, and panic attacks. Several deaths have been reported in association with its use.

In the time since this drug was made illegal, several other designer drugs have presented, which are just modifications of the mephedrone. “Flakka” and “jewelry cleaner” are examples of the modified synthetic cathinone. They all cause amphetamine-like reactions and the risk of overdose is great.

The cost to manufacture the drug is about $8 per unit, but its retail price is $20-$40. Though it takes only 3-5 mg to be effective, packages are sold with 500 mg, making the risk for overdose even greater. It usually takes about 1.5 hours to reach peak rush and the entire experience can last 6-8 hours. There is little difference between the euphoric level and intoxication level, which is what makes the drug so dangerous.

Synthetic drugs are a great danger to all age groups, including toddlers, because of the misleading packaging. But they are especially dangerous because the ingredients vary, and overdose occurs quickly.

It is imperative that parents and teens are made aware of the dangers associated with these drugs and their street names; www.streetdrugs.org is a website designed to educate teachers, parents and students about these drugs and their dangers.

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at pdnews@frontlinemedcom.com.

“Bath salts” is a dangerous illicit drug that teens may be using. It hit the U.S. scene in 2010 after being a big hit in Europe. It’s called “bath salts” because it resembled Epsom salt, but shares no chemical properties with it.

Because it was called bath salts, it initially evaded the Food and Drug Administration, and was sold at gas stations and clubs marked “not for human consumption,” which earned it its name as the “legal high.” Bath salts are creatively packaged in containers that are colorful and attractive, and have aliases such as “plant food,” “Ivory Wave,” “Purple Wave,” “Bloom,” “Cloud Nine,” or “Vanilla Sky,” according to the National Institute on Drug Abuse.

Shortly after the drug’s debut, emergency departments were seeing several hundreds of people with amphetamine-like intoxication and “naked rages.” In 2012, when it became known that these substances were being use as illicit drugs, they were made illegal, but the problem now is there are many derivatives of this drug and their use is becoming more widespread.

Mephedrone is one of the possible active ingredients, and it is derived from the synthetic cathinone, similar to cathinone found naturally in the khat plant (Catha edulis). It stimulates the adrenergic receptors to release dopamine and norepinephrine, and block their reuptake, which makes them act like a stimulant on the nervous system. The result is agitation, hyperalertness, hypertension, tachycardia, diaphoresis, and elevated temperatures to 106<scaps>˚ </scaps>F. The term “naked rage” came into use because users would become overheated and angry, and would rip off their clothes as they raged.

Other synthetic canthinones being used as drugs of abuse include butylone, dimethylcathinone, ethcathinone, ethylone, 3- and 4-fluoromethcathinone, mephedrone, methedrone, methylenedioxypyrovalerone (MDPV), methylone, and pyrovalerone (J. Med. Toxicol. 2012;8:33-42).

MDPV raises dopamine levels in the brain as does cocaine, but is at least 10 times as potent, according to the National Institute on Drug Abuse.

Bath salts can be administered by snorting, ingesting, smoking, or injecting. Necrotizing fasciitis has been associated with its use. Most patients present with elevated temperatures, hypertension, palpitations, and delirium. Hydration and sedation are usually required, and patients usually need to be restrained to prevent them from hurting themselves further. Psychiatric symptoms may include paranoia, hallucinations, and panic attacks. Several deaths have been reported in association with its use.

In the time since this drug was made illegal, several other designer drugs have presented, which are just modifications of the mephedrone. “Flakka” and “jewelry cleaner” are examples of the modified synthetic cathinone. They all cause amphetamine-like reactions and the risk of overdose is great.

The cost to manufacture the drug is about $8 per unit, but its retail price is $20-$40. Though it takes only 3-5 mg to be effective, packages are sold with 500 mg, making the risk for overdose even greater. It usually takes about 1.5 hours to reach peak rush and the entire experience can last 6-8 hours. There is little difference between the euphoric level and intoxication level, which is what makes the drug so dangerous.

Synthetic drugs are a great danger to all age groups, including toddlers, because of the misleading packaging. But they are especially dangerous because the ingredients vary, and overdose occurs quickly.

It is imperative that parents and teens are made aware of the dangers associated with these drugs and their street names; www.streetdrugs.org is a website designed to educate teachers, parents and students about these drugs and their dangers.

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at pdnews@frontlinemedcom.com.

“Bath salts” is a dangerous illicit drug that teens may be using. It hit the U.S. scene in 2010 after being a big hit in Europe. It’s called “bath salts” because it resembled Epsom salt, but shares no chemical properties with it.

Because it was called bath salts, it initially evaded the Food and Drug Administration, and was sold at gas stations and clubs marked “not for human consumption,” which earned it its name as the “legal high.” Bath salts are creatively packaged in containers that are colorful and attractive, and have aliases such as “plant food,” “Ivory Wave,” “Purple Wave,” “Bloom,” “Cloud Nine,” or “Vanilla Sky,” according to the National Institute on Drug Abuse.

Shortly after the drug’s debut, emergency departments were seeing several hundreds of people with amphetamine-like intoxication and “naked rages.” In 2012, when it became known that these substances were being use as illicit drugs, they were made illegal, but the problem now is there are many derivatives of this drug and their use is becoming more widespread.

Mephedrone is one of the possible active ingredients, and it is derived from the synthetic cathinone, similar to cathinone found naturally in the khat plant (Catha edulis). It stimulates the adrenergic receptors to release dopamine and norepinephrine, and block their reuptake, which makes them act like a stimulant on the nervous system. The result is agitation, hyperalertness, hypertension, tachycardia, diaphoresis, and elevated temperatures to 106<scaps>˚ </scaps>F. The term “naked rage” came into use because users would become overheated and angry, and would rip off their clothes as they raged.

Other synthetic canthinones being used as drugs of abuse include butylone, dimethylcathinone, ethcathinone, ethylone, 3- and 4-fluoromethcathinone, mephedrone, methedrone, methylenedioxypyrovalerone (MDPV), methylone, and pyrovalerone (J. Med. Toxicol. 2012;8:33-42).

MDPV raises dopamine levels in the brain as does cocaine, but is at least 10 times as potent, according to the National Institute on Drug Abuse.

Bath salts can be administered by snorting, ingesting, smoking, or injecting. Necrotizing fasciitis has been associated with its use. Most patients present with elevated temperatures, hypertension, palpitations, and delirium. Hydration and sedation are usually required, and patients usually need to be restrained to prevent them from hurting themselves further. Psychiatric symptoms may include paranoia, hallucinations, and panic attacks. Several deaths have been reported in association with its use.

In the time since this drug was made illegal, several other designer drugs have presented, which are just modifications of the mephedrone. “Flakka” and “jewelry cleaner” are examples of the modified synthetic cathinone. They all cause amphetamine-like reactions and the risk of overdose is great.

The cost to manufacture the drug is about $8 per unit, but its retail price is $20-$40. Though it takes only 3-5 mg to be effective, packages are sold with 500 mg, making the risk for overdose even greater. It usually takes about 1.5 hours to reach peak rush and the entire experience can last 6-8 hours. There is little difference between the euphoric level and intoxication level, which is what makes the drug so dangerous.

Synthetic drugs are a great danger to all age groups, including toddlers, because of the misleading packaging. But they are especially dangerous because the ingredients vary, and overdose occurs quickly.

