Grand Rounds Blog Carnival Vol. 6, No. 8

I'd like to thank Colorado Health Insurance Insider, the host of this week's edition of Grand Rounds, for including my post What Mental Health Parity Means for You. Of interest to readers of this blog is a post by Dr. Nancy Brown at Teen Health 411 - The Ideal Relationship With A Parent. In it a group of teens completed the following sentences. My favorite answer is listed after each.

1. The perfect parent would ...
   

Understand when I need someone to talk to who is more understanding than judgmental.

2. The perfect parent would not ...
   

Treat me like a friend, confidant, or source of support.

3. In the perfect world my parent and I would ...
   

Be able to enjoy each others company, but parent would know when to leave me alone.

Read the complete list and tell me which you aspire to as a parent. Better yet, ask your teenager for his or her answer and share it here.


Grand Rounds is "a weekly summary of the best health blog posts on the internet. Each week a different blogger takes turns hosting Grand Rounds, and summarizing the best submissions for the week...It's the oldest and most popular medical blog carnival on the internet."

Depression in Pre-Schoolers?

When researchers at the Washington University School of Medicine published the first longitudinal study of Major Depressive Disorder (MDD) in preschool children, it came as a surprise to many that young children even get depressed. Most people were unaware that MDD had already been found to be as common among preschoolers as among school-age children (approx. 2%).

The significance of the longitudinal study conducted by Dr. Luby and her colleagues is their evidence that depression in preschoolers is similar to that of school-age children. It's already known that an episode of severe depression in childhood often leads to more episodes as children get older. The researchers examined whether the same was true for preschoolers, that is, whether children depressed at the beginning of the study would be depressed two years later.

They also examined the risk factors that predicted depression both at baseline and at follow-up. Among school-age children, the strongest predictor of depression is a family history of depression. Both genetics and a depressed mother independently contribute to childhood depression. Stressful or traumatic events also predict depression, especially, in combination with a family history.

At the beginning of this study, depressed children were more likely to have mothers with a history of depression compared to children with other psychiatric disorders or no disorder. They also had experienced more traumatic events than the other groups. The types of events included "death of a parent, experience of physical or sexual abuse, and removal from one's home."

At follow-up, the strongest predictor of chronic depression was earlier depression. Children who were diagnosed with MDD at baseline were 4 times as likely to have MDD 2 years later. The second most powerful predictor was a family history of depression. Traumatic events contributed to a lesser degree.

Unfortunately, the popular press has reacted with the usual concerns about stigma and psychiatric medication. As Jennifer Gibson states in How Young is Too Young to Diagnose Depression? | Brain Blogger :

Experts are wary of labeling preschool-aged children with depression, since the diagnostic tools for this age group are not well established. However, early identification of depression may save a child from a lifetime of social and emotional consequences. Many adolescents and adults present to health care providers for mental health treatment, indicating that their symptoms started at an early age, and most adults with depression did, in fact, meet diagnostic criteria for depression in childhood. However, if children are labeled as “depressed” so early in life, are they set up for a lifetime of medications and treatments and stigmatization?

This ignores the opportunity for prevention by treating children who have experienced stressful or traumatic events. Most child clinicians are aware that the death of close relatives, prolonged separations from caretakers, separation and divorce of parents, and chronic abuse or neglect can lead to depression in children. I believe the results of this study provide further support for the early treatment of childhood trauma.

The treatment of choice for preschoolers should be psychotherapy. Given that research has found psychotherapy and medication equally effective at treating depression in adolescents and adults, there is no reason to assume it would be different for young children. For safety reasons, I believe anti-depressant medication should be considered only for children with severe or chronic depression that has not responded to psychotherapy.

Luby, J., Si, X., Belden, A., Tandon, M., & Spitznagel, E. (2009). Preschool Depression: Homotypic Continuity and Course Over 24 Months Archives of General Psychiatry, 66 (8), 897-905 DOI: 10.1001/archgenpsychiatry.2009.97

For those without access to the full article, see Dr. Nestor-Duran's review Depression in preschool children: not a temporary phase. - Child Psychology Research Blog.
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This post was featured in Grand Rounds, Vol. 6, No. 13

What Mental Health Parity Means for You

The outcome of health care reform currently under consideration in Congress is uncertain. Fortunately, legislation was passed last year to improve access to mental health services through health insurance. The 2008 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act requires health insurance and self-insured companies to provide equal benefits for physical, mental, and substance abuse conditions. It takes effect for most insurance plans as of January 1, 2010.

