Amy Karon

Elderly patients with type 2 diabetes had diminished frontal brain activity on functional magnetic resonance imaging that correlated with deficits in working memory and executive function, investigators have reported. The results were published online Nov. 17.

“To our knowledge, this study is the first to detect the specific brain mechanisms related to diabetes-induced working memory dysfunction,” wrote Dr. Yaojing Chen of Beijing Normal University, China.

Patients with diabetes also exhibited varying frontal brain deficits depending on the difficulty of the working memory tasks they were asked to perform. The left inferior frontal gyrus had reduced brain activation during easier tasks, while the middle frontal gyrus and the superior frontal gyrus were affected during more difficult tasks (Diabetes Care 2014 Nov. 17 [doi: 10.2337/dc14-1683]).

Type 2 diabetes is known to expedite brain aging and increase the risk of Alzheimer’s disease. Affected patients can develop deficits in executive functioning, attention, memory, and visuospatial abilities, the researchers noted. To visualize the specific structures affected, the researchers performed functional magnetic resonance imaging (fMRI) of 67 patients from the Beijing Aging Brain Rejuvenation Initiative, a longitudinal study of aging and cognitive impairment in the urban elderly population of Beijing.

Patients in the study had no history of dementia or psychiatric illness, coronary artery disease, nephritis, cancer, or gastrointestinal disease.

Compared with 37 controls, the patients with diabetes performed significantly worse on several working memory tasks, including the backward digit span, the digit span, and the Stroop Color and Word Test, which is an executive function task, the researchers reported.

Patients with diabetes also had less fMRI activation in several frontal brain areas, including the right superior frontal gyrus, the bilateral medial frontal gyrus, and the inferior frontal gyrus. Furthermore, the diabetes group had lower fMRI activation of the left inferior frontal gyrus (Brodmann area 13) in the 1-back versus 0-back (working memory) condition, and had less activation of the left middle frontal gyrus and the superior frontal gyrus in the 2-back versus 0-back comparison, they added. “These findings indicate that with increasing task difficulty, additional frontal brain regions might have been recruited to play compensatory roles to complete the harder task,” they said.

Larger longitudinal studies would be needed to confirm the findings and explore their potential for predicting early cognitive changes in patients with type 2 diabetes, they noted.

The research was funded by the Beijing New Medical Discipline Based Group, the Natural Science Foundation of China, the Institute of Basic Research in Clinical Medicine, the China Academy of Chinese Medical Sciences, and the program for New Century Excellent Talents in University. The researchers declared no conflicts of interest.

Elderly patients with type 2 diabetes had diminished frontal brain activity on functional magnetic resonance imaging that correlated with deficits in working memory and executive function, investigators have reported. The results were published online Nov. 17.

“To our knowledge, this study is the first to detect the specific brain mechanisms related to diabetes-induced working memory dysfunction,” wrote Dr. Yaojing Chen of Beijing Normal University, China.

Patients with diabetes also exhibited varying frontal brain deficits depending on the difficulty of the working memory tasks they were asked to perform. The left inferior frontal gyrus had reduced brain activation during easier tasks, while the middle frontal gyrus and the superior frontal gyrus were affected during more difficult tasks (Diabetes Care 2014 Nov. 17 [doi: 10.2337/dc14-1683]).

Type 2 diabetes is known to expedite brain aging and increase the risk of Alzheimer’s disease. Affected patients can develop deficits in executive functioning, attention, memory, and visuospatial abilities, the researchers noted. To visualize the specific structures affected, the researchers performed functional magnetic resonance imaging (fMRI) of 67 patients from the Beijing Aging Brain Rejuvenation Initiative, a longitudinal study of aging and cognitive impairment in the urban elderly population of Beijing.

Patients in the study had no history of dementia or psychiatric illness, coronary artery disease, nephritis, cancer, or gastrointestinal disease.

Compared with 37 controls, the patients with diabetes performed significantly worse on several working memory tasks, including the backward digit span, the digit span, and the Stroop Color and Word Test, which is an executive function task, the researchers reported.

Patients with diabetes also had less fMRI activation in several frontal brain areas, including the right superior frontal gyrus, the bilateral medial frontal gyrus, and the inferior frontal gyrus. Furthermore, the diabetes group had lower fMRI activation of the left inferior frontal gyrus (Brodmann area 13) in the 1-back versus 0-back (working memory) condition, and had less activation of the left middle frontal gyrus and the superior frontal gyrus in the 2-back versus 0-back comparison, they added. “These findings indicate that with increasing task difficulty, additional frontal brain regions might have been recruited to play compensatory roles to complete the harder task,” they said.