It is imperative that parents and teens are made aware of the dangers associated with these drugs and their street names; www.streetdrugs.org is a website designed to educate teachers, parents and students about these drugs and their dangers.

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at pdnews@frontlinemedcom.com.

The 8-year-old child presented to the emergency department with bilateral ankle pain that had progressively worsened over the past 24 hours. This morning he would not walk. He also had a rash on his legs. The astute ED doctor recognized the diagnosis as Henoch-Schönlein purpura (HSP) and arranged admission to the ward. Things were flowing smoothly that day, and the child was soon on the ward and being examined by me and the resident team during morning rounds. In that 45-minute gap, the father had been on his smartphone. At that point he knew more about HSP than my senior resident. Truth be told, I was glad I had treated two cases in the previous 3 months (after going more than 2 years without any cases) so I didn’t feel foolish myself.

Technology is making progressively larger amounts of medical information available to the lay public. That information is being organized in ways that can actually impart knowledge. The Wikipedia entry on HSP has far more information, and has it arranged in a much more useful fashion, than my textbook on pediatrics. Making that comparison was the first time in 5 years that the textbook has even been taken off the shelf. If you have Googled tonsillitis, sprained ankle, or measles in the past 2 months, instead of just a list of websites, you also would have seen half the page filled with images and vetted information about those illnesses. There are apps that help you create a differential diagnosis and even estimate the probabilities of each one.

The victory of Watson, IBM's supercomputer, on Jeopardy showed how information can be organized and retrieved by a computer. It is a good facsimile for knowledge. But what about the wisdom of clinical judgment? Can a computer replace that? Keith Rabois, a member of the PayPal mafia, recently predicted that it will.

Further progress toward replacing doctors has come through changes in legislation to permit all lab tests to be offered directly to consumers. Arizona’s governor signed a law in April 2015 that will change that policy for his state. This isn’t major news, because already more than half the states allow this direct to consumer approach. But what was special about this particular signing ceremony was the involvement of billionaire Elizabeth Holmes, CEO of Theranos, a start-up company prepared to provide the lab testing service.

If done without a doctor’s order, which documents medical necessity, under current practice rules an insurance company won’t pay for these direct to consumer tests. The consumer must pay out of pocket. Of course, those rules may change. If patients want a throat swab to test for strep, maybe it is cheaper to have them go directly to the neighborhood lab than to see a doctor, especially if, when the test is positive, they then expect to phone their doctor for free and get a prescription.

Most medical tests have significant false-positive and false-negative results. Simple rapid strep throat tests and rapid influenza nasal swabs have a sensitivity of only 90%-95%. Many doctors, even those who use the results on a daily basis, cannot convert that information into a positive and negative predictive value. So if a company offers the test directly to the consumer, and reports it out with a “Just the facts, Ma’am” positive or negative result, is the consumer responsible for any misinterpretation, or has the laboratory company deceptively marketed a defective, imperfect product?

The bigger financial impact will be all the follow-up labs and imaging tests generated by the initial false-positive screening labs. Insurance probably will pay for those. Using a similar business model, a few hospitals nationwide now offer free (or close to it) low-dose chest CT scans to smokers and ex-smokers. This is done as a loss leader that generates profits for the hospital from all the follow-up tests, imaging, and biopsies. Compare this model with the old-time practice in which pediatricians in the 1950s to 1980s (and in many places, against guidelines, in the 1990s) had parents bring in a sample of the child’s urine for each well-child visit. That practice was abandoned on cost-benefit-harm arguments because of all the unnecessary subsequent testing, especially kidney ultrasounds, generated by the false positives. Now parents will be able to order the test themselves.

I’m skeptical about how soon a computer will completely replace a physician. Peter Thiel said, “We were promised flying cars and instead what we got was 140 characters.” But Google has finally created the self-driving car. And Elizabeth Holmes has averaged making more money in a week than I will in a career. So who are you going to believe?

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. E-mail him at pdnews@frontlinemedcom.com.

The 8-year-old child presented to the emergency department with bilateral ankle pain that had progressively worsened over the past 24 hours. This morning he would not walk. He also had a rash on his legs. The astute ED doctor recognized the diagnosis as Henoch-Schönlein purpura (HSP) and arranged admission to the ward. Things were flowing smoothly that day, and the child was soon on the ward and being examined by me and the resident team during morning rounds. In that 45-minute gap, the father had been on his smartphone. At that point he knew more about HSP than my senior resident. Truth be told, I was glad I had treated two cases in the previous 3 months (after going more than 2 years without any cases) so I didn’t feel foolish myself.

Technology is making progressively larger amounts of medical information available to the lay public. That information is being organized in ways that can actually impart knowledge. The Wikipedia entry on HSP has far more information, and has it arranged in a much more useful fashion, than my textbook on pediatrics. Making that comparison was the first time in 5 years that the textbook has even been taken off the shelf. If you have Googled tonsillitis, sprained ankle, or measles in the past 2 months, instead of just a list of websites, you also would have seen half the page filled with images and vetted information about those illnesses. There are apps that help you create a differential diagnosis and even estimate the probabilities of each one.

The victory of Watson, IBM's supercomputer, on Jeopardy showed how information can be organized and retrieved by a computer. It is a good facsimile for knowledge. But what about the wisdom of clinical judgment? Can a computer replace that? Keith Rabois, a member of the PayPal mafia, recently predicted that it will.

Further progress toward replacing doctors has come through changes in legislation to permit all lab tests to be offered directly to consumers. Arizona’s governor signed a law in April 2015 that will change that policy for his state. This isn’t major news, because already more than half the states allow this direct to consumer approach. But what was special about this particular signing ceremony was the involvement of billionaire Elizabeth Holmes, CEO of Theranos, a start-up company prepared to provide the lab testing service.

If done without a doctor’s order, which documents medical necessity, under current practice rules an insurance company won’t pay for these direct to consumer tests. The consumer must pay out of pocket. Of course, those rules may change. If patients want a throat swab to test for strep, maybe it is cheaper to have them go directly to the neighborhood lab than to see a doctor, especially if, when the test is positive, they then expect to phone their doctor for free and get a prescription.

Most medical tests have significant false-positive and false-negative results. Simple rapid strep throat tests and rapid influenza nasal swabs have a sensitivity of only 90%-95%. Many doctors, even those who use the results on a daily basis, cannot convert that information into a positive and negative predictive value. So if a company offers the test directly to the consumer, and reports it out with a “Just the facts, Ma’am” positive or negative result, is the consumer responsible for any misinterpretation, or has the laboratory company deceptively marketed a defective, imperfect product?

The bigger financial impact will be all the follow-up labs and imaging tests generated by the initial false-positive screening labs. Insurance probably will pay for those. Using a similar business model, a few hospitals nationwide now offer free (or close to it) low-dose chest CT scans to smokers and ex-smokers. This is done as a loss leader that generates profits for the hospital from all the follow-up tests, imaging, and biopsies. Compare this model with the old-time practice in which pediatricians in the 1950s to 1980s (and in many places, against guidelines, in the 1990s) had parents bring in a sample of the child’s urine for each well-child visit. That practice was abandoned on cost-benefit-harm arguments because of all the unnecessary subsequent testing, especially kidney ultrasounds, generated by the false positives. Now parents will be able to order the test themselves.

