July 4, 2014

Warning of Suicide Risk with Antidepressants Had Unintended Consequences

Remember several years ago, when the FDA issued warnings about the risk of suicide for children and adolescents who were taking antidepressants? Well, stand by for an attitude adjustment. A study published last month in BMJ showed that the effort to save children probably harmed them instead.

The researchers tracked an increase in suicide attempts that seem to have been the result of depressed youngsters failing to seek treatment at all. They said the study shows how public health warnings that were intended to do good sometimes can backfire, especially if the subject is sensitive and gets a lot of media attention.

As the Washington Post recalled, the FDA issued warnings in 2003 and 2004 of an increase in suicidal thoughts among some children and adolescents who were taking a certain class of antidepressants (selective serotonin reuptake inhibitors, or SSRIs); you might recognize some of their brand names — Paxil and Zoloft.

So dire was the potential for harm that the FDA required manufacturers of the drugs to include a “black box” warning on the label. Such warnings denote the highest level of concern about side effects, including death. The warnings specified that the drugs presented an increased risk of suicidal thoughts and behaviors in youths who take them.

The media were all over this story, and the study’s researchers said the coverage focused more on the tiny percentage of patients with those thoughts than on the vastly larger number of youths who benefited from antidepressants.

After the warning, antidepressant prescriptions declined sharply among kids 10 to 17 years old, and among young adults from 18 to 29. Coincidentally, the researchers found, the number of suicide attempts rose by more than 1 in 5 among the younger group, and by more than 1 in 3 among the older group.

Of course the media’s lapel-grabbing headlines — “FDA links drugs to being suicidal” (New York Times), and “FDA confirms antidepressants raise children’s suicide risk” (The Washington Post) — “became frightening alarms to clinicians, parents and young people,” the researchers wrote. But consumers bore some responsibility as well.

“There was a sort of overreaction by the media, but also an excessive caution on the part of patients,” Christine Lu, a Harvard Medical School researcher and co-author of the BMJ study, told The Post. “Lots of people who needed treatment steered clear because of the fear factor. … For any drug, there are risks, for sure. But there’s also the risk of leaving the underlying condition untreated.”

Her team plotted the rise in suicide attempts by studying reports of nonfatal poisonings involving psychiatric medicines, which is a common indicator of attempted suicides. They thought the likely number of suicide attempts probably was much higher, because they didn’t track other suicide methods and poisonings that went unreported.

As The Post noted, the BMJ findings dovetail with a 2007 study in the American Journal of Psychiatry that showed a steep decline in antidepressant prescriptions after the feds issued the warnings.

That study didn’t prove that suicides rose as a direct result of fewer such prescriptions, but experts said there weren’t a lot of other explanations.

Despite their conclusion, the BMJ researchers don’t believe that the FDA was wrong in issuing the warning 10 years ago. But “FDA advisories and boxed warnings can be crude and inadequate ways to communicate new and sometimes frightening scientific information to the public,” they wrote.

And the researchers point out that media attention can raise awareness of medical situations people should know about, like the risk of Reye’s syndrome in children who are given aspirin. But, they said, sometimes “the information may be oversimplified and distorted when communicated in the media.”

Not every scientific mind agreed that advisories were too bold. In Discover magazine, an article by The Neuroskeptic titled “The FDA’s Antidepressant Warning Didn’t Really ‘Backfire,” took issue with the study’s conclusions:

“And while the authors never outright state that the FDA’s warning caused the extra suicide attempts,” it said, “they strongly imply that, using phrases such as ‘It is disturbing that after the health advisories, warnings, and media reports [...] we found substantial reductions in antidepressant treatment and simultaneous, small but meaningful increases in suicide attempts.’ “Are they right to be disturbed? By my reading – no. Their data just don’t support a causal effect.”
Neuroskeptic’s argument is interesting and rather geeky, and deserves consideration. The lesson here is that both regulators and the people who watch them must not be alarmists when communicating drug risks. And the lesson for parents with children who are depressed is to discuss frankly and fully the risks and benefits of all treatments. Like all drugs, antidepressants might be exactly what some people need, and not the best option for others.

It’s a matter of the degree of illness and managing its risk.

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May 16, 2014

Turning Childhood Into Illness

Hearing about the booming numbers of kids diagnosed with worrisome conditions like attention deficit hyperactivity disorder and bipolar disorder can make parenthood seem like punishment. But according to one reasoned mind, kids are no sicker now than they used to be, it’s just that we’re turning childhood into an illness.

Writing on KevinMD.com, Dr. Allen Frances, a psychiatrist and professor emeritus at Duke University, wants people to reject commonly heard “statistics” such as:


  • ADHD has more than tripled in 20 years, and is diagnosed in 1 in 5 teenage boys.

  • Autism occurs in 1 in 68 children and that 20 years ago, it was 1 in 500.

  • Bipolar disorder increased recently by 40-fold.

Too often, said Frances, children are “mislabeled for behaviors that used to be considered part of normal variation.”

What he calls “misplaced diagnostic exuberance” is a product of classroom research that showed that the youngest kids in class are much more likely than the oldest to be diagnosed as having ADHD, and to receive stimulant treatment. (See our blog, “Should Age Determine When Kids Start School?”)

“It is shameful,” writes Frances, “that simple immaturity due to being younger is now mislabeled as mental illness and mistreated with a pill.”

He says diagnosing ADHD should be reserved for kids who have “an early onset of very severe and persistent symptoms displayed in a wide variety of family, school, and social contexts.” That requires not only thorough evaluation, but a period of watchful waiting. That’s more frustrating for many parents and caregivers than rushing to diagnostic judgment and treatment. Make that overtreatment.

Among the harms of such overtreatment for the 2 in 3 active kids who have been misdiagnosed with ADHD is suffering from unnecessary stigma, reduced expectations and drug side effects.

“We need to do a better job of protecting our children from such widespread careless diagnosis and reckless treatment,” he says.”

He blames marketing and greed by pharmaceutical companies for fueling this diagnostic fire. “Massive and cleverly misleading marketing has transformed the stimulant drug market from a minor player to a $10-billion-a-year cash cow,” he notes. “This is great for executives and shareholders but bad for the kids who are mislabeled and mistreated.”

He, like other doctors we’ve written about, wants to reduce the “formidable lobbying” of the pharmaceutical industry, and stop it from advertising directly to consumers.

He wants resources spent on schools, educational tools, not on hawking drugs. “What makes more sense,” he asks, “promiscuous use of pills or smaller class sizes and more facilities for physical activity that allow kids to blow off steam?”

“It is completely irrational to shortchange our schools and then spend a bundle on misguided medical treatment for normally active kids who don’t do well in a stressed school environment.”

“[L]et’s diagnosis and treat our classrooms and playgrounds,” Frances concludes, “not overdiagnose and overtreat our children.”

In other words, let a kid be a kid.

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May 9, 2014

Texting or Parenting: What’s Your Priority?

You love your smartphone, but your kids might not.

An observational study by pediatrician Jenny Radesky indicates that many parents are depriving their children in favor of their phones, and that such techno-addiction can harm the kids.

When Radesky worked at a clinic in a high-tech savvy neighborhood, NPR reported, she realized how often parents ignored their kids while engaged with their mobile device. One mother kept her phone in the stroller between herself and the baby. "The baby was making faces and smiling at the mom," Radesky told NPR, "and the mom wasn't picking up any of it; she was just watching a YouTube video."

That gave Radesky the idea to study 55 different groups of parents and young children eating at fast food restaurants. Forty of the adults pulled out a mobile device immediately, and used it during most of the meal.

That’s bad for kids, Radesky said, because face-to-face interaction is how children learn language, emotional responses and how to regulate them. "They learn by watching us how to have a conversation, how to read other people's facial expressions,” she told NPR. “And if that's not happening, children are missing out on important development milestones."

Is anyone surprised that Radesky and the other researchers observed that kids whose parents were most absorbed in their devices were more likely to act out, trying to get their parents' attention?

Although her research was more of an anthropological observation than solid science, it was published in the journal Pediatrics.

