The Child Mind BlogBrainstorm
Soaring Use of Antipsychotics in Young Children
Aug. 12, 2013 Caroline Miller
The Wall Street Journal broke a story today about a federal investigation into the use of antipsychotic medications to treat children with disruptive behavior. The particular concern is kids in the Medicaid system, and the statistics are fairly alarming. The number of kids under age 20 with Medicaid-funded prescriptions for antipsychotics is said to have tripled between 1999 and 2008. And in 2008 they included 19,000 children under the age of five—more than twice the number in 1999.
These medications, which are called atypical antipsychotics, can be very helpful for children with extreme emotional dysregulation, especially those who are unable to remain with their families without them. But the worry here is that they're being given to lots of kids whose behavior problems are prompted by common underlying issues that deserve treatment—trauma, anxiety, depression, ADHD, learning disorders. These are problems that respond more effectively to behavioral therapy, school supports, and medication targeted to them. But those responses assume expert diagnosis, patience, and other resources that a lot of kids don't have the benefit of, especially kids in the foster care system.
The Journal quotes Dr. Fernando Siles, a Dallas pediatric psychiatrist, who says that antipsychotics may be used to keep kids prone to aggression from being kicked out of their foster homes. "The antipsychotic is to stabilize the behavior of the child, to keep him from being moved and moved again." Dr. Siles notes that there's "no budget" for behavioral therapy.
This is a very disturbing trend and one of the reasons we think it's urgent that more parents have enough information about children's mental health to know when the care they're getting is not good. It's why we wrote our Parents Guide to Getting Good Care—to help weed out clinicians who aren't giving your child the careful attention he needs and deserves before pulling out the prescription pad. We need to try to understand behavior in order to respond to it most effectively, especially when children are young and the right intervention can change the course of their lives.View Comments | Add Comment
When Stomach Aches Indicate Anxiety
Aug. 12, 2013 Rachel Ehmke
A study published today in the journal Pediatrics links childhood stomach aches with future anxiety disorders in adulthood.
The long-term study followed over 300 children who experienced recurring stomach aches without any apparent medical explanation (called functional abdominal pain) throughout adolescence and young adulthood. Researchers at Vanderbilt University found that the kids with functional abdominal pain were more likely to develop anxiety disorders and depression later in life than the almost 150 control children without stomach aches. In fact, in most cases an anxiety disorder was already present before the children were evaluated for functional abdominal pain. This despite the fact that the study's lead author, Lynn S. Walker, PhD, told the New York Times that the majority of kids "had not seen a mental health professional, ever." Which isn't much of a surprise. Anxiety is often overlooked in kids because it tends to have quieter consequences than some other childhood disorders. Anxious kids are often more introverted and, as Dr. Walker says, preoccupied with doing a good job.
This new study is a helpful reminder that the mental health disorders that affect adults often begin in childhood, where they are typically overlooked. Not only does that mean that many kids who are suffering don't get support, it also means that families are missing out on the opportunity to help kids when they are younger and treatment can be most transformative.
Anxiety tends to grow with us—the more time we spend with overwhelming anxiety, the more we learn to contain our discomfort with maladaptive coping techniques that we devise ourselves. This means that anxious kids learn early to close themselves off from things that make them nervous, so they miss out on many of the academic, extracurricular, and social opportunities that their peers get to experience.
Recurring stomach aches, something that kids might be more vocal about, can be a good warning sign for families.View Comments | Add Comment
#dearmentalhealthprofessionals Is Trending on Twitter
Aug. 12, 2013 Caroline Miller
Amanda O'Connell, a woman who runs a mental health training business in Scotland, hit a nerve Saturday when she started the Twitter hashtag #dearmentalhealthprofessionals. Given the very negative effect isolation has on people with mood disorders and other mental health challenges (and, of course, everyone else), it seemed like a good idea. We were curious to see what people might have to say, and whether the posts reflected issues we hear about regularly from parents.
Amanda, who her bio says has experienced some mental health issues herself, wrote, as several others did, about the importance of clinicians treating patients as peers, not condescending to them: "There is no 'them' and 'us.' We can become professionals, and just as easily you can become mentally unwell."