I’m skeptical about how soon a computer will completely replace a physician. Peter Thiel said, “We were promised flying cars and instead what we got was 140 characters.” But Google has finally created the self-driving car. And Elizabeth Holmes has averaged making more money in a week than I will in a career. So who are you going to believe?

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. E-mail him at pdnews@frontlinemedcom.com.

The 8-year-old child presented to the emergency department with bilateral ankle pain that had progressively worsened over the past 24 hours. This morning he would not walk. He also had a rash on his legs. The astute ED doctor recognized the diagnosis as Henoch-Schönlein purpura (HSP) and arranged admission to the ward. Things were flowing smoothly that day, and the child was soon on the ward and being examined by me and the resident team during morning rounds. In that 45-minute gap, the father had been on his smartphone. At that point he knew more about HSP than my senior resident. Truth be told, I was glad I had treated two cases in the previous 3 months (after going more than 2 years without any cases) so I didn’t feel foolish myself.

Technology is making progressively larger amounts of medical information available to the lay public. That information is being organized in ways that can actually impart knowledge. The Wikipedia entry on HSP has far more information, and has it arranged in a much more useful fashion, than my textbook on pediatrics. Making that comparison was the first time in 5 years that the textbook has even been taken off the shelf. If you have Googled tonsillitis, sprained ankle, or measles in the past 2 months, instead of just a list of websites, you also would have seen half the page filled with images and vetted information about those illnesses. There are apps that help you create a differential diagnosis and even estimate the probabilities of each one.

The victory of Watson, IBM's supercomputer, on Jeopardy showed how information can be organized and retrieved by a computer. It is a good facsimile for knowledge. But what about the wisdom of clinical judgment? Can a computer replace that? Keith Rabois, a member of the PayPal mafia, recently predicted that it will.

Further progress toward replacing doctors has come through changes in legislation to permit all lab tests to be offered directly to consumers. Arizona’s governor signed a law in April 2015 that will change that policy for his state. This isn’t major news, because already more than half the states allow this direct to consumer approach. But what was special about this particular signing ceremony was the involvement of billionaire Elizabeth Holmes, CEO of Theranos, a start-up company prepared to provide the lab testing service.

If done without a doctor’s order, which documents medical necessity, under current practice rules an insurance company won’t pay for these direct to consumer tests. The consumer must pay out of pocket. Of course, those rules may change. If patients want a throat swab to test for strep, maybe it is cheaper to have them go directly to the neighborhood lab than to see a doctor, especially if, when the test is positive, they then expect to phone their doctor for free and get a prescription.

Most medical tests have significant false-positive and false-negative results. Simple rapid strep throat tests and rapid influenza nasal swabs have a sensitivity of only 90%-95%. Many doctors, even those who use the results on a daily basis, cannot convert that information into a positive and negative predictive value. So if a company offers the test directly to the consumer, and reports it out with a “Just the facts, Ma’am” positive or negative result, is the consumer responsible for any misinterpretation, or has the laboratory company deceptively marketed a defective, imperfect product?

The bigger financial impact will be all the follow-up labs and imaging tests generated by the initial false-positive screening labs. Insurance probably will pay for those. Using a similar business model, a few hospitals nationwide now offer free (or close to it) low-dose chest CT scans to smokers and ex-smokers. This is done as a loss leader that generates profits for the hospital from all the follow-up tests, imaging, and biopsies. Compare this model with the old-time practice in which pediatricians in the 1950s to 1980s (and in many places, against guidelines, in the 1990s) had parents bring in a sample of the child’s urine for each well-child visit. That practice was abandoned on cost-benefit-harm arguments because of all the unnecessary subsequent testing, especially kidney ultrasounds, generated by the false positives. Now parents will be able to order the test themselves.

I’m skeptical about how soon a computer will completely replace a physician. Peter Thiel said, “We were promised flying cars and instead what we got was 140 characters.” But Google has finally created the self-driving car. And Elizabeth Holmes has averaged making more money in a week than I will in a career. So who are you going to believe?

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. E-mail him at pdnews@frontlinemedcom.com.

The discipline of orthopedic medicine and surgery has dramatically advanced over the last several decades. Improved understanding of biomechanics, tissue healing, and the pathogenesis of musculoskeletal diseases has allowed us to make significant progress in the diagnosis, treatment, and rehabilitation of our patients. Despite these advancements, there is still much to be learned, especially in the field of orthobiologics and regenerative medicine. As our understanding of existing technologies, such as bone marrow aspirate, platelet-rich plasma, and adult stem cells, continues to evolve, even newer biologic treatment options are being developed. This issue of The American Journal of Orthopedics focuses on emerging biologics across the spectrum of orthopedic care.

In this issue, on pages 202-205, Mansour and Conway describe a new prone retrograde technique for obtaining bone graft using the Reamer/Irrigator/Aspirator (RIA) system (Synthes, West Chester, Pennsylvania). While iliac crest bone graft has been the gold standard for many years, use of the RIA system to obtain bone graft has been studied and has been shown to have decreased morbidity when compared with iliac crest harvest.¹ Additionally, intramedullary bone graft from the femur appears to be just as concentrated with biologically active bone marrow as iliac crest harvest.² This new technique allows increased efficiency, especially for surgeries that are done in the prone position.

Melamed and colleagues examine a new biologic to augment repair of rotator cuff tears (see pages 212-216). Chitosan, a linear polysaccharide, has been shown to help with soft-tissue healing. Although in the past its use has been limited secondary to problems with the compound precipitating at physiologic pH, new formulations mitigate that problem. In the authors’ animal model of acute supraspinatus repair, the use of chitosan gel increased the number of fibroblasts and the amount of repair tissue when compared with untreated controls. Additionally, the experimental group showed a decreased inflammatory response when compared with the control group. This is very exciting research as the biologic enhancement of rotator cuff tendon healing could potentially help decrease the rate of rotator cuff repair failure.

Lenehan and colleagues analyze the long-term outcomes of anterior cruciate ligament reconstruction in a cohort of patients studied over an 8-year period (see pages 217-222). During this period, 99 patients were reconstructed with allograft tissue and 24 with autograft. Their analysis, like other recently published work, shows that the rates of revision were much higher for patients under 25 years of age who were reconstructed using allograft tissue. The rate of revision for NCAA (National Collegiate Athletic Association) Division I athletes reconstructed with allograft tissue was found to be 62%, while the revision rate for all patients under the age of 25 years who received an allograft was found to be 20.5%. Clearly, there is still a great deal to learn about the biology of graft incorporation and healing, especially as it relates to allograft tissue.

These 3 articles exemplify the breadth of orthopedic biologics and their potential role in orthopedic surgery. Through efforts of investigators highlighted in this journal and in others, biologics will become better understood and more widely used when appropriate, leading to improved patient outcomes.

The discipline of orthopedic medicine and surgery has dramatically advanced over the last several decades. Improved understanding of biomechanics, tissue healing, and the pathogenesis of musculoskeletal diseases has allowed us to make significant progress in the diagnosis, treatment, and rehabilitation of our patients. Despite these advancements, there is still much to be learned, especially in the field of orthobiologics and regenerative medicine. As our understanding of existing technologies, such as bone marrow aspirate, platelet-rich plasma, and adult stem cells, continues to evolve, even newer biologic treatment options are being developed. This issue of The American Journal of Orthopedics focuses on emerging biologics across the spectrum of orthopedic care.