According to Catherine Steiner-Adair, author of “The Big Disconnect: Protecting Childhood and Family Relationships the Digital Age,” when a parent’s priority is a digital device, there can be significant emotional consequences for the child. "We are behaving in ways that certainly tell children they don't matter, they're not interesting to us, they're not as compelling as anybody, anything, that may interrupt our time with them," she told NPR.

In her research, Steiner-Adair interviewed 1,000 children between 4 and 18 about their parents' use of mobile devices. Several reactions were common: "sad, mad, angry and lonely." Some kids told how they threw their parent's phone into the toilet, put it in the oven or otherwise hid it. One girl said, "I feel like I'm just boring. I'm boring my dad because he will take any text, any call, any time — even on the ski lift!"

Steiner-Adair said it’s not known when the cumulative moments of disconnect between a parent and a child begin to affect the youngster in the long term. So she hopes, before reflexively answering the phone, sending a text or reading email, that parents would make a thoughtful choice between paying attention a mobile device or to their children. If your default is to choose technology over children, you need to rethink your priorities.

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January 17, 2014

Should Age Should Determine When Kids Start School?

There’s been a lot of chatter in recent years about the wisdom of holding kids back from entering school if they are among the youngest members of their class. Dr. Roy Benaroch, a pediatrician and author of “Solving Health and Behavioral Problems from Birth through Preschool: A Parent’s Guide,” recently weighed in on the topic at KevinMD.com.

Benaroch has been skeptical of the trend of “holding back” children with late birthdays. They’re the ones who were born in the summer and are just a few months short of the next grade cut-off. Even “60 Minutes” did a segment about parents who think it’s wise to hold their later-born kids back so that they end up as one of the oldest instead of the youngest kids in their class.

The practice might seem to be advantageous in terms of maturity, academic ability and physical ability. As Benaroch points out, because children generally progress yearly, without later switching grades, kids “held back” in kindergarten should end up bigger and stronger and faster when trying out for teams in high school.

“A good idea?” he asks.

“Recent research has shown some stark differences in children who end up as the youngest versus the oldest kids in a classroom, which gives support to the idea of reconsidering firm birthday-based rules for choosing when to start kids in school,” he says.

One study he likes looked at about 12,000 Icelandic children, grouping them by both birthdate and grade in school. The study found:


  • Mean test scores were lowest among the youngest children, especially in early grades. This gap lessened by middle school, but was still significant.

  • Children in the youngest third of a class were about 50% more likely to be prescribed medication for Attention Deficit Hyperactivity Disorder (ADHD) than kids in the oldest third of the class.

We’ve been wary of overprescribing ADHD drugs (see our blog, “Boom in ADHD Diagnoses Can Lead to Overmedicating and Drug Abuse”), but this study examined a different population from the one we generally write about.

Similar findings, Benaroch says, have been reported by other researchers, so he believes it’s a true effect. “Lumping children together by age creates a disparity in abilities within a classroom, with the youngest children being put at a relative disadvantage. That seems to create a greater likelihood of medical diagnoses and treatment for attention deficit disorder.”

But, it’s important to note, he also concedes, that “It’s not known if holding back these younger kids with ADHD would allow them to become better students without fulfilling an ADHD diagnosis.”

Benaroch isn’t certain what the best approach is. Life, just like school, presents all kinds of diversity everyone must learn to deal with. As he says, “[S]ome kids in any group are going to be the youngest.”

He suggests that maybe smaller classes with a smaller age range of children would be a good idea. Maybe an individualized approach to determining which kids will do best to start sooner versus later would help — that is, not the one-size-fits-all approach of holding back every kid with a certain birthday cut-off. “In the held-back year,” he writes, “children who weren’t ready for school could get extra help with their attention abilities and other skills that will help them advance.”

But Benaroch says this could lead to other problems later on, when kids of greatly varying age, physical ability and sexual maturity are mixed together.

“I don’t have a solution,” Benaroch concludes, “but it seems like this is a genuine problem. We’d better figure out a way to work this out that doesn’t depend on more medications for the youngest kids in a grade.”

On that, we agree.

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January 10, 2014

Having a Conversation with a Child with Autism

Many people feel awkward around someone who is different — in color, gender, nationality or physical/mental ability. It’s part of the human condition, but so is compassion and understanding. Kathleeen O’Grady, a research associate at Concordia University in Montreal and the mother of a son with autism, helps to expand our humanity with advice on how to communicate with a youngster who has autism.

Writing on KevinMd.com, O’Grady notes that an estimated 1 in 88 children is diagnosed with autism, a neurological disorder often characterized by difficulty with social interaction. That can make holding a conversation challenging, but it doesn’t mean you should leave kids with autism out of one.

“Contrary to popular belief,” O’Grady writes, “most kids with autism are not anti-social. Yet, many “neurotypicals” still struggle when it comes to including a child with autism in the conversation. Those that do try, often fail because they don’t know a few essential rules that can help make the interaction possible.”

Here are O’Grady’s three rules for communicating with a kid who has autism.

1. Don’t start the conversation with a question.

Even a simple question like, “How are you?” or “What’s your favorite color?” can seem like a test to some children with autism. And if they fail the first question, the conversation is over before it starts.

These kids generally know what you are saying or how to answer, but sometimes their answer sometimes gets “trapped” between the thought and the expression of it. Any environmental change or interference — background noise, pace of speech, accent or their own anxiety when exposed to new places and people — can make the answer to even a simple question enormously difficult.

So start a conversation with a statement they can build on: “I love your shirt;” or “Cool dinosaurs” are observations that invite a child to comment in kind if he or she wants to. Then you can build on it, conversationally.

2. Be patient.

Usually, kids with autism don’t need you to speak slowly, but they do need time to form a response. “Too often,” O’Grady writes, “I’ve seen adults wait for a child’s response to a question, and when the response doesn’t come, immediately throw another question out there in hopes that the child will respond to the second attempt.

“If they’d simply waited another 20 or so seconds, they may have had a response to their first query.” But throw out another, and the child might get confused and freeze up trying to figure out if they should respond to the first or second query.

Just wait. And just when you think you’ve waited long enough, count out five more seconds in your head, and wait again. Each child has his or her own response time, so it may take a few tries to figure out how long they need.

3. Don’t take it personally, and try again later.

Some adults try and fail to engage children with autism. They presume that the child doesn’t like them or is anti-social generally. Neither is likely to be the case.

Kids on the autism spectrum sometimes just don’t respond to social communication — even when they are fully able, and even when they understand what’s going on.

Maybe the child is imagining something terrific in his or her head — a video game, a piece of music — that is so powerful that he or she can’t be pulled out of the imaginary world and into yours at that moment. In other words, you can’t compete.

Sometimes the environment is overwhelming, and makes the child too anxious or overloaded with sensory stimuli to respond. Sometimes, a kid just doesn’t feel like talking.

It’s not personal. Try again to convince him or her that joining your conversation is worth the effort. If there’s still no response, the mood will pass. Try again later.

The bottom line, O’Grady says, is that you should never leave a child with autism out of the conversation. “Chances are,” she says, “they want to engage, but they need to do so on their terms and within their abilities. Make the effort, and not only will you make a child happy, it’ll make your day too.”

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October 11, 2013

Not Every Child Who Stutters Needs Treatment

If your preschooler is a stutterer, there’s good news from a study recently published in the journal Pediatrics. Four-year-olds who stuttered were not found to be different from their peers when it comes to temperament or mental health. Also, their language skills, nonverbal cognition (the nonword ability to think and process information) and health-related quality of life was superior to that of children who didn't stutter.

As interpreted by MedPageToday.com, the study results support the idea that parents should watch and wait instead of trying to intervene as soon as their youngster begins to stutter.

Long-term stutterers often report a lower quality of life, and they may experience lower educational achievement and a higher incidence of psychological problems, such as social phobias. But the Pediatrics report refutes the idea that all stutterers have poorer health outcomes.

Most young children aren’t aware of stuttering, and generally they don’t react to stuttering behavior, especially when it first begins.

Among the study’s findings:


  • More than 8 in 100 children stuttered by the age of 3; more than 11 in 100 did so by age 4.

  • More than 6 in 100 children recovered within one year of the onset of stuttering, and four of them had professional help, typically from a speech pathologist.