Larger longitudinal studies would be needed to confirm the findings and explore their potential for predicting early cognitive changes in patients with type 2 diabetes, they noted.

The research was funded by the Beijing New Medical Discipline Based Group, the Natural Science Foundation of China, the Institute of Basic Research in Clinical Medicine, the China Academy of Chinese Medical Sciences, and the program for New Century Excellent Talents in University. The researchers declared no conflicts of interest.

Elderly patients with type 2 diabetes had diminished frontal brain activity on functional magnetic resonance imaging that correlated with deficits in working memory and executive function, investigators have reported. The results were published online Nov. 17.

“To our knowledge, this study is the first to detect the specific brain mechanisms related to diabetes-induced working memory dysfunction,” wrote Dr. Yaojing Chen of Beijing Normal University, China.

Patients with diabetes also exhibited varying frontal brain deficits depending on the difficulty of the working memory tasks they were asked to perform. The left inferior frontal gyrus had reduced brain activation during easier tasks, while the middle frontal gyrus and the superior frontal gyrus were affected during more difficult tasks (Diabetes Care 2014 Nov. 17 [doi: 10.2337/dc14-1683]).

Type 2 diabetes is known to expedite brain aging and increase the risk of Alzheimer’s disease. Affected patients can develop deficits in executive functioning, attention, memory, and visuospatial abilities, the researchers noted. To visualize the specific structures affected, the researchers performed functional magnetic resonance imaging (fMRI) of 67 patients from the Beijing Aging Brain Rejuvenation Initiative, a longitudinal study of aging and cognitive impairment in the urban elderly population of Beijing.

Patients in the study had no history of dementia or psychiatric illness, coronary artery disease, nephritis, cancer, or gastrointestinal disease.

Compared with 37 controls, the patients with diabetes performed significantly worse on several working memory tasks, including the backward digit span, the digit span, and the Stroop Color and Word Test, which is an executive function task, the researchers reported.

Patients with diabetes also had less fMRI activation in several frontal brain areas, including the right superior frontal gyrus, the bilateral medial frontal gyrus, and the inferior frontal gyrus. Furthermore, the diabetes group had lower fMRI activation of the left inferior frontal gyrus (Brodmann area 13) in the 1-back versus 0-back (working memory) condition, and had less activation of the left middle frontal gyrus and the superior frontal gyrus in the 2-back versus 0-back comparison, they added. “These findings indicate that with increasing task difficulty, additional frontal brain regions might have been recruited to play compensatory roles to complete the harder task,” they said.

Larger longitudinal studies would be needed to confirm the findings and explore their potential for predicting early cognitive changes in patients with type 2 diabetes, they noted.

The research was funded by the Beijing New Medical Discipline Based Group, the Natural Science Foundation of China, the Institute of Basic Research in Clinical Medicine, the China Academy of Chinese Medical Sciences, and the program for New Century Excellent Talents in University. The researchers declared no conflicts of interest.

An online behavioral intervention helped overweight and obese patients lose an average of 5.5 kilograms in 3 months and maintain that loss at 6 months, according to a prospective randomized study. The results were published online Nov. 17 in Diabetes Care.

The almost fully automated program “is an effective, potentially low-cost option that physicians could use with their overweight and obese patients to reduce the risk of type 2 diabetes and other weight-related diseases,” said John G. Thomas, Ph.D., of Brown University, Providence, R.I.

©KeithBrofsky/thinkstockphotos.com

At 3 months, 41 (53%) of program participants had lost at least 5% of their body weight, and 37 (48%) met that target at 6 months, the researchers said. The control group lost an average of 1.3 kilograms. The findings show that to lose weight, patients need more than physician advice and basic information about diet and exercise, wrote Dr. Thomas and his associates (Diabetes Care 2014 Nov. 17 [doi: 10.2337/dc14-1474]).

The study comprised 154 patients aged 18-70 years whose body mass index was between 25 and 45 kg per m². Eighty percent were women, and most were non-Hispanic whites.

Every week, the intervention group was asked to view a 10- to 15-minute interactive video on topics such as eating in restaurants, changing the home environment, and social support. These patients also used a website to report their daily calorie intake, exercise, and body weight, and received automated feedback based on their progress. In contrast, the control group was asked to view weekly online newsletters about the benefits of healthy eating, weight loss, and exercise, the investigators noted.