In this issue, on pages 202-205, Mansour and Conway describe a new prone retrograde technique for obtaining bone graft using the Reamer/Irrigator/Aspirator (RIA) system (Synthes, West Chester, Pennsylvania). While iliac crest bone graft has been the gold standard for many years, use of the RIA system to obtain bone graft has been studied and has been shown to have decreased morbidity when compared with iliac crest harvest.¹ Additionally, intramedullary bone graft from the femur appears to be just as concentrated with biologically active bone marrow as iliac crest harvest.² This new technique allows increased efficiency, especially for surgeries that are done in the prone position.

Melamed and colleagues examine a new biologic to augment repair of rotator cuff tears (see pages 212-216). Chitosan, a linear polysaccharide, has been shown to help with soft-tissue healing. Although in the past its use has been limited secondary to problems with the compound precipitating at physiologic pH, new formulations mitigate that problem. In the authors’ animal model of acute supraspinatus repair, the use of chitosan gel increased the number of fibroblasts and the amount of repair tissue when compared with untreated controls. Additionally, the experimental group showed a decreased inflammatory response when compared with the control group. This is very exciting research as the biologic enhancement of rotator cuff tendon healing could potentially help decrease the rate of rotator cuff repair failure.

Lenehan and colleagues analyze the long-term outcomes of anterior cruciate ligament reconstruction in a cohort of patients studied over an 8-year period (see pages 217-222). During this period, 99 patients were reconstructed with allograft tissue and 24 with autograft. Their analysis, like other recently published work, shows that the rates of revision were much higher for patients under 25 years of age who were reconstructed using allograft tissue. The rate of revision for NCAA (National Collegiate Athletic Association) Division I athletes reconstructed with allograft tissue was found to be 62%, while the revision rate for all patients under the age of 25 years who received an allograft was found to be 20.5%. Clearly, there is still a great deal to learn about the biology of graft incorporation and healing, especially as it relates to allograft tissue.

These 3 articles exemplify the breadth of orthopedic biologics and their potential role in orthopedic surgery. Through efforts of investigators highlighted in this journal and in others, biologics will become better understood and more widely used when appropriate, leading to improved patient outcomes.

The discipline of orthopedic medicine and surgery has dramatically advanced over the last several decades. Improved understanding of biomechanics, tissue healing, and the pathogenesis of musculoskeletal diseases has allowed us to make significant progress in the diagnosis, treatment, and rehabilitation of our patients. Despite these advancements, there is still much to be learned, especially in the field of orthobiologics and regenerative medicine. As our understanding of existing technologies, such as bone marrow aspirate, platelet-rich plasma, and adult stem cells, continues to evolve, even newer biologic treatment options are being developed. This issue of The American Journal of Orthopedics focuses on emerging biologics across the spectrum of orthopedic care.

In this issue, on pages 202-205, Mansour and Conway describe a new prone retrograde technique for obtaining bone graft using the Reamer/Irrigator/Aspirator (RIA) system (Synthes, West Chester, Pennsylvania). While iliac crest bone graft has been the gold standard for many years, use of the RIA system to obtain bone graft has been studied and has been shown to have decreased morbidity when compared with iliac crest harvest.¹ Additionally, intramedullary bone graft from the femur appears to be just as concentrated with biologically active bone marrow as iliac crest harvest.² This new technique allows increased efficiency, especially for surgeries that are done in the prone position.

Melamed and colleagues examine a new biologic to augment repair of rotator cuff tears (see pages 212-216). Chitosan, a linear polysaccharide, has been shown to help with soft-tissue healing. Although in the past its use has been limited secondary to problems with the compound precipitating at physiologic pH, new formulations mitigate that problem. In the authors’ animal model of acute supraspinatus repair, the use of chitosan gel increased the number of fibroblasts and the amount of repair tissue when compared with untreated controls. Additionally, the experimental group showed a decreased inflammatory response when compared with the control group. This is very exciting research as the biologic enhancement of rotator cuff tendon healing could potentially help decrease the rate of rotator cuff repair failure.

Lenehan and colleagues analyze the long-term outcomes of anterior cruciate ligament reconstruction in a cohort of patients studied over an 8-year period (see pages 217-222). During this period, 99 patients were reconstructed with allograft tissue and 24 with autograft. Their analysis, like other recently published work, shows that the rates of revision were much higher for patients under 25 years of age who were reconstructed using allograft tissue. The rate of revision for NCAA (National Collegiate Athletic Association) Division I athletes reconstructed with allograft tissue was found to be 62%, while the revision rate for all patients under the age of 25 years who received an allograft was found to be 20.5%. Clearly, there is still a great deal to learn about the biology of graft incorporation and healing, especially as it relates to allograft tissue.

These 3 articles exemplify the breadth of orthopedic biologics and their potential role in orthopedic surgery. Through efforts of investigators highlighted in this journal and in others, biologics will become better understood and more widely used when appropriate, leading to improved patient outcomes.

At the risk of stating the obvious, our patients are becoming increasingly complex. Life is prolonged and comorbidities accumulate, creating dizzying laundry lists of medical problems.

Within the context of clinical or, increasingly, nonreimbursed telephonic or electronic visits, we attack the medical problem with the worst severity in an attempt to tamp it down to the level of its comorbid brethren.

Almost without exception, depression rears its ugly head in our sickest patients. Antidepressants will be started and added to the three pages (double-spaced, with 1-inch margins) of medications.

But in all of these patients, are we treating the disease or just the symptom? What if inflammation is causing the depression? Will reduction of inflammation treat the depression?

Dr. Ole Köhler of Aarhus University Hospital, Denmark, and his colleagues conducted a systematic review on the antidepressant effects of anti-inflammatory medications (JAMA Psychiatry 2014;71:1381-91). Fourteen trials informed the meta-analysis, 10 that evaluated NSAID drugs (for example, celecoxib, naproxen, ibuprofen), and 4 that investigated cytokine inhibitors (for example, etanercept, infliximab). Six of the 10 NSAID studies evaluated NSAIDs as monotherapy. All four of the cytokine-inhibitor trials evaluated them as monotherapy. Length of treatment was between 6 and 12 weeks.

The pooled effect suggests that anti-inflammatory treatment reduced depressive symptoms. Celecoxib seemed to have the strongest effect on remission and clinical response. No increase in adverse events was reported.

We know that proinflammatory drugs can induce depression. So the opposite is quite possibly true, and these data suggest it to be so. Findings suggest that reducing the inflammatory state among our patients with depression may be a useful adjunct to antidepressant therapy, at least in the initial period.

Whatever we can do to facilitate depressive symptom relief seems a worthy goal. So, here again, we could tell our patients presenting with depression to take two (with an SSRI, perhaps) and call us in the morning. But how best to do this and in what patients remains uncertain.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified, practicing clinician.

At the risk of stating the obvious, our patients are becoming increasingly complex. Life is prolonged and comorbidities accumulate, creating dizzying laundry lists of medical problems.

Within the context of clinical or, increasingly, nonreimbursed telephonic or electronic visits, we attack the medical problem with the worst severity in an attempt to tamp it down to the level of its comorbid brethren.

Almost without exception, depression rears its ugly head in our sickest patients. Antidepressants will be started and added to the three pages (double-spaced, with 1-inch margins) of medications.

But in all of these patients, are we treating the disease or just the symptom? What if inflammation is causing the depression? Will reduction of inflammation treat the depression?