Of course there were some who voiced criticisms: "When I'm struggling, in crisis and ask for help, don't call me an attention seeker and actually help." But also some thank yous: "... And now because of your persistence, humanity and compassion I am well enough to return to med school."
Availability is obviously a sore subject, and rightly so. One wrote: "do not prescribe medication that increases suicidal thoughts & then not offer an appointment for 6 weeks." Another "I shouldn't have to beg to be allowed to see you" and finally "There aren't enough of you. Government has failed us all."
The final word goes to Amanda herself, from a post which may have referred either to the hashtag or to mental health care in general, but applies equally well to both: "Appropriate humour can actually be really helpful. Everything doesn't need to be really serious."View Comments | Add Comment
Asperger's: Out of DSM but Still in the Brain?
Aug. 6, 2013 Harry Kimball
The DSM-5 may have done away with the diagnosis of Asperger's syndrome—as distinct from autism—but the conversation (fracas is often a better word) over how to and whether we should differentiate low- and high-functioning autism continues. The latest item to address this thorny issue is a study out of Boston Children's Hospital that aimed to uncover physical brain differences between Asperger's children and children with the wider autism spectrum disorder diagnosis using electroencephalography, or EEG. The results are...mixed.
Lead researcher Frank Duffy had already, in a previous study, determined that EEG could differentiate pretty well between kids with autism diagnoses and a typically developing control group. He did this by attaching those familiar EEG electrodes to their scalps and recording the electrical impulses the brain uses to communicate with itself. This paints a picture of connectivity between brain regions—and allows researchers to differentiate between stronger or weaker connections. Using some sophisticated data analysis tools, they were able to show that most kids with autism have similar differences in connectivity when compared to the control group. That is, properly interpreted EEG data agreed with clinical diagnosis.
Now, to the current study: Let's say that Duffy's earlier work showed EEG could reliably differentiate between apples (kids with autism spectrum disorders) and oranges (typically developing kids). The new study reaches two conclusions that fall neatly on either side of the Asperger's debate. First, in the new study Duffy distinguished three groups of kids: those with Asperger's, those with autism, and those who were typically developing. Duffy found that, physiologically, Asperger's and other forms of autism are much more like each other than they are like the control group. Apples were still grouped with apples, oranges with oranges.
But! Duffy's second discovery is that if you compare kids with Asperger's and other kids on the autism spectrum, EEG can reliably differentiate them based on brain connectivity. There are brain differences that support the (now passé) clinical separation between Asperger's and autism. So the study shows that Asperger's is on the autism spectrum, but also distinct—they're both still apples, but Asperger's is a Red Delicious and autism is Granny Smith.
I detect in Duffy's paper where his affections lie, and it isn't a far-fetched position for anyone who has experience with the incredibly wide range of the autism spectrum. "Although the findings above in many ways agree with the DSM-5 placement of [Asperger's disorder] within the broad autistic spectrum," the study authors write, "they also demonstrate that patients with Asperger's can be physiologically distinguished from those with ASD. Recognition of Asperger's as a separate entity is important from the patients' perspectives of obtaining appropriate medical and educational services as well as of establishing a personal identity."
In other words, though the diagnosis has changed, the kids are the same, and need the same personalized supports. This is true whether a child has limited communication and self-injurious behaviors or is highly verbal, intelligent, and socially awkward to the point of impairment. The results of this study could lead to new tools for diagnosis, prognosis, and monitoring of treatment efficacy. But in the meantime, it helps to remember what I've been told by every experienced autism clinician I have spoken with. "You've seen one child with autism," the saying goes, "and you've seen one child with autism."View Comments | Add Comment
Kicking OCD's Butt at the International OCD Foundation Conference
Aug. 6, 2013 Rachel Ehmke
The International OCD Foundation's annual conference is different from other conferences. Instead of just convening professionals, the IOCDF conference includes people with OCD. A large portion of their programming is aimed at people personally impacted by the disorder—kids and adults with OCD as well as parents, spouses, and siblings. This is because the association includes nonprofessionals in its membership, which gives a unique immediacy to the work being done there.