The federal government is in the process of issuing the regulations that will enforce the details of the new law. Insurance companies and employers will have some leeway in what benefits they offer, and some plans are exempt from the law. There will be fewer changes in plans offered in states that already have mental health parity laws.

What does the new law require?

Health insurance plans can no longer provide lesser benefits for mental health or substance abuse conditions. Until now, many plans had higher deductibles, co-pays, and maximum out-of-pocket expenses; lower annual and lifetime dollar limits; and fewer treatment visits and hospital days per year for mental health services. Plans that offered out-of-network benefits for physical health often allowed only in-network benefits for mental health.

The law applies to group plans for companies with more than 50 employees that provide mental health or substance abuse benefits. Individual plans and group plans for companies with 50 or fewer employees do not have to comply. They will continue to follow existing state regulations.

The new law does not require health insurance companies or self-insured employers to include mental health or substance abuse benefits in their plans, but if they do, the benefits must be equal to those for physical health.

What can you expect?

Parity should result in lower out-of-pocket expenses for mental health services. However, employers may choose to provide equal benefits by increasing co-pays and other costs for physical health services. Employers may drop coverage for mental health services altogether to avoid having to provide equal benefits. It also appears that they may be able to exclude all but the most severe mental health disorders from their plans.

Whether or not you have ever used your mental health benefits, you should look carefully at the details in choosing between new plans offered by your employer. A lower cost plan may not cover mental health at all, or cover fewer diagnoses than your current plan does. Don't wait until you need services to find out. And don't assume that no one in your family will need mental health or substance abuse treatment. With 1 in 5 children and 1 and 4 adults needing help for mental illnesses each year, it would be foolish to take the risk.

For more information, see the following factsheets:

APA Help Center - Managed Care & Health Insurance - "How Does the New Mental Health Parity Law Affect My Insurance Coverage?"

Mental Health America: Equity Campaign Parity Legislation
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This post was featured in Grand Rounds, Vol. 6, No. 8

Child Abuse is the Primary Cause of Infant Homicides

Child abuse of any sort is difficult to understand, but the homicide of infants by caretakers is beyond most people's imagination. A new study sheds some light on who commits these acts.

Fujiwara, T., Barber, C., Schaechter, J., & Hemenway, D. (2009). Characteristics of Infant Homicides: Findings From a U.S. Multisite Reporting System PEDIATRICS, 124 (2) DOI: 10.1542/peds.2008-3675

The study reports on 72 cases drawn from the National Violent Injury Statistics System. The system was developed to provide detailed information from multiple sources--death certificates, coroner/medical examiner reports, police reports, and crime laboratories--to be used for public health research. The purpose of this study was to describe features of different types of infant homicide (under age 2) to inform prevention efforts.

Three-quarters of infant homicides were due to beating/shaking by a caretaker (Type 1). The perpetrator was most often the father (43%) or the mother's boyfriend (30%). In almost all cases, emergency medical treatment was sought by either the abuser or another household member. The authors conclude that Type 1 homicides are impulsive and largely unintentional in nature. However, in most cases there was evidence of prior physical abuse. Their recommendations for prevention are early identification of child abuse and education directed at male caretakers.

In contrast, most Type 2 homicides were committed by women (69%), were intentional, and no medical treatment was sought. The deaths were related to domestic violence, psychosis, other crime, or occurred within 24 hours of birth. There were too few cases of each kind to draw conclusions useful for prevention. A larger study would be needed.

Of note, nearly half of the Type 1 homicides were caused by shaking. Young adult males with little or no experience can find it difficult to care for a baby that continually cries. Some will shake a baby out of frustration and anger to stop it crying without realizing the damage shaking will cause. Not all shaken babies die, but survivors' injuries may include severe brain damage, blindness, learning disabilities, and physical impairments.