  • This rate of stuttering was about twice that of previous reports.


Among factors that predicted the onset of stuttering onset were:

  • mothers with higher education;

  • male gender;

  • twins.


It’s interesting to note that family history of stuttering was not among predicting factors.

Most children, the study shows, resolve their stuttering disorder within about 4 years from its onset, but intervention can help those who don't. Current guidelines, according to MedPage Today, advise parents to wait one year to see if kids will recover on their own before launching into expensive, time-intensive treatment. The new study suggests suggest many could wait longer.

"What we used to think was a disorder that required earlier intervention is a disorder that we could do a more watch-and-see approach with," Irv Wollman, clinical director of speech-language pathology at Cincinnati Children’s Hospital Medical Center told MedPage Today. "Rushing into early intervention may not necessarily be the route to go."

There’s a difference, though, between stuttering and the more troubling symptoms of such distress at the disorder that kids avoid talking, or they talk only with increased physical effort. If that describes your child, it’s time to consult with a speech-language pathologist.

Otherwise, the researchers said the more conservative, wait-and-see approach would reserve scarce resources for the few children for whom stuttering doesn't resolve and who suffer adverse outcomes.

At least one powerful voice has been raised in opposition to that advice. As reported on MedPage Today, The Stuttering Foundation called the study conclusions a "blunder" that could mislead parents into believing that there's little cause for concern or no immediate need to seek help.

"The biggest problem with the data,” said Jane Fraser, president of the foundation, “is that it stops at age 4, just when one might expect to see some harmful effects from stuttering. It is far too early to interpret the findings because we do not know how many of these children continued to stutter and what effects it had on them and their lives."

For The Stuttering Foundation’s advice to parents, link here.

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September 6, 2013

Study Showing Association Between Induced Labor and Higher Autism Risk for Boys Is Sloppy Science

A study published last month in JAMA Pediatrics indicated that boys whose mothers needed help to initiate or move the process of labor along may have a higher risk of autism.

But there are several reasons why the research contributes less to the body of knowledge and more to the mass of misinformation.

As reported by Bloomberg.com, induced labor, which stimulates the uterus in order to prompt contractions, and augmented labor, which increases the strength, duration and frequency of contractions, showed a 35 percent greater risk of autism in boys than babies whose mothers didn’t need those procedures.

According to the Centers for Disease Control and Prevention, 1 in 50 U.S. children between 6 and 17 years old is diagnosed with an autism spectrum disorder (ASD). Few childrens’ psychological disorders have been given more attention recently than autism, leading to a breathtaking wealth of misinformation about its causes, from vaccinations to diet.

The study was published in JAMA Pediatrics, a prestigious publication that, suggests writer Emily Willingham, should know better than to publish such incomplete research as the induced labor-autism risk study … or at least fully explain its considerable shortcomings.

In her analysis of the study on Forbes.com, Willingham points out that the study “did not show a cause and effect between induced (initiated) or augmented (hastened) labor and autism. It found an increased odds that a child born following a labor induction and augmentation would later be labeled as autistic by special education services. Yet there are problems with reaching even that conclusion.”

Instead of the cause-and-effect conclusion the researchers drew, Willingham said, they could just as easily have said, “Labor induction risk may be raised when child is autistic.”

Willingham noted several possibly influential factors that weren’t included in the study, probably, she surmised, because they weren’t available: mother’s BMI [body mass index, a measure of fitness that identifies percentages of fat and muscle] from pre-pregnancy; father’s age; child head circumference; specific child birth weight; mother’s insurance status; presence of any sibling births in the cohort; and whether or not the child had autistic siblings. “Lack of availability of relevant data,” Willingham states, “can sometimes make a study untenable, at least, and at best should warrant considerable caution in interpretation and speculation.”

Willingham goes into interesting detail about the study’s take on chances of an autism diagnosis and whether or not the mother has a college degree, or smokes, demonstrating, again, that science isn’t simple. We’d go a step further: Social pressure can’t overcome our desire to make it so.

To be clear, the researchers didn’t conclude that standard clinical practices be changed as a result of their study. “The results,” the lead author told Reuters, “don’t dictate there be any change in any clinical practices surrounding birth. The dangers to the mothers and the infants by not inducing or augmenting far outweigh the elevated risk for development of autism.”

In some circumstances, of course, induced labor can help reduce deaths among mothers and babies. But more studies are required to understand more fully why such procedures might be associated with the risk of disorders as elusive as autism.

Willingham’s conclusion reinforces what we hope readers will always consider when reading about research studies, even in the original form:

“This study didn’t show that induction or augmentation during childbirth substantially increases the risk for autism, although it hints at a greater influence of socioeconomic status and by implication, healthcare access. If anything, based on earlier literature, it adds a slight if only mathematical confirmation of the perception that births involving autistic children can be associated with more complications, such as the presence of meconium [fetal defecation], gestational diabetes and fetal distress, than births involving nonautistic children. And that points to induction and augmentation as useful in these situations, not as problematic, and certainly does not affirm them as a risk.”

For more information, see our blogs, “Autism Rates Rise,” and “Helping Parents Through the Autism Maze.”

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August 30, 2013

Overcoming Bed-Wetting

A recent “explainer” posted on The Conversation will be welcome information for many parents. It’s about bed-wetting.

The writers of the report on The Conversation, an independent source of news and opinion for public consumption by members of Australia’s academic and research communities, are Caroline Walsh, a continence nurse at The Children’s Hospital at Westmead (Sydney), and Patrina Ha Yuen Caldwell, who heads the enuresis service for the hospital. “Enuresis” is lack of urinary control, especially nighttime bed-wetting.

Walsh and Caldwell say that bed-wetting, although embarrassing and traumatic, is common among children. It affects 15-20 out of 100 school-aged children, the vast majority of whom grow out of it. But there are treatments to hurry the evolutionary process.

Like adults, children usually wake up when they have a full bladder, but bed-wetters have a defective arousal response. They can’t wake fully. So when urine production exceeds bladder capacity, a child urinates in his or her sleep.

The disorder has a genetic link, so if you or your spouse had the problem, it’s more likely your kid will too. Bed-wetting is more common among boys, but women are more likely to pass the genetic inclination to their children. Gee, thanks mom!

Because bed-wetting carries such emotional baggage, and can affect a child’s self-esteem, mental health and early peer relationships, parents must handle the issue with sensitivity.

There are several treatments for bed-wetting, primarily alarm training, urotherapy and medication. Treatment is appropriate generally around the age of 6.

Alarm training

Usually, this is the first line of treatment, and the goal is to train the child to recognize the full-bladder signal before urinating in his or her asleep. There are two kinds of alarms:


  • Pad and bell alarms connect a mat to an alarm box placed on the child’s bed. The alarm activates when the mat senses liquid.

  • Personal alarm sensors are secured either in a panty liner or clipped to the child’s underpants. The alarm activates when the sensor detects liquid.

    This method requires patience. It should be used every night until the child achieves 14 consecutive dry nights. It can take two to four months of training before the child reacts consistently enough to the signal to be deemed fully effective.



Urotherapy

This covers a wide range of practices, primarily:


  • ensuring the child has an adequate daily fluid intake (5 to 6 drinks per day that do not contain caffeine, including chocolate milk);

  • avoiding the consumption of fluids late in the evening or close to bedtime;

  • avoiding or readily treating constipation, which can affect bladder function;

  • ensuring appropriate toilet posture, such as adequate foot support when sitting on the toilet (this supports complete evacuation of both the bowel and bladder);

  • taking bathroom breaks regularly throughout the day, and encouraging the child not to postpone a trip to the toilet when the urge occurs.


Medication

This approach should be for a short-term solution or as a last resort. It relies on desmopressin, a synthetic hormone that has an anti-diuretic effect. It acts on the kidneys to reduce overnight urine production. Effective in about 7 in 10 child cases, desmopressin might be useful for sleep-overs or school camps when alarm training isn’t practical. It can also be combined with other treatments to ensure a dry night.

Like all medicines, desmopressin can prompt a negative reaction when combined with some other drugs, so make sure your pediatrician has a complete record of what your child takes.

Imipramine was one of the first medications used to treat nocturnal enuresis, but because of its risky side effects, including thoughts of harming or killing oneself, it’s not recommended as a first-line treatment.