Dr. Ole Köhler of Aarhus University Hospital, Denmark, and his colleagues conducted a systematic review on the antidepressant effects of anti-inflammatory medications (JAMA Psychiatry 2014;71:1381-91). Fourteen trials informed the meta-analysis, 10 that evaluated NSAID drugs (for example, celecoxib, naproxen, ibuprofen), and 4 that investigated cytokine inhibitors (for example, etanercept, infliximab). Six of the 10 NSAID studies evaluated NSAIDs as monotherapy. All four of the cytokine-inhibitor trials evaluated them as monotherapy. Length of treatment was between 6 and 12 weeks.

The pooled effect suggests that anti-inflammatory treatment reduced depressive symptoms. Celecoxib seemed to have the strongest effect on remission and clinical response. No increase in adverse events was reported.

We know that proinflammatory drugs can induce depression. So the opposite is quite possibly true, and these data suggest it to be so. Findings suggest that reducing the inflammatory state among our patients with depression may be a useful adjunct to antidepressant therapy, at least in the initial period.

Whatever we can do to facilitate depressive symptom relief seems a worthy goal. So, here again, we could tell our patients presenting with depression to take two (with an SSRI, perhaps) and call us in the morning. But how best to do this and in what patients remains uncertain.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified, practicing clinician.

At the risk of stating the obvious, our patients are becoming increasingly complex. Life is prolonged and comorbidities accumulate, creating dizzying laundry lists of medical problems.

Within the context of clinical or, increasingly, nonreimbursed telephonic or electronic visits, we attack the medical problem with the worst severity in an attempt to tamp it down to the level of its comorbid brethren.

Almost without exception, depression rears its ugly head in our sickest patients. Antidepressants will be started and added to the three pages (double-spaced, with 1-inch margins) of medications.

But in all of these patients, are we treating the disease or just the symptom? What if inflammation is causing the depression? Will reduction of inflammation treat the depression?

Dr. Ole Köhler of Aarhus University Hospital, Denmark, and his colleagues conducted a systematic review on the antidepressant effects of anti-inflammatory medications (JAMA Psychiatry 2014;71:1381-91). Fourteen trials informed the meta-analysis, 10 that evaluated NSAID drugs (for example, celecoxib, naproxen, ibuprofen), and 4 that investigated cytokine inhibitors (for example, etanercept, infliximab). Six of the 10 NSAID studies evaluated NSAIDs as monotherapy. All four of the cytokine-inhibitor trials evaluated them as monotherapy. Length of treatment was between 6 and 12 weeks.

The pooled effect suggests that anti-inflammatory treatment reduced depressive symptoms. Celecoxib seemed to have the strongest effect on remission and clinical response. No increase in adverse events was reported.

We know that proinflammatory drugs can induce depression. So the opposite is quite possibly true, and these data suggest it to be so. Findings suggest that reducing the inflammatory state among our patients with depression may be a useful adjunct to antidepressant therapy, at least in the initial period.

Whatever we can do to facilitate depressive symptom relief seems a worthy goal. So, here again, we could tell our patients presenting with depression to take two (with an SSRI, perhaps) and call us in the morning. But how best to do this and in what patients remains uncertain.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified, practicing clinician.

Obstetric providers are being called upon to care for an increasing number of cancer survivors. Whether it was a childhood cancer or one faced in early adulthood, pregnant cancer survivors raise a unique set of questions and concerns. A general knowledge about management is essential in counseling these women prior to and early in pregnancy.

For the woman who presents preconception, one of the most common questions is when is the best time for pregnancy. Importantly, there are no absolute guidelines on how long a woman should be “disease free.” Many providers suggest waiting 2 years from the time of diagnosis. This “conventional wisdom” is not based on evidence (Oncology 2005;19:693-7). Instead, the type of cancer and the length of treatment can help determine the answer.

Many oncologists prefer a specific time for monitoring after treatment to ensure that initial treatment has been successful. For example, in the case of melanoma, after 2 years, the estimate of recurrence risk may be more accurate (Cancer Causes Control 2008;19:437-42). After breast cancer, women are often followed with MRI with contrast and mammogram. Since both are problematic in pregnancy, 3-5 years may be more appropriate.

Many patients are concerned about the risk of recurrence during pregnancy. Though data are limited, pregnancy does not appear to increase the risk of disease recurrence or decrease disease-free survival, even in the case of more aggressive cancers such as melanoma. This remains true in the setting of hormone receptor–positive cancers, specifically breast cancer (Lancet 1997;350:319-22).

Preconception counseling

The risks for a cancer survivor during pregnancy will vary depending on the treatments she has received. Preconception evaluation should be modified for the specific oncologic therapies. For example, women who received chest radiation, or anthracycline-based chemotherapies (or any cardiotoxic medications) should have a cardiac evaluation as they are at risk of cardiac dysfunction prior to and during pregnancy (Matern. Child. Health J. 2006;10[suppl. 1]:165-8).

Additionally, because chemotherapy may be hepatotoxic or nephrotoxic, baseline liver and renal function tests should almost always be performed. It is not unreasonable to follow these during pregnancy given the physiologic changes.

Many women also are concerned about the risks that prior cancer therapies may have for their baby. Prior chemotherapy and radiation therapy do not appear to confer any increased risk for genetic conditions, anomalies, or childhood cancer (Am. J. Obstet. Gynecol. 2002;187:1070-80). Additionally, previous chemotherapy alone does not increase the risk of adverse pregnancy outcomes.

In contrast, prior radiation to the abdomen and pelvis has been associated with an increased risk of miscarriage, growth restriction, preterm delivery, and stillbirth (J. Natl. Cancer Instit. Monogr. 2005;34:64-8; Lancet 2010;376:624-30). There is an increased risk of cancer in the offspring of women whose cancer is the result of hereditary cancer syndromes, such as BRCA or hereditary nonpolyposis colorectal cancer. Discussions with a genetics counselor may be helpful if there are any questions related to these syndromes.

Pregnancy management

Once pregnant, management requires a multidisciplinary approach. Surveillance options are limited during pregnancy. CT should be avoided, and radiographs limited. Ultrasound of the abdomen is safe, but optimal images are often obscured in later trimesters. Ultimately, indicated imaging should not be forsaken if there are any signs or symptoms that raise concerns for recurrence. Additionally, many tumor markers may be unreliable during pregnancy, such as CA-125 in the first trimester, or alpha-FP and CEA anytime.

Specific recommendations for antenatal testing do not exist and should be assessed on a case-by-case basis; especially in the case of women who have had prior radiation therapy. Our recommendation is to perform growth surveillance, which may include sonography at varying intervals. Also consider weekly fetal testing from 32 weeks in normally growing fetuses.

Solely being a cancer survivor is not an indication for early delivery or induction of labor. In the majority of cases, mode of delivery should be guided by obstetric indications, though previous pelvic surgery and reconstruction may be indications for cesarean delivery. Despite being in remission, some cancers metastasize to the placenta, most commonly melanoma and hematologic cancers. Very rarely, these cancers can also metastasize to the fetus. Thus, the placenta should be sent for histologic evaluation, with a notation to the pathologist about the patient’s prior cancer (Obstet. Gynecol. Surv. 1989;44:535-40; Ultrasound. Obstet. Gynecol. 2009;33:235-44).