A team from the Child Mind Institute attending this year's conference seized the opportunity to run a workshop for kids with OCD called A Weekend Adventure of Kicking OCD's Butt! Led by Dr. Jerry Bubrick and Dr. Rachel Busman, the team provided what's known as exposure and response prevention—a cognitive behavioral therapy used for treating OCD—to over 30 children over the course of two days. The conference was in Atlanta, but the kids participating came from all across the country—from Seattle to New Jersey, Florida to California. What's more, the kids came with a wide range of experiences with cognitive behavior therapy. Some kids had never received CBT, some received regular CBT back home, others were used to driving several hours for treatment because there aren't any providers near them—an all too familiar story. There was a range of ages in attendance, too—from 9 to 15 years old—but the kids were able to build a supportive community, which is important for the kind of therapy they were doing.
Exposure therapy works by gradually exposing people to things they are afraid of, with the idea that our anxiety over something diminishes the more we become accustomed to it. With the help of CMI staff Marc Shuldiner, Jessica Meister, Erika Rooney, Naomi Reyfield, and Julia Brilliante, the kids performed what's known as "exposures." Some kids at the workshop were afraid of germs, so they'd practice handling money, sitting on the hotel conference room floor, and not washing their hands. Some kids with obsessions over symmetry or making things "just right" practiced not correcting mistakes, wearing twisted socks, or putting shirts on backwards. Kids who were afraid of heights took rides in the hotel's big glass elevator with Dr. Bubrick. One boy who was very troubled by aggressive thoughts that he couldn't control practiced holding a plastic knife to a clinician's arm.
The idea of doing something you're afraid of in a room full of strangers sounds tough, but in this case it might have actually been an advantage. At the beginning of the workshop the team from the Child Mind Institute spent time explaining what OCD is and what symptoms might look like. "We saw a lot of head nodding," said Dr. Busman. "Kids would call out, 'Oh, I used to do that.'" Some kids remembered each other from attending past conferences, but others got to know each other quickly, bonding over shared experiences. The boy who was disturbed by his aggressive thoughts told the group that just admitting that he had these fears was an exposure on its own, but his peers were in a unique position to understand what he was going through, which helped destigmatize his confession.
The kids also understood how to help each other during exposures. One of the hardest concepts for parents of children with OCD to grasp is how to provide comfort without giving reassurance, which can actually exacerbate a child's anxiety. During one difficult exposure, Dr. Busman remembered one boy who recognized the dilemma telling her, "I want to say something supportive, but I don't want to be reassuring."
Parents didn't participate in the workshop directly. Some watched from the sidelines, but many attended parent-targeted talks happening elsewhere at the conference. Instead, the kids worked through their exposures together, and everyone made progress. "It was very challenging and very cool," said Dr. Busman.
The workshop was a mini version of Fearless Friends, the Child Mind Institute's intensive weeklong treatment program for kids with OCD and specific phobias that starts again August 19th. The Child Mind Institute also hopes to do another workshop for next year's IOCDF conference in Los Angeles.View Comments | Add Comment
Liza Long's Son Talks About His Mental Illness
Aug. 5, 2013 Caroline Miller
Liza Long, best known as the woman who wrote "I am Adam Lanza's mother" in the wake of the Newtown school shootings, was criticized at the time for exposing her son to public scrutiny, though she changed his name. She wrote that he had frightening rages: "A few weeks ago, Michael pulled a knife and threatened to kill me and then himself after I asked him to return his overdue library books."
Now Long has recorded an irresistible interview with Michael on StoryCorps in which the 13-year-old talks about the outburst she wrote about. He says his memory of the knife-wielding incident is a little blurry, but her description was pretty much accurate. "I didn't want to do it, but I didn't have control," he says.
You can read about the interview on the NPR site, but it's better to listen to his voice, which reminds you just how young 13 years old is. "It almost feels like there's some extraterrestrial being taking control of me," Michael says, "and making me do all these crazy things."