One hospital-based prevention education program directed at both parents has been successful in reducing the number of cases, and the program has been replicated elsewhere (Upstate New York Shaken Baby Syndrome Education Program). The basic elements of this and other prevention education are to raise awareness of injuries caused by shaking and teach caretakers how to soothe a crying baby and cope with their own frustration.

For more information: The National Center on Shaken Baby Syndrome

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This post was featured in Grand Rounds Vol. 5 No. 51, comes to Paramedicine! « Medic999

Grand Rounds Blog Carnival Vol. 5, No. 44

I've been included in this week's edition of Grand Rounds hosted by Doc Gurley. Grand Rounds is "a weekly summary of the best health blog posts on the internet. Each week a different blogger takes turns hosting Grand Rounds, and summarizing the best submissions for the week...It's the oldest and most popular medical blog carnival on the internet." More info, and the schedule for upcoming editions is available at Better Health Blog.

Thanks to Doc Gurley for including my submission Ten Common Causes of Child Trauma Due to Violence.

Parents Are Concerned about Psychiatric Medications

Popular press coverage has once again raised concern about the use of psychiatric medications to treat emotional and behavioral problems in children. A recent study has linked the use of stimulant medication (such as Ritalin) with 10 deaths in a sample of 564 children and adolescents who died suddenly for unexplained reasons. It's important to note that the study was unable to demonstrate that stimulant medication was the cause of the deaths. For an explanation of the study see Questions Raised About Stimulants and Sudden Death from the National Institute of Mental Health.

Each wave of negative news reports about rare side-effects increases mistrust of psychiatric medications. Previous examples include the long-standing controversy over anti-depressants' effects on suicidal thoughts and behavior. As a result, parents reject medication despite substantial evidence of beneficial effects. Parents are already concerned about whether medications are safe and effective for treating their children's problems. Sensational headlines and profiles of tragic cases only serve to raise fears and provide little helpful information. Seldom is sufficient attention paid to the larger context of risks and benefits for using, and for not using, medication. Stories that end with the usual caveat "these results may not apply to individuals" and a recommendation to "consult your physician" do little to reduce parents' anxiety and confusion.

Yet parents must rely on the professional opinions of physicians--either their child's pediatrician or a child psychiatrist. (My bias is towards the latter--see my previous post.) Research on safety and effectiveness is incomplete, especially, for newer medications. Factors that must be considered in choosing a medication include accurate diagnoses, appropriate and effective dosage, common and uncommon side effects, and interactions with other medications. The effects on children's long-term development may not be known because studies are not completed until long after approval by the U.S. Food and Drug Administration. "Off-label" use of medications that have not been approved for children or other conditions is common with little or no evidence of safety or effectiveness.

Don't get me wrong, I am not advocating the wide-spread use of psychiatric medications. I understand parents' reluctance to consider medication and I am also cautious about recommending it's use. I generally don't suggest medication unless a patient's symptoms are severe (for example, Major Depression), it's a standard treatment for a particular condition (such as ADHD), or there has been insufficient response to psychological therapies. In addition, research has demonstrated for certain conditions that medication or psychotherapy is equally effective, but it is the combination that is most effective. In any case, a careful evaluation is needed to determine what is the best course to take for a particular child or adolescent.

I also believe an underlying factor in negative public response is lack of acceptance that serious mental illness exists among children and adolescents. Popular myths continue to undermine efforts to identify and treat children before their conditions become disabling and affect their long-term development. Contrast the sometimes hysterical public rejection of psychiatric medications associated with very rare serious side effects to the continued acceptance of medications that treat "real" conditions like pain despite much more common side effects. Tara Parker-Pope's blog post Reasons Not to Panic Over a Painkiller and Dr. Rob's Tylenol can Kill are examples of more balanced responses to the recent concerns over acetaminophen.