In most cases, pregnancy after cancer is uncomplicated with good outcomes for both mother and baby. However, there are potential medical and obstetric complications that cannot be overlooked. Interdisciplinary management is crucial to ensure a safe transition from cancer survivor to mother.

What to consider when counseling cancer survivors about pregnancy

• The recommended disease-free interval prior to pregnancy may vary by cancer type, and is largely driven by disease surveillance needs and recurrence intervals.

• Prior cancer, associated operations, and chemotherapies do not typically confer additional risks in pregnancy. Exceptions include melanoma and blood cell cancers, which may metastasize to the placenta and fetus, even following periods of remission.

• Radiation therapy to the abdomen and pelvis may induce changes that predispose to growth restriction, preterm birth, and stillbirth. Enhanced surveillance may be reasonable in these cases.

• Preconception or early pregnancy assessment for end organ dysfunction is recommended for women who have received certain therapies: cardiac evaluation following chest radiation or anthracycline-based therapy; liver and kidney function for most chemotherapies.

Dr. Ivester is an associate professor of maternal-fetal medicine and an associate professor of maternal and child health at the University of North Carolina at Chapel Hill. Dr. Dotters-Katz is a maternal-fetal medicine fellow at University of North Carolina at Chapel Hill, who completed her ob.gyn. residency at Duke University. Her academic interests include oncology and infectious diseases as they relate to pregnancy. The authors reported having no financial disclosures. Email them at obnews@frontlinemedcom.com.

Obstetric providers are being called upon to care for an increasing number of cancer survivors. Whether it was a childhood cancer or one faced in early adulthood, pregnant cancer survivors raise a unique set of questions and concerns. A general knowledge about management is essential in counseling these women prior to and early in pregnancy.

For the woman who presents preconception, one of the most common questions is when is the best time for pregnancy. Importantly, there are no absolute guidelines on how long a woman should be “disease free.” Many providers suggest waiting 2 years from the time of diagnosis. This “conventional wisdom” is not based on evidence (Oncology 2005;19:693-7). Instead, the type of cancer and the length of treatment can help determine the answer.

Many oncologists prefer a specific time for monitoring after treatment to ensure that initial treatment has been successful. For example, in the case of melanoma, after 2 years, the estimate of recurrence risk may be more accurate (Cancer Causes Control 2008;19:437-42). After breast cancer, women are often followed with MRI with contrast and mammogram. Since both are problematic in pregnancy, 3-5 years may be more appropriate.

Many patients are concerned about the risk of recurrence during pregnancy. Though data are limited, pregnancy does not appear to increase the risk of disease recurrence or decrease disease-free survival, even in the case of more aggressive cancers such as melanoma. This remains true in the setting of hormone receptor–positive cancers, specifically breast cancer (Lancet 1997;350:319-22).

Preconception counseling

The risks for a cancer survivor during pregnancy will vary depending on the treatments she has received. Preconception evaluation should be modified for the specific oncologic therapies. For example, women who received chest radiation, or anthracycline-based chemotherapies (or any cardiotoxic medications) should have a cardiac evaluation as they are at risk of cardiac dysfunction prior to and during pregnancy (Matern. Child. Health J. 2006;10[suppl. 1]:165-8).

Additionally, because chemotherapy may be hepatotoxic or nephrotoxic, baseline liver and renal function tests should almost always be performed. It is not unreasonable to follow these during pregnancy given the physiologic changes.

Many women also are concerned about the risks that prior cancer therapies may have for their baby. Prior chemotherapy and radiation therapy do not appear to confer any increased risk for genetic conditions, anomalies, or childhood cancer (Am. J. Obstet. Gynecol. 2002;187:1070-80). Additionally, previous chemotherapy alone does not increase the risk of adverse pregnancy outcomes.

In contrast, prior radiation to the abdomen and pelvis has been associated with an increased risk of miscarriage, growth restriction, preterm delivery, and stillbirth (J. Natl. Cancer Instit. Monogr. 2005;34:64-8; Lancet 2010;376:624-30). There is an increased risk of cancer in the offspring of women whose cancer is the result of hereditary cancer syndromes, such as BRCA or hereditary nonpolyposis colorectal cancer. Discussions with a genetics counselor may be helpful if there are any questions related to these syndromes.

Pregnancy management

Once pregnant, management requires a multidisciplinary approach. Surveillance options are limited during pregnancy. CT should be avoided, and radiographs limited. Ultrasound of the abdomen is safe, but optimal images are often obscured in later trimesters. Ultimately, indicated imaging should not be forsaken if there are any signs or symptoms that raise concerns for recurrence. Additionally, many tumor markers may be unreliable during pregnancy, such as CA-125 in the first trimester, or alpha-FP and CEA anytime.

Specific recommendations for antenatal testing do not exist and should be assessed on a case-by-case basis; especially in the case of women who have had prior radiation therapy. Our recommendation is to perform growth surveillance, which may include sonography at varying intervals. Also consider weekly fetal testing from 32 weeks in normally growing fetuses.

Solely being a cancer survivor is not an indication for early delivery or induction of labor. In the majority of cases, mode of delivery should be guided by obstetric indications, though previous pelvic surgery and reconstruction may be indications for cesarean delivery. Despite being in remission, some cancers metastasize to the placenta, most commonly melanoma and hematologic cancers. Very rarely, these cancers can also metastasize to the fetus. Thus, the placenta should be sent for histologic evaluation, with a notation to the pathologist about the patient’s prior cancer (Obstet. Gynecol. Surv. 1989;44:535-40; Ultrasound. Obstet. Gynecol. 2009;33:235-44).

In most cases, pregnancy after cancer is uncomplicated with good outcomes for both mother and baby. However, there are potential medical and obstetric complications that cannot be overlooked. Interdisciplinary management is crucial to ensure a safe transition from cancer survivor to mother.

What to consider when counseling cancer survivors about pregnancy

• The recommended disease-free interval prior to pregnancy may vary by cancer type, and is largely driven by disease surveillance needs and recurrence intervals.

• Prior cancer, associated operations, and chemotherapies do not typically confer additional risks in pregnancy. Exceptions include melanoma and blood cell cancers, which may metastasize to the placenta and fetus, even following periods of remission.

• Radiation therapy to the abdomen and pelvis may induce changes that predispose to growth restriction, preterm birth, and stillbirth. Enhanced surveillance may be reasonable in these cases.

• Preconception or early pregnancy assessment for end organ dysfunction is recommended for women who have received certain therapies: cardiac evaluation following chest radiation or anthracycline-based therapy; liver and kidney function for most chemotherapies.

Dr. Ivester is an associate professor of maternal-fetal medicine and an associate professor of maternal and child health at the University of North Carolina at Chapel Hill. Dr. Dotters-Katz is a maternal-fetal medicine fellow at University of North Carolina at Chapel Hill, who completed her ob.gyn. residency at Duke University. Her academic interests include oncology and infectious diseases as they relate to pregnancy. The authors reported having no financial disclosures. Email them at obnews@frontlinemedcom.com.

Obstetric providers are being called upon to care for an increasing number of cancer survivors. Whether it was a childhood cancer or one faced in early adulthood, pregnant cancer survivors raise a unique set of questions and concerns. A general knowledge about management is essential in counseling these women prior to and early in pregnancy.