He says he doesn't mean to blow up the way he does. "I actually don't like it. And yet there's not really anything I can do about it." He worries that what he calls his "stupid rages" make him "unlikable."
He adds, poignantly, that "people can't actually understand what mental illness is if they don't either have a mental illness or have lived and been with someone who does."
Michael describes having a string of diagnoses—bipolar disorder, ADHD, intermittent explosive disorder, oppositional defiant disorder—and says what he'd really like is a treatment that cures him of the mental illness, rather than just helping with symptoms.
In the meantime he says he gets pleasure from reading and writing—he's up to 47,000 words on his novel, The Demi-Gods From Outer Space. "It's a mix between sci-fi and mythology," he says.
"Wow," says his mom. "Well, thank you. I really appreciate you taking time to talk to me." We appreciate it, too.View Comments | Add Comment
Our Wishes for the Royal Baby
July 23, 2013 Caroline Miller
I can't resist a baby, royal or otherwise, so count me in with the millions worldwide who were pleased by the news of the birth of the young prince yesterday.
Ever since Kate Middleton's pregnancy was announced, the prospect of a new heir to the throne has worked as a nice antidepressant for Britons laid low by the prolonged recession there and the austerity prescribed to cure it. The royal birth also promises, pundits tell us, to act as a stimulant to the lagging British economy, though I'm not sure how that works. How many commemorative baby spoons, HRH onesies, and Union Jack booties can the populace really buy?
As for the unnamed prince—as of this writing, psychics say he'll be George but bookmakers are favoring Henry—what we wish for him is a happy childhood in the most ordinary sense: loving parents with a good relationship, high but realistic expectations, and protection from the intrusive press.
For the rest of us, Kate and Wills and their son offer some of the magic of the young Charles and Diana-fairy tale royalty with a modern twist. Like Diana, Kate is a commoner with a radiant smile. The text alert I got on my phone about the birth yesterday described the new baby as "descended from kings and coal miners."
Unfortunately, the marriage of Charles and Diana was modern in the worst way, with betrayals and counter-betrayals, psychic warfare dissected in painful detail by a rabid tabloid press. Long before Diana died, the royal fantasy had been thoroughly bloodied, and we felt sorry that her lovely boys could hardly avoid hearing constantly about the mess of their parents' marriage.
So we hope the Duke and Duchess of Cambridge take greater pleasure in each other's company, and are able to form a strong and loving relationship that will give their children an emotionally rich upbringing. It's the best gift any child could get.View Comments | Add Comment
Outrage and Apology Over Rap Lyrics
July 22, 2013 Caroline Miller
Over the weekend, the autism community responded with outrage to some offensive lyrics from hip-hop artists Drake and J. Cole—and drew a surprisingly swift and effusive apology from Cole. The lyrics involved were the use of "autistic" and "retarded" as a putdown, in the recently released track "Jodeci Freestyle," as in, "I'm artistic, you niggas is autistic, retarded."
This backlash-and-apology were particularly interesting in the context of the song itself, which manages to call women "hoes," sluts, bitches and freaks, among other things, and ends practically every sentence with "niggas," which lots of news sites feel the need to reproduce as "n---as."
While a lot of us feel outrage fatigue when it comes to hip hop lyrics, autism bloggers and advocates have been using this sort of off-handed insult effectively as a rallying cry and teachable moment. And this time Cole decided to take instruction. "Last week, when I first saw a comment from someone outraged about the lyric, I realized right away that what I said was wrong," he wrote. "I was instantly embarrassed that I would be ignorant enough say something so hurtful."
There is no way to know whether Cole was suddenly schooled by the blogger attacks or the petition to boycott the two rappers or the fact that, as Rolling Stone reminds us, both Lil Wayne and Rick Ross lost endorsement deals recently because of offensive lyrics—Lil Wayne's about Emmett Till, and Ross's appearing to condone date rape. Or perhaps it was all of the above. As a commenter on Cole's web site said, defending him from the charge of acting ignorantly: "J. Cole graduated Magna Cum Laude from St. Johns University, with a degree in communications."