Besides relying on professional opinions, parents can also educate themselves about psychiatric medications. Here are some good sources of information:

• Mental Health Medications - National Institute of Mental Health
• How can I get information about medications? - Mental Health America
• Medications - National Alliance on Mental Illness
• Psychiatric Medication For Children And Adolescents: Part I-How Medications Are Used, Part II - Types Of Medications, Part III: Questions To Ask - American Academy of Child and Adolescent Psychiatry

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This post was featured in Grand Rounds, Vol. 5, No. 46: Emergiblog

Children's Access to Mental Health Care

Much of the conversation about health care reform has focused on the uninsured and on reducing the costs of medical care. Some attention has been paid to access to services, in particular, the effect of declining numbers of primary care physicians available to treat patients. Often left out of the discussion is access to mental health care.

It's been known for some time that the majority of children and adolescents with mental illness are not getting the treatment they need. The Surgeon General reported ten years ago that 1 in 5 children and adolescents have a diagnosable mental illness; 1 in 10 suffer significant impairment in their day-to-day lives; yet, only 20% of those needing treatment in any one year are identified and receive mental health services.



A recent study illustrates some of the reasons children don't get treatment. A survey of primary care physicians found that two-thirds report being unable to get outpatient mental health services for their patients. Internists, family practitioners, and pediatricians all reported similar problems in referring patients due to no or inadequate health insurance. But it was the pediatricians who reported the greatest difficulty due to health plan barriers and a shortage of mental health providers.(Cunningham, P. J. (Apr. 14, 2009). "Beyond Parity: Primary Care Physicians’ Perspectives on Access to Mental Health Care, Health Affairs Web Exclusive, w490–w500.)

In an op-ed in the Boston Globe, pediatrician Claudia Gold describes her problems in referring children she treats for ADHD when they develop symptoms of serious mental illness. Although the standard-of-care requires referral to a specialist, she has difficulty finding child psychiatrists who can take her patients. In the meantime, she remains responsible for their care. She asks:

So how have we gotten to this unfortunate situation where primary care doctors, who are clearly not qualified, are expected and encouraged to treat children with serious mental illness? I believe three main factors are at work. First, the pharmaceutical industry has been successful at promoting the idea that a pill will fix these often complex problems. Second, the insurance industry has made it very difficult for primary care doctors to refer patients for any mental health services. And third, there is a severe shortage of child psychiatrists.

In my area of the country (outside of Washington, D.C.), the shortage is not so much the number of available child psychiatrists but the number who participate in insurance panels. There is no monetary incentive for them to accept insurance. They can easily fill their practices with patients whose parents are willing to pay their fee. Families who must use their insurance may have to wait two to three months for an appointment.

Primary care physicians are put in the unenviable position of being asked to fill the gap in psychiatric services despite their all-too-justified reservations about doing so. Dr. Rob of Musings of a Distractible Mind tells his own story about a child patient needing medication, and I credit his post for raising my awareness of the primary care physician's side of the problem. He also offers a solution--raise low reimbursement rates to encourage more physicians to specialize in psychiatry.
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This post was featured in Grand Rounds, Vol. 5, No. 47 - Cost Containment In Healthcare : The Covert Rationing Blog

Ten Common Causes of Child Trauma Due to Violence

I started this post several weeks ago to answer the question "What are the most common causes of child trauma?" It was much harder than I expected. The task of reviewing statistics wasn't just comparing apples to oranges. It was, instead, like comparing the ingredients of a fruit salad. The statistics varied greatly, in part, due to differences in research design:

• Some studies reported how many children experienced traumatic events in one year while others reported lifetime experience (incidence vs prevalence).
• Some included only children or adolescents while others asked adults to report on their entire childhood.
• Most focused on one type of trauma (for example child sexual abuse) rather than a wider range of traumatic experiences.
  
• Most weren't large enough or representative enough of the entire nation to draw firm conclusions. (Unfortunately, few researchers are able to obtain the funding needed to conduct large, representative studies.)
• Those that relied on victim reports to child welfare or law enforcement weren't able to estimate the number of victims who had not reported.
  

There are several ways to estimate how many children have experienced trauma. One way is to ask about a short period of time (incidence) rather than a person's entire childhood (prevalence). Some advantages of this approach is that it relies less on memory, and it is easier to compare different ages. Otherwise, when asked if an event has ever occurred, more teenagers are likely to report an experience than younger children simply because they've had more years for it to have happened.