Compared with controls, the intervention group reported significantly more weeks in which they had cut their calorie and fat intake, consumed more fruits and vegetables, and exercised more than at baseline, the researchers said. Differences for the calorie and fat measures remained significant at 6 months, and the others trended toward significance, they reported. “Given that about 80% of U.S. adults use the Internet, this approach may provide a cost-effective alternative or complement to the face-to-face counseling models of obesity treatment, including that which is currently reimbursable by the Centers for Medicare & Medicaid Services,” they added.

Participants in behavioral weight loss programs tend to initially lose weight and then slowly regain it, but the researchers noted that they did not follow patients at the time point when they would be most likely to regain weight. The study design required patients to visit an academic medical center several times, and that could have influenced the results, the researchers added.

The National Heart, Lung, and Blood Institute funded the study. The authors reported having no conflicts of interest.

An online behavioral intervention helped overweight and obese patients lose an average of 5.5 kilograms in 3 months and maintain that loss at 6 months, according to a prospective randomized study. The results were published online Nov. 17 in Diabetes Care.

The almost fully automated program “is an effective, potentially low-cost option that physicians could use with their overweight and obese patients to reduce the risk of type 2 diabetes and other weight-related diseases,” said John G. Thomas, Ph.D., of Brown University, Providence, R.I.

©KeithBrofsky/thinkstockphotos.com

At 3 months, 41 (53%) of program participants had lost at least 5% of their body weight, and 37 (48%) met that target at 6 months, the researchers said. The control group lost an average of 1.3 kilograms. The findings show that to lose weight, patients need more than physician advice and basic information about diet and exercise, wrote Dr. Thomas and his associates (Diabetes Care 2014 Nov. 17 [doi: 10.2337/dc14-1474]).

The study comprised 154 patients aged 18-70 years whose body mass index was between 25 and 45 kg per m². Eighty percent were women, and most were non-Hispanic whites.

Every week, the intervention group was asked to view a 10- to 15-minute interactive video on topics such as eating in restaurants, changing the home environment, and social support. These patients also used a website to report their daily calorie intake, exercise, and body weight, and received automated feedback based on their progress. In contrast, the control group was asked to view weekly online newsletters about the benefits of healthy eating, weight loss, and exercise, the investigators noted.

Compared with controls, the intervention group reported significantly more weeks in which they had cut their calorie and fat intake, consumed more fruits and vegetables, and exercised more than at baseline, the researchers said. Differences for the calorie and fat measures remained significant at 6 months, and the others trended toward significance, they reported. “Given that about 80% of U.S. adults use the Internet, this approach may provide a cost-effective alternative or complement to the face-to-face counseling models of obesity treatment, including that which is currently reimbursable by the Centers for Medicare & Medicaid Services,” they added.

Participants in behavioral weight loss programs tend to initially lose weight and then slowly regain it, but the researchers noted that they did not follow patients at the time point when they would be most likely to regain weight. The study design required patients to visit an academic medical center several times, and that could have influenced the results, the researchers added.

The National Heart, Lung, and Blood Institute funded the study. The authors reported having no conflicts of interest.

An online behavioral intervention helped overweight and obese patients lose an average of 5.5 kilograms in 3 months and maintain that loss at 6 months, according to a prospective randomized study. The results were published online Nov. 17 in Diabetes Care.

The almost fully automated program “is an effective, potentially low-cost option that physicians could use with their overweight and obese patients to reduce the risk of type 2 diabetes and other weight-related diseases,” said John G. Thomas, Ph.D., of Brown University, Providence, R.I.

©KeithBrofsky/thinkstockphotos.com

At 3 months, 41 (53%) of program participants had lost at least 5% of their body weight, and 37 (48%) met that target at 6 months, the researchers said. The control group lost an average of 1.3 kilograms. The findings show that to lose weight, patients need more than physician advice and basic information about diet and exercise, wrote Dr. Thomas and his associates (Diabetes Care 2014 Nov. 17 [doi: 10.2337/dc14-1474]).

The study comprised 154 patients aged 18-70 years whose body mass index was between 25 and 45 kg per m². Eighty percent were women, and most were non-Hispanic whites.

Every week, the intervention group was asked to view a 10- to 15-minute interactive video on topics such as eating in restaurants, changing the home environment, and social support. These patients also used a website to report their daily calorie intake, exercise, and body weight, and received automated feedback based on their progress. In contrast, the control group was asked to view weekly online newsletters about the benefits of healthy eating, weight loss, and exercise, the investigators noted.