Other Options

Behavioral therapies can be helpful in treating bed-wetting. They include taking the child to the toilet during the night and rewarding him or her when he or she stays dry. “Try to create a positive environment and involve the child in decision-making,” the writers suggest, “so they can take ownership of the problem.”

But given the physiological nature of the disorder, psychological treatments often aren’t as effective as alarm training or medication.

Some complementary and alternative medicine interventions, such as hypnotherapy and acupuncture, have been tried, but the evidence to support their use is limited.

If your child doesn’t respond to common treatments, seek advice from a pediatric urologist. Or try to ride out what usually is a youngster’s affliction that does improve with age.

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April 12, 2013

Boom in ADHD Diagnoses Can Lead to Overmedicating and Drug Abuse

The news last month from the Centers for Disease Control and Prevention (CDC) was widely reported: Nearly 1 in 5 high-school age U.S. boys and more than 1 in 10 of all school-age children have been diagnosed with attention deficit hyperactivity disorder (ADHD).

ADHD generally is thought to result from abnormal chemical levels in the brain that impair the ability to pay attention and compromise impulse control.

The New York Times was among the media outlets that reported the significant increase of the diagnosis, and the concern about overprescribing the drugs used to treat it. We, too, have questioned the practice.

More than 6 million children 4 to 17 have been diagnosed with ADHD; their numbers have increased 16 percent since 2007, and more than doubled in a decade. More than 2 in 3 currently diagnosed take Ritalin or Adderall, stimulants that certainly help the afflicted, but, according to the The Times, also can cause addiction, anxiety and even psychosis.

Sales of stimulants to treat ADHD, The Times says, have more than doubled to $9 billion in 2012 from $4 billion in 2007.

Some people legitimately need these drugs, but experts estimate that only 3 to 7 in 100 children suffer from ADHD, and that the meds are being given to people with mild symptoms who shouldn’t be taking them.

As The Times puts it, “While some doctors and patient advocates have welcomed rising diagnosis rates as evidence that the disorder is being better recognized and accepted, others said the new rates suggest that millions of children may be taking medication merely to calm behavior or to do better in school.”

Kids often share or sell their meds to classmates, so the boom in ADHD opens the door to drug abuse and its consequent health risks. CDC Director Thomas R. Frieden compared the rising rates of stimulant prescriptions among children to the overuse of pain medications and antibiotics in adults.

One heartbreaking illustration of this scenario was presented last week in a commentary in the New York Times. The writer, Ted Gup, told the story of his son David, who was diagnosed with ADHD as a first-grader and told by one psychiatrist that he wouldn’t even see the child until he was medicated.

Gup resisted, but after a year of David’s “rambunctious” behavior, he started taking Ritalin, then Adderall.

As a 21-year-old college senior, he was found on the floor of his room, dead from a fatal mix of alcohol and drugs. The date was Oct. 18, 2011.

No one made him take the heroin and alcohol, and yet I cannot help but hold myself and others to account. I had unknowingly colluded with a system that devalues talking therapy and rushes to medicate, inadvertently sending a message that self-medication, too, is perfectly acceptable.

My son … was known to trade in Adderall, to create a submarket in the drug among his classmates who were themselves all too eager to get their hands on it. What he did cannot be excused, but it should be understood. What he did was to create a market that perfectly mirrored the society in which he grew up, a culture where Big Pharma itself prospers from the off-label uses of drugs, often not tested in children and not approved for the many uses to which they are put.

Stories like David’s are likely to repeat. As The Times points out, the American Psychiatric Association is planning to broaden the definition of ADHD in the upcoming edition of the Diagnostic and Statistical Manual of Mental Disorders (see our blog, “Controversy Swirls as Psychiatry Manual Gets an Update.”)

That invites more people to be diagnosed and be medicated, possibly many for whom other treatments are more appropriate.

Pharmaceutical company marketing enables any parent seeking to help a kid who’s misbehaving and whose grades are falling. The Times noted that the brochure for Vyvanse, an ADHD drug, shows a parent looking at her son and saying, “I want to do all I can to help him succeed.”

Dr. Jerome Groopman, professor of medicine at Harvard Medical School, told The Times, “There’s a tremendous push where if the kid’s behavior is thought to be quote-unquote abnormal — if they’re not sitting quietly at their desk — that’s pathological, instead of just childhood.”

Diagnosing ADHD is a difficult judgment call. As The Times notes, there’s no definitive test for it—it’s determined only by extensive communication with patients, parents and teachers, and by ruling out other possible causes for its behavioral symptoms. The process is subjective and made more difficult when parents pressure doctors for a diagnosis. ADHD is a chronic condition that often endures in adulthood.

More than twice as many boys as girls have been diagnosed with ADHD—15 in 100 versus 7 in 100. The rates were highest among high-schoolers—1 in 10 girls, and nearly twice as many boys. About 1 in 10 high-school boys takes ADHD medication.

Before yours becomes one of them, find out if your kid truly is suffering from a mental disorder. Explore other treatment options, such as counseling, and causes for unacceptable behavior that might be social (bullying?) instead of chemical. Drugs can be lifesavers, but they also can harm.

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April 5, 2013

More Proof that Vaccines Have Nothing to Do With Autism

A new, large study by the Centers for Disease Control and Prevention (CDC) should help redirect the concern of parents who still wonder if vaccines have a role in children developing autism.

The science-based medical establishment has not wavered from the position that children should be vaccinated against a variety of diseases (See our blog, “Feds Say Childhood Vaccine Schedule Is Safe and Effective”), but a campaign devoid of science and juiced by quackery keeps planting the seeds of skepticism about whether vaccines do more harm than good.

As reported last week on NPR, the answer, again, is a categorical “no.” The CDC study found no connection between the number of vaccines a child received and his or her risk of autism spectrum disorder. And even though kids get more vaccines than they used to, they’re far less able to provoke an immune response than older versions.

That’s because newer vaccines have fewer antigens. Those substances cause the body to produce antibodies, which are proteins that fight infection. Our bodies are experienced antibody-producers because we’re routinely exposed to microbes, whether they’re the bacteria responsible for a sinus infection or a virus that results in a cold sore. In other words, antibody production is a natural, vital part of human life. To believe it’s responsible for causing a mental disorder is nonsensical.

The CDC study compared the vaccine histories of about 250 children diagnosed with autism spectrum disorder with the histories of 750 kids who weren’t. Researchers compared medical records to see how many antigens each child received and whether that affected the risk of autism. The results, published in The Journal of Pediatrics, were clear.

"The amount of antigens from vaccines received on one day of vaccination or in total during the first two years of life is not related to the development of autism spectrum disorder in children," said lead author Frank DeStefano, director of the Immunization Safety Office of the CDC. Because kids, like everyone else, are constantly exposed to antigens from bacteria and viruses, "It's not really clear why a few more antigens from vaccines would be something that the immune system could not handle," he said.

The the number of vaccines a kid is supposed to get has increased, but the number of antigens in vaccines has decreased. A lot. In the late 1990s, vaccinations exposed children to several thousand antigens, the study said. By 2012, that number was 315.

That’s because the science of vaccination has improved; it’s more precise in how antibodies kick-start the immune system.

The problem with supporters of quack science is not only that they leave their children and others in their community vulnerable to the problems vaccines address, they also divert resources into worthless pursuits that otherwise would contribute to the body of science, not waste time trying to overcome it.

"I certainly hope that a carefully conducted study like this will get a lot of play, and that some people will find this convincing," Ellen Wright Clayton told NPR. She’s a professor at Vanderbilt University who contributed to a report on vaccine safety for the Institute of Medicine. “That would let researchers pursue more important questions.

"The sad part is, by focusing on the question of whether vaccines cause autism spectrum disorders, they're missing the opportunity to look at what the real causes are," she said. "It's not vaccines."

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January 4, 2013

TVs Don’t Belong in Kids’ Bedrooms

If the post-holiday gift haul has overwhelmed you with a wave of electronic diversions, a story in the Los Angeles Times issues a kind of tsunami warning. It’s a bad idea, says a study published in the American Journal of Preventive Medicine, to put a TV in a child's bedroom.