A disadvantage is that the results do not reflect the full magnitude of a problem which is often better represented by an estimate of prevalence. For example, a familiar childhood statistic such as "one out of four girls experience sexual victimization before age 18" will be higher than the number of girls victimized in one year. Still, the advantages can outweigh the disadvantages when comparing rates across various traumatic experiences within different age groups, and a one-year snapshot of new cases can be more useful for current policy and service delivery.

My list is limited to child trauma caused by violence because there has been more research done for it than for other traumas (such as disaster or accidental injury). I selected a single study that included a wide range of violence-related victimizations by David Finkelhor and colleagues designed to address many of the issues listed above.

Finkelhor, D., Ormrod, R., Turner, H., & Hamby S. L. (2005). The Victimization of Children and Youth: A Comprehensive, National Survey Child Maltreatment, 10 (1), 5-25 DOI: 10.1177/1077559504271287


Their study included:

• a large, nationally representative sample of children ages 2 to 17
• younger children (through interviews with their parents)
  
• a comprehensive list of child abuse and other victimization experiences
• examined the number of victims for each trauma during one year
• relied on direct reports rather indirect statistics collected by reporting agencies
• reported how many children experienced multiple traumas

Of the 34 different direct and indirect victimizations included in the study, I've selected the top ten I believe best fit the criteria needed to diagnose PTSD. I converted population rates (number per 1000) to percentages more familiar to most readers. I've also included the definition of each trauma used in the study.

1. Bullying - 22% - A peer picked on child (for example, by chasing, grabbing hair or clothes, or making child do something he or she did not want to do).

2. Assault with injury - 10% - Someone hit or attacked child, and child was physically hurt when this happened. (Hurt means child felt pain the next day, or had a bruise, a cut that bled, or a broken bone.) No weapon was used.

3. Assault with a weapon - 8% - Someone hit or attacked child on purpose with something that would hurt (like a stick, rock, gun, knife or other thing).

4. Exposure to shooting, bombs, riots - 6%
Child was in a place (in real life) where child could see or hear random shootings, terror bombings, or riots.

5. Non-sexual genital assault - 5% - A peer tried to hurt child's private parts on purpose by hitting or kicking.

6. Robbery by nonsibling- 4% - A nonsibling (peer or adult) used force to take something away from child that child was carrying or wearing.

7. Physical abuse by caregiver - 4%
An adult in child's life hit, beat, kicked, or physically abused child in any way.

8. Witness domestic violence - 4% - Child saw one parent get hit (for example, slapped, hit, punched, or beat up) by another parent, or parent's boyfriend or girlfriend.

9. Sexual assault - 3% - Someone touched child's private parts when unwanted, make child touch their private parts, or forced child to have sex. Or attempted any of these acts.

10. Murder of someone close - 3% - Someone close to child (for example, family member, friend, or neighbor) was murdered.

There are some surprises here. Bullying was the most common. Significant numbers of children in the United States have been exposed to shootings, bombs, or riots. Many children have had someone close to them murdered though perhaps this shouldn't be surprising given the U.S.'s high murder rate.

In this article, I've focused on the number of children in the United States who experience trauma related to violence. In future articles, I will address other forms of child trauma such as disaster or serious accidents. I will also, from time to time, provide an in-depth look at items in the list including what is known about rates of PTSD and other negative consequences.
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This post was featured in Doc Gurley » Grand Rounds, Vol. 5, No. 44: Mystery!

Grand Rounds Blog Carnival Vol. 5, No. 36

Slightly off-topic, I've been included in this week's edition of Grand Rounds hosted by See First which is exciting to me, at least, as it's my first time. For those of you who don't know what I'm talking about, Grand Rounds is "a weekly summary of the best health blog posts on the internet. Each week a different blogger takes turns hosting Grand Rounds, and summarizing the best submissions for the week...It's the oldest and most popular medical blog carnival on the internet." It's featured at Medscape when there is a new host. More info, and the schedule for upcoming editions is available at Better Health Blog.

Thanks to See First for including my submission "Debate about ADHD Multimodal Treatment Study," and to Dr. Helen for linking back to my post.