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Behavior ’ Category
Thursday, December 19th, 2013
The biggest news in 2013 on Pediatric Bipolar Disorder (PBD) centered on a new diagnosis in the DSM-5 – Disruptive Mood Dysregulation Disorder (DMDD) – introduced in part to prevent the overdiagnosis of bipolar disorder in youth. The idea was to provide a separate diagnostic category for kids who have explosive emotional outbursts and severe disruptive behavior without other signals of PBD.
This situation represents another lightning rod in the debates on how we diagnosis psychiatric disorders in youth. Some applaud the attempt to reduce misdiagnosis of PBD. Some argue that while this is a good thing, it’s a bad thing to introduce yet another diagnosis that can lead to medicating kids who may not “have” a disorder.
The fact is that research has validated the use of a PBD diagnosis in youth via clinical and longitudinal studies – but it is very difficult to diagnose at any one moment in time in youth. There is no substitute for evaluation performed by a team that includes substantial experience in assessing PBD – I have personally seen clinicians with little experience with PBD applying the diagnosis inappropriately. What is disconcerting is that the DMDD category was introduced in DSM-5 without the typical platform of studies examining the reliability and (especially) predictive validity of the diagnosis.
Let’s anticipate that the discussions about PBD and DMDD will spur intensive studies focused on differential diagnosis and clinical utility of each diagnostic category.
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Wednesday, December 18th, 2013
Is ADHD underdiagnosed? Overdiagnosed? Overtreated? Undertreated?
These questions continue to get debated in 2013 with no resolution. On the one hand, we see statistics indicating how the rate of ADHD is going up – although many times these studies do not perform gold standard diagnoses of kids but rather report how many kids have been given a diagnosis. Yet talk to many practitioners and they will have stories of kids who clearly show evidence of ADHD yet do not receive a diagnosis.
How do we make sense of all this? One lens to apply is a simple one: we need to know how kids are getting diagnosed. I have contented that we have an ADHD paradox in this country – many kids get the label (and a pill) when they probably wouldn’t be diagnosed if they went through a comprehensive evaluation, yet many kids with ADHD are not properly diagnosed and treated (including behavioral and psychosocial interventions) because they don’t get a comprehensive evaluation. The common denominator here is a lack of a comprehensive evaluation. Ideally this is done by an experienced team that can apply a multidisciplinary perspective to fully examine cognitive, neuropsychological, behavioral, educational, and emotional functioning – and then offer an evidence-based plan of action.
That’s what is lacking. But it takes funding, insurance coverage, and a national commitment to mental health research and treatment.
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Wednesday, December 18th, 2013
Two themes stand out when I reflect on autism research in 2013.
First, there was substantial debate about how we diagnose autism, primarily spurred by changes introduced in DSM-5 (which was published in May). The reformulation of the diagnostic criteria – which led to a discontinuation of the category of Asperger Syndrome in favor of a broad-based category of Autism Spectrum Disorder (ASD) – spurred concerns that many youth would no longer qualify for a diagnosis and hence have their intervention options limited. Others suggested that more precise diagnostic criteria are needed to ensure that ASD does not get overdiagnosed. While we await empirical resolution via publication of well-designed studies, it’s clear that the DSM-5 debate will stand out as an important time in which we wrestled (again) with the best way to be inclusive in diagnosis without expanding diagnostic criteria too broadly.
Second, we are seeing more research on the early diagnosis of ASD, or at least detection of early warning signs, using methods like tracking eye movements of babies when looking at a human face. While this line of work will need to continue to refine the validity and feasibility of the approach – particularly when studying infants – it is an intriguing approach that may eventually have important implications for delivering interventions in the first year of life. Given the proven utility of early intervention, the hope is that the earliest interventions may hold the most promise for promoting development.
Wherever these research directions take us, we know for sure that early detection and intervention is essential. That’s one message that has not changed in 2013.
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ASD, Asperger Syndrome, autism, babies, diagnosis, DSM 5, Health, infants, Kids Health, Psychiatric Disgnosis | Categories:
Behavior, Health, Intervention, Must Read, Parenting, Red-Hot Parenting
Friday, December 6th, 2013
As we mark the one year anniversary of the Sandy Hook shooting, it is a salient time to consider the substantial public health challenges that were raised by that tragedy – and that still remain. Three are most prominent.
School safety is an ever-present concern. Although no school can eliminate the potential for a tragedy, strides are being made at many schools across the country to put into place practices and technologies to keep children as safe as possible. It has been suggested that 90% of school systems have made some type of concrete change to improve school safety in response to the Sandy Hook tragedy. Lock down drills have become a reality for children, practiced with the regularity and acceptance of a fire drill. Teachers and administrators are trained to know how to react in the event of an attack and how to best try to secure the safety of their students.