For most American households, says The Times, it’s too late: In the U.S., 7 in 10 kids between 8 and 18 have a television in their bedroom.

As research has long shown, more "screen time" is linked to higher rates of obesity. (See our post about screen time and fitness .) The new study says that not only do kids with a TV in their bedroom tend to watch more TV, but compared with television watched in other household settings (the family room), the screen time a kid logs in the bedroom is associated, hour for hour, with more belly fat, higher triglycerides (blood fats) and overall greater risk of developing heart disease and diabetes.

The new study compared kids with about the same diets and the same levels of physical activity. The ones with a TV in their bedrooms had more cardiometabolic risk factors—that is, test results indicating greater risks to heart function and greater insulin resistance—than the ones who must watch TV in one of their home's common rooms.

The study’s lead author said that beyond the effects of sitting too long in front of a TV, a television in the bedroom has the potential to disrupt sleep patterns and interfere with shared family meals. Sleep deprivation is another risk factor for obesity and metabolic dysfunction. And family mealtimes seem to promote more healthful eating, lower obesity rates and less use of alcohol, drugs and tobacco by kids.

Vicky Rideout, an independent consultant who has written extensively about children's media exposure and its effects, told The Times that "Research has consistently shown better outcomes for kids who don’t have a TV in their bedroom than for those who do, whether we’re talking about obesity, sleep or academic achievement."

In addition to removing the TV from the kids’ rooms, Rideout wants parents to pay attention to all newer technologies as well. "Keep an eye on your child’s smartphone and computers too, because food companies are now marketing games, websites and mobile apps designed to boost consumption of foods kids should be eating less of, not more of," she told The Times.

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December 21, 2012

The Harm of Sibling Rivalry and What to Do About It

What’s the No. 1 parents’ complaint about family life?

Somebody else is always hiding the remote?

Somebody never remembers to lower the toilet seat?

Somebody always returns the car with an empty tank of gas?

Wrong, wrong, wrong. According to researchers at Penn State, parents’ chief concern and complaint is sibling rivalry.
As reported on ScienceDaily.com, the researchers studied 174 rural and urban families. Each family had one child in the fifth grade and one in the second, third or fourth grade. They collected data from the parents by questionnaire, and interviewed each sibling privately. They also videotaped family interactions.

Although siblings screaming at and competing with each other can drive parents to distraction, the researchers, from the Prevention Research Center for the Promotion of Human Development, said that a program they designed demonstrates that elementary school age kids can learn to get along. That’s not only a relief for fraught parents, it’s good for the kids’ health and well-being.

"Negative sibling relationships are strongly linked to aggressive, anti-social and delinquent behaviors, including substance use," research Professor Mark Feinberg said in a news release by Penn State. "[But] positive sibling relationships are linked to all kinds of positive adjustment, including improved peer and romantic relationship quality, academic adjustment and success, and positive well-being and mental health.”

The program developed by Feinberg, Susan McHale, director of the Social Science Research Institute at Penn State and their colleagues, is designed to help siblings learn how to manage their conflicts and avoid engaging in troublesome behaviors.

Called SIBlings Are Special (SIBS), it’s intended for families whose oldest children are on the brink of middle school. That’s the age when kids are more likely to be exposed to and involved in risky behaviors for the first time. The families participating in the study were randomly assigned to take part in SIBS or to be in a control group that wasn’t part of the program.
Among other elements, SIBs includes a series of 12 after-school sessions to teach small groups of sibling pairs how to:

  • communicate in positive ways;
  • solve problems;
  • devise win-win solutions;
  • see themselves as part of a team rather than as competitors.
"We found that the siblings who were exposed to the program showed more self-control and social confidence; performed better in school, according to their teachers; and showed fewer internalizing problems, such as depressive symptoms, than the siblings in the control group," Feinberg said.

But it wasn’t only the youngsters who were “trained”; SIBs offers parenting strategies that Feinberg said led to “significantly fewer depressive symptoms” among mothers in the intervention group than mothers in the control group.

It’s interesting that no effects of the program were seen for fathers regarding depression.

Parents interested in pulling the plug on sibling rivalry needn’t be involved in a specific program; many of SIBs’ lessons are available to all.

If kids are fighting, don’t intervene with a resolution—instead, help them discuss the problem calmly and let them resolve the problem on their own. It’s a matter of providing tools to fix something that’s broken instead of fixing it for them. Once kids experience success with the tools, they’re more likely to use them again when things get thorny.

Also, staying calm when the children aren’t, models behavior they can use. It shows them how discussion and resolution are more likely to occur when the atmosphere isn’t charged with anger.

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December 14, 2012

New Prenatal Test Is Less Risky but Less Trustworthy

Prospective parents who want to know if their baby has a genetic disorder such as Down syndrome are advised to consider amniocentesis or chorionic villus sampling (CVS). Amnio, generally performed during the second trimester, involves inserting a needle into the amniotic fluid surrounding the fetus. The CVS probe removes a sample of the sac surrounding the fetus toward the end of the first trimester. Both carry a small risk of miscarriage.

So some people are choosing a different procedure that can be done as early as 10 weeks into the pregnancy and involves only drawing the mother’s blood. Three versions of the test have been available for a year, and although its convenience is appealing, according to a recent story by Kaiser Health News and the Washington Post, the decision to use it is complicated. The technology is not subject to regulation by the FDA, and the body of research about its accuracy is slim.

Thousands of the tests have been performed (at a cost of as much as $1,900) while they remain under review. Insurance companies don’t (yet) cover the cost, and because the test is so new, it’s unclear if, eventually, it will reduce miscarriages and the cost of complications by reducing the use of the more invasive tests. Will the tests, instead, increase costs because women who otherwise would pass on amniocentesis will opt for the blood draw?

According to the KHN/Post story, amnio is performed about 200,000 times every year in the U.S. In the Washington, D.C. area it costs about $2,500. As a standard test, it’s generally included in maternity coverage.

The new tests, typically, are offered only to women whose age and medical history put their fetus at a higher risk of having a chromosome abnormality; standard screening tests often are offered to all pregnant women.

The risks of having a fetus with a genetic disorder are greater if the mother:


  • is 35 or older;

  • has a history of miscarriages or children born with birth defects;

  • has a family history of genetic disease.


In addition, prenatal genetic testing is recommended if either parent has a family history of genetic disease or is known to be a carrier of a genetic disease.

The new test examines DNA fragments to see if a fetus carries three instead of the normal two copies of chromosomes 21, 18 or 13. An extra copy of 21, a called trisomy 21, is the main cause of Down syndrome; and extra copy of 18, called trisomy 18, causes a less common disorder, Edwards syndrome. Trisomy 13 is also known as Patau syndrome. All three are linked to serious developmental and medical problems.

Earlier this year, we wrote about the fate of babies handicapped by two of these conditions.

The test checks the mother’s blood levels of pregnancy-associated proteins and hormones and includes an ultrasound to see if there’s extra fluid at the back of the fetus' neck. The two procedures appear to detect about 9 in 10 cases of Down syndrome, and an even higher ratio of trisomies 18 and 13.

As the KHN/Post story says, 5 in 100 tests result in a false-positive—that is, showing a defective gene when there isn’t one. Only amniocentesis or CVS provide definitive answers.

Last month the American College of Obstetricians and Gynecologists said that the tests "should not be part of routine prenatal laboratory assessment." The organization hedged that statement, however, by noting that the tests can be offered to patients at increased risk of having a baby with a trisomy, but must be preceded by counseling about their limitations. Other professional groups, the National Society of Genetic Counselors and the International Society for Prenatal Diagnosis, agreed.

Given the lack of research proving the accuracy of the new test, all three organizations recommend that anybody who received a positive result undergo amniocentesis or chorionic villus sampling to verify the diagnosis.

So the question arises: If you have to confirm a diagnosis, should you have the test in the first place? Is the minimal risk of complication, in comparison to the greater, but still small risk of miscarriage with the standard, proven tests, worth it?