Compared with controls, the intervention group reported significantly more weeks in which they had cut their calorie and fat intake, consumed more fruits and vegetables, and exercised more than at baseline, the researchers said. Differences for the calorie and fat measures remained significant at 6 months, and the others trended toward significance, they reported. “Given that about 80% of U.S. adults use the Internet, this approach may provide a cost-effective alternative or complement to the face-to-face counseling models of obesity treatment, including that which is currently reimbursable by the Centers for Medicare & Medicaid Services,” they added.

Participants in behavioral weight loss programs tend to initially lose weight and then slowly regain it, but the researchers noted that they did not follow patients at the time point when they would be most likely to regain weight. The study design required patients to visit an academic medical center several times, and that could have influenced the results, the researchers added.

The National Heart, Lung, and Blood Institute funded the study. The authors reported having no conflicts of interest.

SAN DIEGO – Clinicians who perform cryolipolysis should inform patients about the risk of paradoxical adipose hyperplasia, “a newly described, rare side effect” consisting of a “usually permanent” increase in fatty tissue at the treatment site, said Dr. Andrew Nelson, a dermatologist in private practice in St. Petersburg, Fla.

Based on case reports to date, the estimated incidence of paradoxical adipose hyperplasia (PAH) is only about 0.0051%, or 1 case per 20,000 treatment cycles, Dr. Nelson added. But use of cryolipolysis is growing rapidly, including use among physician extenders, he noted. “We should be counseling all our patients on the possibility of PAH, and we need to generate more data to determine its cause and the best treatment options.”

© AndreyPopov/Thinkstock

Even a single cycle of cryolipolysis can trigger PAH, which seems to occur at least 2-3 months later and requires invasive treatment to resolve, Dr. Nelson said at the annual meeting of the American Society for Dermatologic Surgery (ASDS). “Most patients report an initial reduction of fat before PAH develops,” he added.

Histology at the site of PAH typically shows disorganized adipocytes that vary more in size and shape than does normal panniculus, but the overlying dermis and epidermis appear normal. About half of cases reported to date have involved men, “but women are treated at a higher rate than men, so there may be a preponderance of men,” he said.

No one knows why PAH occurs, Dr. Nelson noted. Possibilities include recruitment of local or circulating preadipocytes or stem cells; changes in the expression of receptors or soluble factors that play a role in adipocyte metabolism; reduced sympathetic innervation; and hypoxic injury, he said. Hypoxic injury is known to spur capillary growth, which can cause fat hypertrophy, he added.

In a case reported at the ASDS meeting by Dr. Brian Raphael, a 75-year-old woman developed PAH approximately 4 months after undergoing two sessions of cryolipolysis that had been spaced 1 month apart. The adipose tissue had accumulated in the center of the treatment site “in a distribution identical to the device applicator,” Dr. Raphael and his associates reported. They performed a wedge biopsy to confirm that the fat accumulation was benign, and then carried out a pannectomy to remove the unwanted fat, they said.

Cryolipolysis works by slowly cooling adipocytes, which are more sensitive to temperature decreases than epidermal and dermal cells, Dr. Nelson said. The adipocytes crystallize, which is thought to trigger their apoptosis and gradual elimination from the body in the months after treatment. Adverse effects besides PAH are usually mild and include edema, pain, and temporary redness at the treatment site, he noted. About two-thirds of patients also have a temporary, localized loss of sensation that can last up to 8 weeks, he added.

Dr. Nelson and Dr. Raphael reported no conflicts of interest.

SAN DIEGO – Clinicians who perform cryolipolysis should inform patients about the risk of paradoxical adipose hyperplasia, “a newly described, rare side effect” consisting of a “usually permanent” increase in fatty tissue at the treatment site, said Dr. Andrew Nelson, a dermatologist in private practice in St. Petersburg, Fla.

Based on case reports to date, the estimated incidence of paradoxical adipose hyperplasia (PAH) is only about 0.0051%, or 1 case per 20,000 treatment cycles, Dr. Nelson added. But use of cryolipolysis is growing rapidly, including use among physician extenders, he noted. “We should be counseling all our patients on the possibility of PAH, and we need to generate more data to determine its cause and the best treatment options.”

© AndreyPopov/Thinkstock

Even a single cycle of cryolipolysis can trigger PAH, which seems to occur at least 2-3 months later and requires invasive treatment to resolve, Dr. Nelson said at the annual meeting of the American Society for Dermatologic Surgery (ASDS). “Most patients report an initial reduction of fat before PAH develops,” he added.