For the woman who presents preconception, one of the most common questions is when is the best time for pregnancy. Importantly, there are no absolute guidelines on how long a woman should be “disease free.” Many providers suggest waiting 2 years from the time of diagnosis. This “conventional wisdom” is not based on evidence (Oncology 2005;19:693-7). Instead, the type of cancer and the length of treatment can help determine the answer.

Many oncologists prefer a specific time for monitoring after treatment to ensure that initial treatment has been successful. For example, in the case of melanoma, after 2 years, the estimate of recurrence risk may be more accurate (Cancer Causes Control 2008;19:437-42). After breast cancer, women are often followed with MRI with contrast and mammogram. Since both are problematic in pregnancy, 3-5 years may be more appropriate.

Many patients are concerned about the risk of recurrence during pregnancy. Though data are limited, pregnancy does not appear to increase the risk of disease recurrence or decrease disease-free survival, even in the case of more aggressive cancers such as melanoma. This remains true in the setting of hormone receptor–positive cancers, specifically breast cancer (Lancet 1997;350:319-22).

Preconception counseling

The risks for a cancer survivor during pregnancy will vary depending on the treatments she has received. Preconception evaluation should be modified for the specific oncologic therapies. For example, women who received chest radiation, or anthracycline-based chemotherapies (or any cardiotoxic medications) should have a cardiac evaluation as they are at risk of cardiac dysfunction prior to and during pregnancy (Matern. Child. Health J. 2006;10[suppl. 1]:165-8).

Additionally, because chemotherapy may be hepatotoxic or nephrotoxic, baseline liver and renal function tests should almost always be performed. It is not unreasonable to follow these during pregnancy given the physiologic changes.

Many women also are concerned about the risks that prior cancer therapies may have for their baby. Prior chemotherapy and radiation therapy do not appear to confer any increased risk for genetic conditions, anomalies, or childhood cancer (Am. J. Obstet. Gynecol. 2002;187:1070-80). Additionally, previous chemotherapy alone does not increase the risk of adverse pregnancy outcomes.

In contrast, prior radiation to the abdomen and pelvis has been associated with an increased risk of miscarriage, growth restriction, preterm delivery, and stillbirth (J. Natl. Cancer Instit. Monogr. 2005;34:64-8; Lancet 2010;376:624-30). There is an increased risk of cancer in the offspring of women whose cancer is the result of hereditary cancer syndromes, such as BRCA or hereditary nonpolyposis colorectal cancer. Discussions with a genetics counselor may be helpful if there are any questions related to these syndromes.

Pregnancy management

Once pregnant, management requires a multidisciplinary approach. Surveillance options are limited during pregnancy. CT should be avoided, and radiographs limited. Ultrasound of the abdomen is safe, but optimal images are often obscured in later trimesters. Ultimately, indicated imaging should not be forsaken if there are any signs or symptoms that raise concerns for recurrence. Additionally, many tumor markers may be unreliable during pregnancy, such as CA-125 in the first trimester, or alpha-FP and CEA anytime.

Specific recommendations for antenatal testing do not exist and should be assessed on a case-by-case basis; especially in the case of women who have had prior radiation therapy. Our recommendation is to perform growth surveillance, which may include sonography at varying intervals. Also consider weekly fetal testing from 32 weeks in normally growing fetuses.

Solely being a cancer survivor is not an indication for early delivery or induction of labor. In the majority of cases, mode of delivery should be guided by obstetric indications, though previous pelvic surgery and reconstruction may be indications for cesarean delivery. Despite being in remission, some cancers metastasize to the placenta, most commonly melanoma and hematologic cancers. Very rarely, these cancers can also metastasize to the fetus. Thus, the placenta should be sent for histologic evaluation, with a notation to the pathologist about the patient’s prior cancer (Obstet. Gynecol. Surv. 1989;44:535-40; Ultrasound. Obstet. Gynecol. 2009;33:235-44).

In most cases, pregnancy after cancer is uncomplicated with good outcomes for both mother and baby. However, there are potential medical and obstetric complications that cannot be overlooked. Interdisciplinary management is crucial to ensure a safe transition from cancer survivor to mother.

What to consider when counseling cancer survivors about pregnancy

• The recommended disease-free interval prior to pregnancy may vary by cancer type, and is largely driven by disease surveillance needs and recurrence intervals.

• Prior cancer, associated operations, and chemotherapies do not typically confer additional risks in pregnancy. Exceptions include melanoma and blood cell cancers, which may metastasize to the placenta and fetus, even following periods of remission.

• Radiation therapy to the abdomen and pelvis may induce changes that predispose to growth restriction, preterm birth, and stillbirth. Enhanced surveillance may be reasonable in these cases.

• Preconception or early pregnancy assessment for end organ dysfunction is recommended for women who have received certain therapies: cardiac evaluation following chest radiation or anthracycline-based therapy; liver and kidney function for most chemotherapies.

Dr. Ivester is an associate professor of maternal-fetal medicine and an associate professor of maternal and child health at the University of North Carolina at Chapel Hill. Dr. Dotters-Katz is a maternal-fetal medicine fellow at University of North Carolina at Chapel Hill, who completed her ob.gyn. residency at Duke University. Her academic interests include oncology and infectious diseases as they relate to pregnancy. The authors reported having no financial disclosures. Email them at obnews@frontlinemedcom.com.

Introduction

Stimulant medications are an important part of attention-deficit/hyperactivity disorder (ADHD) treatment for most affected children and teens. But studies suggest that children and teens may not take their prescribed medication anywhere from 13% to as much as 64% of the time. As teenagers develop an appropriate increased desire for autonomy, they wish to have greater participation in their medication decisions, sometimes to the dismay of their parents.

Case

Will is an engaging young man who has been on stimulants for many years. However, he is frequently in conflict with his parents over an array of issues, including being annoyed at being reminded to take his medications. Although he is willing to take medication some of the time, he often forgets. He commonly fails to complete his homework, a further source of conflict.

Discussion

Parents can get frustrated with their teens and drawn into a control struggle over medication and other issues. Teenagers want to have more control of their lives, and sometimes this takes the form of not wanting to take medication. The No. 1 goal is to help the family move away from digging themselves further into conflict, and instead to have a genuine discussion about the pros and cons of medication.

This starts with listening seriously to the teenager. It helps to reassure teens that you are not going to get mad at them for not taking medication, but that instead you really value the information about how often they are taking it and, if they are skipping some doses or not taking it at all, the reason for that.

It is crucial to find out the real reason why someone is not taking his medication. Sometimes teens are genuinely forgetting. Here it can be helpful to be sure that the medication has to be taken as few times a day as possible, and then to set some kind of alarm reminder. This is one area where the omnipresence of cell phones is very useful. Help parents and teens negotiate about whether the parent will remind the teen, as repeated reminders can be irritating. Divided pill containers help both the parent and teen know whether the medication has been taken or not. If you formulate a plan with the family, write it down so that you can ask next time how it worked out, because if you are asking someone to make a behavior change, it is important to pay attention to whether they did it or not.

Other times it is clear that the teen doesn’t want to take the medication. In this situation, it is important to get the specifics. It is key to convey that the teen’s point of view is very important.

Reasons for not wanting to take a medication include some type of side effect, embarrassment about having to take the medication in school, inconvenience, or a general feeling that the teen doesn’t want to be on medication.