Maybe, especially if you are in the high-risk group for fetal genetic abnormalities. And although cost might be a factor, at this point, the companies who market the tests offer considerable subsidies. According the KHN/Post story, “[T]he most that women with insurance have to pay out of pocket is $235 for the MaterniT21 Plus test (list price $1,900) and $200 for Verifi (list price $1,200), even if their plan declines to cover the test. Both companies offer self-pay options for women without insurance: The price is $450 to $500 for MaterniT21 Plus and an ‘introductory price’ of $495 for Verifi.”

Insurance companies regularly review new technologies and treatments to make decisions about covering them. As the research file about the maternal blood tests grows, if the evidence of their accuracy is compelling, the tests eventually could be considered “standard.”

But that’s not their status today, and their worth must be determined on an individual case basis after frank and full discussion between the obstetrician and the parents.

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November 23, 2012

Study Supports Using the Toilet Training Method that Works for You

For a lot of parents, toilet training is an early focus of worry about inflicting psychological harm on a child. Everyone, it seems, has an opinion about how to accomplish human housebreaking, and all the things that can go wrong if you don’t do it their way. But relief is in sight: A recent study published in Clinical Pediatrics concludes that a kid’s urinary accidents are unrelated to the method his or her parents use for toilet training.

But they do recommend starting toilet training sooner rather than later.

“Our study,” the authors wrote, “showed that the method used for toilet training had no association with the development of dysfunctional voiding symptoms. This information may be helpful for parents of children with dysfunctional voiding who feel guilty for using the wrong training method. Further research should be conducted to [refine] the toilet training methods in order to find any significant difference, but as of now, parent-oriented and child-oriented toilet training should be considered equally effective.”

The researchers also concluded that earlier toilet training, between the ages of 24 and 32 months, is more important for reducing the risk of urinary concerns that whatever method parents use.

According to the study, children undergo toilet training at a later age now than in the past. In 1980, the average age was 25 to 27 months; in 2003, it was 36.8 months. Some studies have indicated that the later age has a negative impact, that late toilet training might be more difficult for parents because the child is more likely to resist their efforts to train. That can cause problems, such as constipation, daytime accidents (a “voiding dysfunction”) and infection.

One recent study showed that children with symptoms of voiding dysfunction (which also includes the frequent or urgent need to urinate) were toilet trained later than children who didn’t have these problems. But the delay can have a benefit—it produced the toilet training approach that follows a child’s readiness to participate rather than forced learning.

The study defines two broad categories of toilet training—parent-oriented and child-oriented. The former was more common before 1960; it supports early toilet training with firm parental direction, often using rewards to support the desired result and punishments or withdrawal of positive reinforcement to negatively reinforce accidents. The child-oriented approach is when a kid shows interest and willingness to learn to use the toilet, generally around 18 months of age or later. It praises success and avoids punishment. Both methods have myriad modifications, though, that might include rewards or the withdrawal of rewards to encourage kids to get with it.

The new study followed 215 children ages 4 to 12. Both genders were represented. Parental reports and medical examinations were included. The study compared the methods of training in two groups. The control group of 147 subjects had no urinary problems after training was completed. The other group of 58 subjects showed voiding dysfunction.

No association was found between the method used and urinary symptoms that may have followed training.

“Our study reveals that the decades of debate about the preferred method of training was not based on scientific evidence, but rather expert opinion,” said the lead researcher. “The evidence presented in our research should help ease parents’ concerns that if their child has urinary difficulties, it might be the result of incorrect training or the training method chosen. It isn’t.”

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June 26, 2012

Poll Sends Clear Message to Presidential Candidates about Child Health Issues

It’s election season, and there is no shortage of either polls or opinions. A recent national survey by the University of Michigan’s National Poll on Children’s Health found that a majority of adults agree on four major issues they want the presidential candidates to address.

More than 2,100 adults were surveyed, and were asked to select the single most important child health issue from 24 common health concerns. These priorities represented more than half of all responses, and crossed party and ethnic lines:


Because many adult health problems often are seeded in childhood—obesity, heart disease, diabetes, depression—the need for early intervention is acute, and is a matter of public policy.
To see the full report, link here.

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April 13, 2012

Autism Rates Rise

When awareness of a disease or disorder hits critical mass, often its rate of diagnosis increases. That provokes the chicken-and-egg question of which came first, the incidence of disorder or the awareness of it?

In recent years, many people have looked at autism, and the spectrum of autism disorders, through that lens. A recent study boosts the notion that the prevalence of autism in children is increasing. The U.S. Centers for Disease Control and Prevention concluded that 1 in 88 8-year-olds has some form of autism. The previous estimate was 1 in 110.

Based on 2008 data, the updated figure is sure to fuel debate, according to the Los Angeles Times, over whether a growing environmental threat could be responsible. “But autism researchers around the country said the CDC data—including striking geographic and racial variations in the rates and how they have changed—suggest that rising awareness of the disorder, better detection and improved access to services can explain much of the surge, and perhaps all of it.”

Some experts questioned the validity of relying on records to reach the new estimate.
David Mandell, an autism expert at the University of Pennsylvania, told The Times that the CDC's numbers primarily reflect the degree to which the diagnosis and services have become established in different places and among different groups.

"As the diagnosis is associated with more and more services, this becomes a less and less rigorous way to determine the prevalence of autism," he said, referring to the CDC's methods.

Among the CDC’s results:


  • Utah, which has widespread screening programs, had the highest rate—1 in 47 children.

  • New Jersey, which also boasts generous autism services, is next at 1 in 49.

  • Alabama, one of the poorest states in the country, ranked last. Its autism rate fell between 2006 and 2008 from 1 in 167 to 1 in 208.


The study did have limitations. Researchers looked at tens of thousands of health and special education records in 14 states, looking for an autism diagnosis or symptoms that might indicate one. In some areas, researchers had access only to health records, not school records, and prevalence estimates there generally were lower.

The researchers’ goal was to focus attention on the need for more vigorous screening early in life. Early intervention has been shown to confer the best long-term prospects for autistic children. More than 1 in 5 children deemed autistic by the CDC had no such diagnosis in their records.

A recent series of studies in the journal Nature indicated that the genetic origin of autism is complicated and involves multiple genes. The cause of autism is unknown. There is no blood test or other biological marker—it’s diagnosed by symptoms, which are social and communication difficulties starting in early childhood, and repetitive behaviors or abnormally intense interests. The severity of symptoms can vary widely. Boys are more likely to have the disorder, and whites somewhat more likely than minorities. Ultimately, a diagnosis involves clinical judgment.

Some people, including representatives of Autism Speaks, an advocacy group, believe that the disorder is becoming epidemic in the United States. Others say raised awareness of the disorder enables health-care providers and school authorities to deem a child autistic.

To learn the symptoms of autism, link here. Autism Speaks’ Autism Response Team (ART) members are trained to connect families with information, resources and opportunities. Contact them at 888-288-4762.

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March 26, 2012

Early Sleep Problems Signal Later Emotional Troubles

A milestone in child development, at least for many parents, is when the kid finally sleeps through the night. But a recent study suggests that it’s a good idea for parents to monitor how the wee ones are sleeping as well as how long.

Published in the journal Pediatrics, the study shows that children who have problems breathing while they sleep are more likely to experience behavioral problems such as hyperactivity and aggressiveness when they get older. They’re also more likely to have emotional issues such as difficult peer relationships.

Researchers from the University of Michigan and the Albert Einstein College of Medicine at Yeshiva University followed the sleeping patterns of more than 11,000 children for six years. They found that kids who snored, breathed heavily through their mouths and experienced apnea—long pauses between breaths during sleep—were at risk.

Collectively known as sleep-disordered breathing (SDB), the problem peaks when children are between 2 and 6 years old, but can occur when they are younger. Approximately 1 in 10 children snores regularly and 2 to 4 in 100 have sleep apnea, according to the American Academy of Otolaryngology–Health and Neck Surgery (AAO-HNS). Common causes of SDB are enlarged tonsils or adenoids, but be wary of the “quick-fix” of tonsillectomy—as we have reported, that surgical procedure is often unnecessary, and to conclude that tonsils contribute to sleep disorders requires careful diagnosis.

Quite simply, the study’s authors said, “Parents and pediatricians alike should be paying closer attention to sleep-disordered breathing in young children, perhaps as early as the first year of life.”