Histology at the site of PAH typically shows disorganized adipocytes that vary more in size and shape than does normal panniculus, but the overlying dermis and epidermis appear normal. About half of cases reported to date have involved men, “but women are treated at a higher rate than men, so there may be a preponderance of men,” he said.

No one knows why PAH occurs, Dr. Nelson noted. Possibilities include recruitment of local or circulating preadipocytes or stem cells; changes in the expression of receptors or soluble factors that play a role in adipocyte metabolism; reduced sympathetic innervation; and hypoxic injury, he said. Hypoxic injury is known to spur capillary growth, which can cause fat hypertrophy, he added.

In a case reported at the ASDS meeting by Dr. Brian Raphael, a 75-year-old woman developed PAH approximately 4 months after undergoing two sessions of cryolipolysis that had been spaced 1 month apart. The adipose tissue had accumulated in the center of the treatment site “in a distribution identical to the device applicator,” Dr. Raphael and his associates reported. They performed a wedge biopsy to confirm that the fat accumulation was benign, and then carried out a pannectomy to remove the unwanted fat, they said.

Cryolipolysis works by slowly cooling adipocytes, which are more sensitive to temperature decreases than epidermal and dermal cells, Dr. Nelson said. The adipocytes crystallize, which is thought to trigger their apoptosis and gradual elimination from the body in the months after treatment. Adverse effects besides PAH are usually mild and include edema, pain, and temporary redness at the treatment site, he noted. About two-thirds of patients also have a temporary, localized loss of sensation that can last up to 8 weeks, he added.

Dr. Nelson and Dr. Raphael reported no conflicts of interest.

SAN DIEGO – Clinicians who perform cryolipolysis should inform patients about the risk of paradoxical adipose hyperplasia, “a newly described, rare side effect” consisting of a “usually permanent” increase in fatty tissue at the treatment site, said Dr. Andrew Nelson, a dermatologist in private practice in St. Petersburg, Fla.

Based on case reports to date, the estimated incidence of paradoxical adipose hyperplasia (PAH) is only about 0.0051%, or 1 case per 20,000 treatment cycles, Dr. Nelson added. But use of cryolipolysis is growing rapidly, including use among physician extenders, he noted. “We should be counseling all our patients on the possibility of PAH, and we need to generate more data to determine its cause and the best treatment options.”

© AndreyPopov/Thinkstock

Even a single cycle of cryolipolysis can trigger PAH, which seems to occur at least 2-3 months later and requires invasive treatment to resolve, Dr. Nelson said at the annual meeting of the American Society for Dermatologic Surgery (ASDS). “Most patients report an initial reduction of fat before PAH develops,” he added.

Histology at the site of PAH typically shows disorganized adipocytes that vary more in size and shape than does normal panniculus, but the overlying dermis and epidermis appear normal. About half of cases reported to date have involved men, “but women are treated at a higher rate than men, so there may be a preponderance of men,” he said.

No one knows why PAH occurs, Dr. Nelson noted. Possibilities include recruitment of local or circulating preadipocytes or stem cells; changes in the expression of receptors or soluble factors that play a role in adipocyte metabolism; reduced sympathetic innervation; and hypoxic injury, he said. Hypoxic injury is known to spur capillary growth, which can cause fat hypertrophy, he added.

In a case reported at the ASDS meeting by Dr. Brian Raphael, a 75-year-old woman developed PAH approximately 4 months after undergoing two sessions of cryolipolysis that had been spaced 1 month apart. The adipose tissue had accumulated in the center of the treatment site “in a distribution identical to the device applicator,” Dr. Raphael and his associates reported. They performed a wedge biopsy to confirm that the fat accumulation was benign, and then carried out a pannectomy to remove the unwanted fat, they said.

Cryolipolysis works by slowly cooling adipocytes, which are more sensitive to temperature decreases than epidermal and dermal cells, Dr. Nelson said. The adipocytes crystallize, which is thought to trigger their apoptosis and gradual elimination from the body in the months after treatment. Adverse effects besides PAH are usually mild and include edema, pain, and temporary redness at the treatment site, he noted. About two-thirds of patients also have a temporary, localized loss of sensation that can last up to 8 weeks, he added.

Dr. Nelson and Dr. Raphael reported no conflicts of interest.

SAN DIEGO – A tailored version of the mindfulness-based stress reduction (MBSR) program benefited mothers in treatment for opioid addiction, according to a small qualitative analysis presented at the annual meeting of the American Academy of Pediatrics.