Whatever it is, we can't disagree with this comment, from his apology:
To the parents who are fighting through the frustrations that must come with raising a child with severe autism, finding strength and patience that they never knew they had; to the college student with Asperger's syndrome; to all those overcoming autism. You deserve medals, not disrespect.
I know some activists won't like the part about "overcoming autism," but you have to like the part about medals, not disrespect. Hopefully Cole remembers: Word is bond.View Comments | Add Comment
Brainwave Test for ADHD Skips the Science
July 22, 2013 Harry Kimball
Last week we heard news that the FDA has approved the use of a medical device to aid in the diagnosis of ADHD, based on the electroencephalogram, or EEG—electrodes placed at different points around the scalp to measure the electrical activity in your brain. In theory, this sort of innovation is exciting—the practical application of advances in neuroscience that show us that real brain differences underlie psychiatric disorders. These illnesses are now diagnosed by so-called "subjective" means: clinical interviews, rating scales, observation. The objective "blood test"—or in this case "brainwave test"—for ADHD or depression or autism is in many corners the Holy Grail of psychiatric research.
But even those who search for that prize acknowledge that we aren't there yet, and experts are skeptical of the device's readiness for primetime. The company who makes it contends that it helped clinicians make a better diagnosis than they would have without it, but doesn't offer any data on that claim. And EEG researchers aren't confident in the technique's accuracy without larger studies and more data. (Dr. Michael Milham, director of the Center for the Developing Brain at the Child Mind Institute, points to a recent study which concludes that the EEG method used by the device does not have diagnostic value in ADHD patients.) Finally, there is the question of exactly what the device measures. If at best the test replicates the observations of a trained clinician, it could simply be identifying symptoms—symptoms that can indicate a variety of disorders, and require the interpretation of a trained clinician. "What's the point?" one ADHD expert asks The New York Times.
But it got FDA approval! That's not as hard as people think, says Dr. Milham, particularly with a passive, non-invasive technique. The fact is that the FDA weighs a drug or a device's benefit against its risk. In this case, it seems by many accounts that the agency was convinced there wasn't any reason not to approve it. But that doesn't mean it's the answer, though we hope that one day EEG and other technologies like MRI and genotyping can be fully leveraged to get the best care to kids who need it.View Comments | Add Comment
Summer Scribblers Intensive Writing Intervention Is a Hit
July 20, 2013 Harry Kimball
Recently the Child Mind Institute held our first ever session of Summer Scribblers, an intensive writing intervention designed to help struggling kids improve everything from individual word choice and usage to the overarching logic of paragraph construction. All 9 attendees—kids from fourth to eight grade—improved over the week. But what is perhaps more telling is that both they and their parents reported that they were ready to continue honing their skills at home and at school. And that's the sort of impact we like to make.
Summer Scribblers is the brainchild of Dominick Auciello, PsyD, of the Child Mind Institute's Learning and Development Center. Similar to our other intensive programs, Dr. Auciello took a proven intervention—in this case the University of Kansas' Learning Strategies Curriculum—and tried to see if he could condense an intermittent months-long approach into an intensive one without losing effectiveness. The weeklkong program is supported by booster sessions later in the summer, and perhaps through the school year. Everyone seems to agree that we're on the right track.
But intensive doesn't mean exhausting, Child Mind Institute neuropsychologist Ken Schuster told me. In order that the students not get tired or frustrated by "pounding away at paragraphs," Dr. Schuster said, the week was broken up with field trips. These offered a breather, sure, but also allowed instructors to reinforce the writing lessons in conversation and provided the students material for when they had to put pen to paper again.
"All the students made progress from their initial baseline-writing sample," says Dr. Auciello. And there was also some defying of expectations. "Some parents expressed surprise that children who are typically very resistant to writing attended so willingly, at how much they enjoyed it, and at how readily they engaged in a boat-load of writing during that week." We can't wait to hear how the first Summer Scribblers class greets the new school year. Based on the week's experiences, the sky's the limit.View Comments | Add Comment