Although earlier studies indicated sleep problems could signal later difficulties, they involved only small numbers of patients, short follow-up of a single symptom or limited control of individual traits such as low birth weight that could be responsible for some symptoms.

In the new, more substantial study, children whose symptoms peaked between the ages of six and 18 months were much more likely to experience behavioral problems when they were 7 compared with children who breathe normally during sleep. Children whose SDB symptoms persisted throughout the evaluation period, and were most severe at 30 months, expressed the most severe behavioral problems.

Researchers theorize that SDB might be responsible for behavioral problems because of its effect on the brain. Decreased oxygen levels and increased carbon dioxide interrupts the restorative process of sleep and disrupts various chemical systems. Such malfunctions can impair one’s ability to pay attention, plan ahead and organize. They also impede one’s ability to regulate emotions.

To learn more about SDB and treatment options, consult the AAO-HNS fact sheet.

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February 13, 2012

Panel Recommends Suicide Warning Be Added to ADHD Drug Label

A panel of pediatric experts has recommended that the FDA change the label for Focalin to address the risk of suicidal thoughts by children, according to Reuters.

The drug is prescribed for attention deficit disorder and is manufactured by Novartis AG. It was approved for children 6 and older in 2001.

Children with ADHD are excessively restless, impulsive, easily distracted and often have behavioral issues. Symptoms generally are relieved with behavioral therapy and medication (at least short term; the long term benefits of medication are less clear).

The FDA is not required to follow the advice of its panels, but usually does. It is required to hold regular advisory meetings to review the safety of drugs used by children. The panel also recommended that Focalin's label acknowledge the risk of anaphylaxis, an allergic reaction, and angioedema, a type of swelling beneath the skin.

The current label for Focalin advises patients about psychotic or manic side effects, but does not mention suicidal thoughts.

The FDA received eight reports of suicidal thoughts by children or adolescents who took the drug over the last six years. This risk did not present during the clinical trials of the drug, and the number of such reports is tiny in comparison to the number of patients taking it. If your child is taking Focalin, he or she shouldn’t stop taking it. But do consult your pediatrician.

Diagnoses of ADHD (attention deficit hyperactivity disorder) have boomed in recent years; an estimated 3 to 5 kids in 100 are affected. Some experts question whether these diagnoses are made too quickly and drugs prescribed too easily. We’ve addressed the suitability of prescription drugs for ADHD.

According to Reuters, approximately 2.7 million people in the U.S. have prescriptions for ADHD drugs. Approximately 1.8 children received prescriptions for Focalin or its generic versions from 2005 to 2011.

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December 20, 2011

Adults Are Worrying More than Kids Are Sexting

We’ve all heard stories about the unthinking transmission of sexually explicit material via telephone texts. We’ve even been a bystander to the more notorious episodes (two words: Anthony Weiner).

But when the willing participants in such naughty trafficking are children, there is less smirking and more worrying.

But a recent study in the journal Pediatrics concluded that kids don’t text sex stuff as much as conventional thought suggests.

“Sexting”—sending or receiving risqué or even explicit photos or videos on a cellphone—is legally fraught when it involves a minor. It’s a criminal offense. It’s child pornography.

Researcher Kimberly J. Mitchell co-authored two studies in Pediatrics, one of which estimates that in 2008-2009, police in the U.S. investigated 3,500-some cases of sexual images sent by adolescents. In 1 of 3 of those cases, an adult received them.

But there doesn’t appear to be an epidemic of kids sending naked photos of themselves to here, there and everywhere, including the Internet. As a story on Reuters.com noted, youth sexting isn’t as common as earlier polls indicated.

A 2008 survey by the National Campaign to Prevent Teen and Unplanned Pregnancy found that 1 in 5 teens has sent or posted online nude or semi-nude pictures or videos of themselves. Mitchell and her colleagues got much smaller numbers in a 2010 national survey. According to phone interviews with more than 1,500 children 10 to 17 years old, only 2.5 in 100 had appeared in or produced nude or nearly nude photos or videos. And only 1 in 100 did so if only sexually explicit material -- naked breasts, genitals or rear ends -- was included. Around 6 or 7 in 100 adolescents said they'd received such images or videos.

"Overall, our results are actually quite reassuring," Mitchell told Reuters. "With any sort of new technology that kids become involved in there is a tendency to become easily alarmed. What we are instead seeing is that sexting may just make some forms of sexual behavior more visible to adults."

Her advice to parents is to make sure their kids understand the legal risks (being busted for transmitting child porn) and the digital risk of Internet exposure. If someone is a sexting recipient, delete the text immediate and certainly don’t redistribute it.

A spokesman for the National Campaign to Prevent Teen and Unplanned Pregnancy was gratified by the study’s finding, but also a bit skeptical. Bill Albert told Reuters the numbers didn’t surprise him because researchers surveyed younger kids as well as teenagers. As he pointed out, "I wonder if teens are being as truthful as they might be. … It's a good opportunity to sit down with your kid and talk about it."

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September 19, 2011

Treatment for Depression Among Teens Is Troubling

Mental illness. Depression. Suicide. The dark side of the human condition is sad whenever and whomever it strikes. But when the victims are young people, it seems unacceptably unnatural. Yet suicide is the third most common cause of death among teenagers.

So programs such as TeenScreen that survey young people to determine their risk of depression make sense. Those who seem to be at risk are referred for treatment. But John Horgan, writing in Scientific American, raises profound questions about whether screening teens for mental illness is really a good idea for them, or only for a society that wants to feel as though it is doing something.

Some people are opposed to this mental health screening, contending that these issues are private for the youngsters and their families. They contend that they also promote overprescribing of psychiatric medications.

Horgan agrees with the latter concern, noting that:


  • Psychiatrists say that more than 1 in 10 children suffer from mental illnesses — from attention-deficit disorder to full blown psychosis. In 2008, the General Accounting Office estimated that 1 in 16 children is “seriously mentally ill.”

  • The number of children so mentally disabled that their families are eligible for government assistance has swelled from 16,200 in 1987 to 561,569 in 2007, a 35-fold increase. During the same period, those requiring government assistance for all other ailments declined from 728,110 to 559,448.

  • 3.5 million U.S. children take Ritalin and similar medications for (attention deficit hyperactivity disorder) ADHD, up from only 150,000 or so in the late 1970s -- or about 1 in 23 children from 4 to 17.

  • U.S.children consume three times as many ADHD medications as the rest of the world’s children combined.

  • A 2002 study estimates that 1 in 40 children 18 or younger takes antidepressants. Numerous studies indicate that whereas antidepressants can provide short-term relief for some children, some treated with antidepressants may experience side effects ranging from anxiety and insomnia to full-blown mania and psychosis.

  • Since 1995, the number of children diagnosed with bipolar disorder has multiplied more than 40-fold to roughly 800,000.

  • Children diagnosed as bipolar are treated with drugs — notably antipsychotics normally prescribed for adult schizophrenics — that have severe physiological as well as mental side effects, including obesity, diabetes and involuntary tremors.

  • More than 500,000 children (including infants) ingest antipsychotics, a trend The New York Times reported has been aggressively promoted by manufacturers of antipsychotics.


The promoters of TeenScreen, Horgan writes, have ties to the pharmaceutical industry.
Some psychiatrists advocate medicating young people deemed to be “at risk” of schizophrenia based on behavior less than compelling or because they have schizophrenic relatives.

"Mental illness is devastating for children as well as adults," Horgan concludes, "and medication, when used wisely and sparingly, can help. But clearly our current approach to treating disturbed young people is broken."

Certainly, a disturbed, dangerously unhappy teenager deserves medical attention and appropriate intervention. But before parents agree to an aggressive regimen of psychotropic drugs, they should fully inform themselves of the side effects and risks. There are a lot of ways to treat depression. Drugs is only one.

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August 14, 2011

Helping Parents Through the Autism Maze

It’s parental instinct to want to make a child’s world as safe and normal as possible. And when that world is different from the one most other children live in, parents want to know why.

When a pediatrician’s patient lives in the world of autism, explaining the whys and whats to the parents is particularly daunting. Writing in the New York Times recently, Dr. Perri Klass addressed how she relates to parents of autistic children who want to know the cause and, for prospective parents, how they can reduce the risk for children they’re planning to have.