Some schools have video surveillance systems in place that are monitored for potentially suspicious activity. Schools may have changed their policies concerning entry at different times of the day. And at some schools there is a police presence or security guards in place. Yet these types of changes will undoubtedly need to be evaluated, and potentially evolve over time. It does appear, however, that that sad and startling day at Sandy Hook Elementary promoted a nearly universal awareness that no school can be assumed to be safe – and that every school needs to take a comprehensive approach to trying to best ensure their students’ safety.
Gun control – always a polarizing topic – remains a hotly contested issue in the aftermath of Sandy Hook. There have been some actions to promote gun control in some states, and some reactions to ensure gun owner’s rights in other states. As the swinging pendulum of gun control plays out across the country – evidenced by the current swirl of debate surrounding how access to firearms should be regulated – what remains most clear is that we are no where close to coming up with a focused effort to reduce the likelihood of someone with a gun entering a school and killing children and adults. Most influential – and sobering and inspiring – has been the efforts of Sandy Hook parents to promote a ‘cultural change campaign’ to properly orient our attention on violence prevention, particularly gun violence aimed at our children. It is hoped that this effort will inspire a change in our collective mindset that will do away with the philosophical rhetoric about the pros and cons of gun control and gun rights and focus instead on ways to prevent gun violence from permeating our schools.
Mental health remains another core public health issue that has been illuminated by the Sandy Hook massacre. We have yet to get a good handle – at the most public level – on the burdens faced by those with mental illness, the importance of properly recognizing and treating those who suffer, and the myths and realities about the risk posed to society by some individuals. What can be stated with confidence is that despite the substantial progress made over the last few decades in the identification and treatment of mental illness, we simply need much more support for research and intervention.
This unfortunately comes at a time when our national finances are such that research funding has been cut dramatically over the last few years. We just witnessed a government shutdown that kept scientists away from doing their work. Deciphering the inner workings of the brain, the effects of genes on development, and the impact of a multitude of environmental factors that convey risk for mental illness is a task of extraordinary complexity. Bringing sustainable, evidence-based interventions to those in the population who need them is a daunting undertaking. Until we grasp how important this effort is, and embrace how much financial support it will take, we may find ourselves wondering and debating if a future shooting could have been prevented via advances in knowledge and practice.
Although these three public health challenges remain, it is good to know that they are at least not being dismissed or are fading away. We may eventually look back on that horrific day at Sandy Hook Elementary as a turning point and catalyst for making real and sustainable progress in our efforts to keep children safe in school.
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Gun Control, Health, Kids Health, Mental Health, public health, Sandy Hook Anniversary, Sandy Hook Shooting, School Safety | Categories:
Behavior, Health, Must Read, Parenting, Questions, Red-Hot Parenting, Stories
Monday, November 25th, 2013
When discussing the 4 types of sibling relationships, the unique profile of siblings who have high levels of both positivity and negativity in their relationship was flagged. Why is this group particularly salient to researchers who study siblings? Because they are more likely to get in trouble – together.
The idea was formalized decades ago by the late Dr. David Rowe. He was studying twins and examining their similarity for delinquent behavior during the teen years. He found that twins were very much alike in this regard – if one twin was getting into trouble, the other twin was likely to do so as well. But the key observation was that this similarity was not due to genetics – something the twin design gets at by comparing identical and fraternal twins. Similarity for DNA didn’t matter much. What mattered was how much time the twins spent together, and if they had common friends.
Now of course just spending time together with a sibling doesn’t promote delinquency. Over the years, research has shown that the combination of both high positivity – hanging out, having fun, having common friends – and high negativity – fighting, arguing – signals the possibility of rule breaking behavior in the teen years. Observational research shows how this can happen. These sibs end up laughing and fighting at the same time – and they end up enjoying and reinforcing each other’s negative behaviors (one hits, the other laughs, hits back, they laugh). Getting into trouble becomes fun. Other studies show how this becomes a mechanism by which an older sibling introduces a younger sibling to substances at very early ages – ages which are problematic. These influences are most prominent when sibs are closer in age (typically within a few years) – but the principle applies to both brothers and sisters (so it’s not just limited to boys).
So what’s a parent to do? How do you know if what’s going on is just part of the complex sib relationship – or the foundation for legal difficulties in the teen years? A few things to keep in mind. First, maintain good limit setting and monitoring – sibs can join forces and undermine parental efforts. Second, don’t let the negative get out of hand in the early years. Just because it’s normative for sibs to argue and fight now and then doesn’t mean it should define their relationship – it becomes habit and carries over to other social relationships. Third, keep an eye on what the older sib is introducing to the younger sib – no 12-year-old should be exposed to drinking or substances.
While sibling relationship features don’t guarantee developmental pathways, having insight into the ways in which the sibling bond can lead to problem behaviors.
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Brothers, Delinquency, Health, Kids Health, Siblings, Sisters, Teen Drinking, teen drug use | Categories:
Behavior, Genetics, Health, Must Read, Parenting, Red-Hot Parenting, Relationships