A genuinely collaborative attitude is the best approach. Restate what you have heard from the teen about his or her viewpoint. Help the parents state their concerns (for instance, about school success, driving safety, or the potential for impulsive behavior) in a noncritical manner. Then outline options and discuss the possible pros and cons of the different choices, including going off the medication as one option. By considering this as an option, you will have an opportunity to discuss what the drawbacks, as well as the advantages, might be.

When it comes to ADHD, there are many choices. These can include trying a different stimulant or using a nonstimulant such as atomoxetine or an alpha-adrenergic agonist. Because these medications have very different side effect profiles, they may be more acceptable to the teenager, although they also may have different efficacy. There are also psychotherapeutic options such as organizational skills training. By discussing a variety of choices and listening to the teen’s concerns and hopes, the teenager is engaged in taking responsibility for his own choices.

Once a choice is decided upon, it is important to follow up and review how well the plan is working and revise if necessary.

When to consult

If parents and teens are unable to participate in discussion and come up with a plan, family therapy to improve communication and address parenting issues can be recommended.

Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Hall said that she had no relevant financial disclosures. To comment, e-mail her at pdnews@frontlinemedcom.com.

Introduction

Stimulant medications are an important part of attention-deficit/hyperactivity disorder (ADHD) treatment for most affected children and teens. But studies suggest that children and teens may not take their prescribed medication anywhere from 13% to as much as 64% of the time. As teenagers develop an appropriate increased desire for autonomy, they wish to have greater participation in their medication decisions, sometimes to the dismay of their parents.

Case

Will is an engaging young man who has been on stimulants for many years. However, he is frequently in conflict with his parents over an array of issues, including being annoyed at being reminded to take his medications. Although he is willing to take medication some of the time, he often forgets. He commonly fails to complete his homework, a further source of conflict.

Discussion

Parents can get frustrated with their teens and drawn into a control struggle over medication and other issues. Teenagers want to have more control of their lives, and sometimes this takes the form of not wanting to take medication. The No. 1 goal is to help the family move away from digging themselves further into conflict, and instead to have a genuine discussion about the pros and cons of medication.

This starts with listening seriously to the teenager. It helps to reassure teens that you are not going to get mad at them for not taking medication, but that instead you really value the information about how often they are taking it and, if they are skipping some doses or not taking it at all, the reason for that.

It is crucial to find out the real reason why someone is not taking his medication. Sometimes teens are genuinely forgetting. Here it can be helpful to be sure that the medication has to be taken as few times a day as possible, and then to set some kind of alarm reminder. This is one area where the omnipresence of cell phones is very useful. Help parents and teens negotiate about whether the parent will remind the teen, as repeated reminders can be irritating. Divided pill containers help both the parent and teen know whether the medication has been taken or not. If you formulate a plan with the family, write it down so that you can ask next time how it worked out, because if you are asking someone to make a behavior change, it is important to pay attention to whether they did it or not.

Other times it is clear that the teen doesn’t want to take the medication. In this situation, it is important to get the specifics. It is key to convey that the teen’s point of view is very important.

Reasons for not wanting to take a medication include some type of side effect, embarrassment about having to take the medication in school, inconvenience, or a general feeling that the teen doesn’t want to be on medication.

A genuinely collaborative attitude is the best approach. Restate what you have heard from the teen about his or her viewpoint. Help the parents state their concerns (for instance, about school success, driving safety, or the potential for impulsive behavior) in a noncritical manner. Then outline options and discuss the possible pros and cons of the different choices, including going off the medication as one option. By considering this as an option, you will have an opportunity to discuss what the drawbacks, as well as the advantages, might be.

When it comes to ADHD, there are many choices. These can include trying a different stimulant or using a nonstimulant such as atomoxetine or an alpha-adrenergic agonist. Because these medications have very different side effect profiles, they may be more acceptable to the teenager, although they also may have different efficacy. There are also psychotherapeutic options such as organizational skills training. By discussing a variety of choices and listening to the teen’s concerns and hopes, the teenager is engaged in taking responsibility for his own choices.

Once a choice is decided upon, it is important to follow up and review how well the plan is working and revise if necessary.

When to consult

If parents and teens are unable to participate in discussion and come up with a plan, family therapy to improve communication and address parenting issues can be recommended.

Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Hall said that she had no relevant financial disclosures. To comment, e-mail her at pdnews@frontlinemedcom.com.

Introduction

Stimulant medications are an important part of attention-deficit/hyperactivity disorder (ADHD) treatment for most affected children and teens. But studies suggest that children and teens may not take their prescribed medication anywhere from 13% to as much as 64% of the time. As teenagers develop an appropriate increased desire for autonomy, they wish to have greater participation in their medication decisions, sometimes to the dismay of their parents.

Case

Will is an engaging young man who has been on stimulants for many years. However, he is frequently in conflict with his parents over an array of issues, including being annoyed at being reminded to take his medications. Although he is willing to take medication some of the time, he often forgets. He commonly fails to complete his homework, a further source of conflict.

Discussion

Parents can get frustrated with their teens and drawn into a control struggle over medication and other issues. Teenagers want to have more control of their lives, and sometimes this takes the form of not wanting to take medication. The No. 1 goal is to help the family move away from digging themselves further into conflict, and instead to have a genuine discussion about the pros and cons of medication.

This starts with listening seriously to the teenager. It helps to reassure teens that you are not going to get mad at them for not taking medication, but that instead you really value the information about how often they are taking it and, if they are skipping some doses or not taking it at all, the reason for that.

It is crucial to find out the real reason why someone is not taking his medication. Sometimes teens are genuinely forgetting. Here it can be helpful to be sure that the medication has to be taken as few times a day as possible, and then to set some kind of alarm reminder. This is one area where the omnipresence of cell phones is very useful. Help parents and teens negotiate about whether the parent will remind the teen, as repeated reminders can be irritating. Divided pill containers help both the parent and teen know whether the medication has been taken or not. If you formulate a plan with the family, write it down so that you can ask next time how it worked out, because if you are asking someone to make a behavior change, it is important to pay attention to whether they did it or not.

Other times it is clear that the teen doesn’t want to take the medication. In this situation, it is important to get the specifics. It is key to convey that the teen’s point of view is very important.

Reasons for not wanting to take a medication include some type of side effect, embarrassment about having to take the medication in school, inconvenience, or a general feeling that the teen doesn’t want to be on medication.

A genuinely collaborative attitude is the best approach. Restate what you have heard from the teen about his or her viewpoint. Help the parents state their concerns (for instance, about school success, driving safety, or the potential for impulsive behavior) in a noncritical manner. Then outline options and discuss the possible pros and cons of the different choices, including going off the medication as one option. By considering this as an option, you will have an opportunity to discuss what the drawbacks, as well as the advantages, might be.

When it comes to ADHD, there are many choices. These can include trying a different stimulant or using a nonstimulant such as atomoxetine or an alpha-adrenergic agonist. Because these medications have very different side effect profiles, they may be more acceptable to the teenager, although they also may have different efficacy. There are also psychotherapeutic options such as organizational skills training. By discussing a variety of choices and listening to the teen’s concerns and hopes, the teenager is engaged in taking responsibility for his own choices.

Once a choice is decided upon, it is important to follow up and review how well the plan is working and revise if necessary.

When to consult

If parents and teens are unable to participate in discussion and come up with a plan, family therapy to improve communication and address parenting issues can be recommended.

Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Hall said that she had no relevant financial disclosures. To comment, e-mail her at pdnews@frontlinemedcom.com.