“[A]lthough there is more research in this area than ever before,” she writes, “it sometimes feels as if it’s getting harder, not easier, to provide answers that do justice to the evidence and also offer practical guidance.”

Autism is a complex disorder that research has shown is driven by both genetic and environmental factors. As Klass describes, “Genes matter, but we usually can’t tell how. Environmental exposures matter, but we usually don’t know which.”

Not much there for parents to work with.

A study of autism in twins showed that fraternal twins were both likely to have the disorder, which seems to compromise the strength of the genetic component (since fraternal twins share fewer genes than identical twins).

A couple of generations ago, when ignorance about all mental disorders was evident far more than common sense, autism was blamed on remote parenting. More recently, a noisy campaign was based on fake science supposedly indicating an association between childhood vaccinations and autism, a theory that has been wholly discredited.

But the genetic influences have been proved scientifically sound, and autism spectrum disorder has been described by the American Psychiatric Association as “among the most heritable of psychiatric disorders.”

This evolution of understanding has led scientists to accept that autism results both from genetic predisposition and from environmental influence. But “environment” is a fluid concept.

As one researcher quoted by Klass put it, it’s “everything that’s not the inherited DNA.” Parents might wonder about the chemical ingredients of the placenta’s soup, about the mother’s nutritional profile, her stress level, about the caustic cleaning products under the sink … They’re all part of a developing fetus’s environment.

According to Klass, “The causal links most strongly supported by research include rubella (measles) infection during pregnancy and prenatal exposure to medications like thalidomide and valproic acid, an anti-seizure drug.” Air pollution and exposure to pesticides have an association with autism, but there’s no evidence of causality.

Phthalates, which are chemicals found in flexible plastic products such as shower curtains and other household furnishings such as carpet and shampoo, can leach out in microscopic amounts and disrupt a variety of developmental processes, including brain development. But, again, they haven’t been shown to be a cause of autism, only as an association with its symptoms.

Bottom line: Autism is a custom-made disorder, and probably the result of several factors.
“So it’s hard — and frustrating — to offer prospective parents advice about avoiding risks we still can’t clearly identify,” Klass observes, “and factors that may differ from family to family.”

You can’t completely sanitize your environment, you can’t turn your uterus into a scientific “clean” room — potential toxins are simply a part life. But Klass does offer prospective parents concerned about autism some advice that’s more a prescription of common sense than a prophylactic:


  • Take prenatal vitamins before trying to conceive.

  • Ensure your immunizations are up to date.

  • Get good prenatal care.

  • Discuss the risks and benefits of any medications you take with your doctor.

  • Avoid pesticides.

  • Don’t microwave food plastic containers.

  • Use fragrance-free personal products.


“Still, Klass concludes, “it’s hard to talk about this without terrifying parents. And I wonder if in giving advice about prevention, we risk repeating the errors of the past, making parents feel they’re to blame for a child’s autism because they failed to micromanage an environment full of complex agents with potential to interact with fetal genes in a range of damaging but poorly understood disruptions.”

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August 4, 2011

Bed-Sharing with Mom and Dad Doesn't Hurt Toddlers

Few things are as satisfying in the parent-child relationship as affectionate physical contact. But some psychologists have drawn the line at parents sharing their bed with their children. As noted in a story on WebMD, the American Academy of Pediatrics advises parents not to sleep with their infants because of an increased risk of sudden infant death syndrome, but what about toddlers, who often are the ones seeking the comfort of the parental bed?

Not to worry. New research published in the journal Pediatrics says that toddlers who share a bed with their parents do not face increased risks for behavioral or learning problems at age 5.

"The idea that bed sharing may be bad for toddlers is mostly based on folklore," researcher R. Gabriela Barajas of Teachers College of Columbia University told WebMD. "From what we see, there is no additional risk of behavioral and cognitive problems among toddlers who share a bed with their parents."

The study involved children from 944 low-income families who were assessed at ages 1, 2, 3, 4 and 5. Nearly 50% of families said they had shared a bed at least once; 73% of the families in the study were living below the poverty line. The study did not look at why the children were sleeping in their parents' beds, information that could be critical.

"In some higher socioeconomic groups, co-bedding can be a parenting-style issue and in others, it may be trouble-shooting a sleep problem," said Nanci Yuan, M.D., of the Pediatric Sleep Center at Lucile Packard Children's Hospital at Stanford University.

"If it is because you feel like it is bonding and your child is otherwise healthy, growing, and thriving, then bed sharing is not associated with cognitive and behavioral problems," she said.

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August 1, 2011

Crossing a Street Safely When You Have ADHD

A new study published in the journal Pediatrics offers insight into why children with attention-deficit/hyperactivity disorder (ADHD) are able to observe safety measures when crossing the street, but often fail to do so.

Seventy-eight children from 7 to 10 years years old were involved in the study. Thirty-nine were diagnosed with ADHD and 39 were typically developing children. Researchers looked at three things: (1) how they evaluated their environment before crossing the street; (2) how they decided to begin crossing; and (3) how safe was the environment after the decision to cross was made.

No significant differences emerged in the latter two factors, but the children with ADHD chose riskier pedestrian environments in which to cross. Researchers concluded that this reflected trouble within the brain's "executive function" -- that is, the kids with ADHD were less able to process perceived information necessary to permit a safe cross.

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July 26, 2011

Study Shows Working Mothers Needn't Feel Guilty

Mothers of young children concerned about wagging tongues impugning their parenting ability if they also hold jobs can stop worrying. A new study from the United Kingdom determined that "There was no evidence of detrimental effects of maternal employment in the early years on subsequent child socio-emotional behaviour."

The research, published in the Journal of Epidemiology & Community Health, compared parental employment with the social and emotional behavior of their children at three different ages up to 5. Researchers analyzed if the mothers' work status affected the childrens' risk for problems when they were older.

No surprise that the results indicated that the best situation for any child is one in which both mothers and fathers were present in the household and in paid work, regardless of the mother's educational level and the household income.

But, clearly, one formula that does not compute is Mom + Job=Trouble.

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July 25, 2011

Rat Study Suggests Problems for Ritalin & Prozac Combo for Teens

Many adolescents diagnosed with depression and attention deficity-hyperactivity disorder (ADHD) are prescribed both methylphenidate (Ritalin) and fluoxetine (Prozac). A study on rats given the two drugs might give humans pause.

As reported in the Los Angeles Times, the study showed that adult rats who got that drug combination as pups were more likely than those with no early exposure to psychotropic drugs to choose highly sugared water over plain water, and to linger in a compartment where they had gotten a dose of cocaine, which suggests they were hoping for more. Those are disturbing signs of developing addiction.

"Taking Ritalin and Prozac together during adolescence appears to set in motion subtle changes in brain function that, in adulthood, makes an individual more sensitive to reward as well as to stress, and more likely to exhibit the pessimism and hopelessness seen in depression," was how The Times summarized the study published in the Journal of Neuroscience.

The study's authors wrote, "combining methyphenidate and fluoxetine early in life may lead to lifelong behavioral and chemical abnormalities." They said the drugs--one a stimulant, one an anti-depressant--in combination appeared to act on the brain in much the same way as does cocaine.

Those drugs affect production of certain proteins in the brain's reward circuitry. If it's disrupted during adolescence, the adult later might struggle with the ability to regulate mood and to moderate reward-seeking behavior such as eating or sexual activity.

Baby rats who got only Prozac seemed more sensitive to rewards as adults, but were also more resilient to stress than those who didn't. The rats who got only Ritalin demonstrated less inclination toward sugar water, as well as a "significant aversion to cocaine" as adults--a sign that treating ADHD might thwart drug abuse later. But they also showed greater sensitivity to stress later on.

A rat is not a kid, and a trial subject rat is not depressed or afflicted with ADHD. So no straight line can be drawn between the study results and a child with these disorders who takes these drugs. If the study is notable, it is too preliminary for parents to withhold these drugs if they've been prescribed for their children with mood and behavioral problems. It's never too early, however, for a conversation with your doctor about the appropriate use of prescription drugs, and alternative treatments.

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