The intervention was the first in the United States to teach mindfulness-based parenting techniques to mothers with opioid addiction, lead investigator Diane J. Abatemarco, Ph.D., M.S.W., said in an interview.

“Mindfulness-based parenting is an effective method to enhance parenting, increase bonding and attachment, and reduce parental anxiety, stress, and reactivity,” added Dr. Abatemarco of the department of pediatrics and director of pediatric population health research at Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University in Philadelphia.

Parents with substance-use disorders tend to suffer more stress than do other parents, and stress increases the risk of relapse among former users, Dr. Abatemarco and her associates noted. Mindfulness-based stress reduction – which focuses on compassion, nonjudgment, emotional awareness, and self-regulation – has been explored in studies of addiction and parenting, but rarely as combined approach for both stressors, said the researchers.

Therefore, they conducted a single-arm study of 34 mothers of infants or young children who were in outpatient treatment for opioid addiction, they said. Participants averaged 30 years of age, most were white and unmarried, and about half had a high school education or less, they reported.

As in traditional MBSR, the mothers attended 12 weekly group sessions to learn sitting meditation and loving-kindness techniques, said the investigators. But because of participants’ past substance abuse and high rates of childhood trauma – including family violence, sexual assault, and emotional mistreatment – they struggled with the loving-kindness techniques that are typically used in MBSR courses, said Dr. Abatemarco. “Loving-kindness is difficult for those of us who have had adverse childhood exposure or trauma as a result of abuse and neglect,” she added. “We need to realize this and ensure that the program is trauma-informed, so that we come to kindness in different ways. “The researchers therefore introduced terms such as ‘caring for yourself,’ and ‘being gentle to yourself,’ and added loving-kindness practice only after participants had begun learning sitting meditation, she said.

Mothers said two techniques particularly helped them feel more compassion toward themselves, pay more attention to their children, and elicit their children’s cooperation more often, Dr. Abatemarco and her associates reported. These included the STOP practice – which is used in some MBSR courses and stands for “stop, take a breath, observe, proceed” – and the “settle your glitter” approach, in which participants filled a globe of water with three different colors of glitter to symbolize emotions, physical sensations, and thoughts, the investigators said. The mothers then carried the sealed globes around with them and, when stressed, shook them and watched the glitter settle, symbolizing the mental effects of breathing and allowing thoughts and sensations to pass, they reported. “Moms say that just looking at the globe after it is shaken reminds them that they can easily get to a place of peace and that better decisions are available to them,” added Dr. Abatemarco.

The investigators are planning another study to test the intervention’s effects on substance use, parenting, and childhood outcomes, said Dr. Abatemarco. They also are starting a mindfulness-based parenting and childbirth course for inner-city black women who are pregnant and at risk for preterm birth, she added.

The Children’s Bureau of the Administration for Children and Families funded the study. The researchers declared no relevant conflicts of interest.

SAN DIEGO – A tailored version of the mindfulness-based stress reduction (MBSR) program benefited mothers in treatment for opioid addiction, according to a small qualitative analysis presented at the annual meeting of the American Academy of Pediatrics.

The intervention was the first in the United States to teach mindfulness-based parenting techniques to mothers with opioid addiction, lead investigator Diane J. Abatemarco, Ph.D., M.S.W., said in an interview.

“Mindfulness-based parenting is an effective method to enhance parenting, increase bonding and attachment, and reduce parental anxiety, stress, and reactivity,” added Dr. Abatemarco of the department of pediatrics and director of pediatric population health research at Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University in Philadelphia.

Parents with substance-use disorders tend to suffer more stress than do other parents, and stress increases the risk of relapse among former users, Dr. Abatemarco and her associates noted. Mindfulness-based stress reduction – which focuses on compassion, nonjudgment, emotional awareness, and self-regulation – has been explored in studies of addiction and parenting, but rarely as combined approach for both stressors, said the researchers.

Therefore, they conducted a single-arm study of 34 mothers of infants or young children who were in outpatient treatment for opioid addiction, they said. Participants averaged 30 years of age, most were white and unmarried, and about half had a high school education or less, they reported.

As in traditional MBSR, the mothers attended 12 weekly group sessions to learn sitting meditation and loving-kindness techniques, said the investigators. But because of participants’ past substance abuse and high rates of childhood trauma – including family violence, sexual assault, and emotional mistreatment – they struggled with the loving-kindness techniques that are typically used in MBSR courses, said Dr. Abatemarco. “Loving-kindness is difficult for those of us who have had adverse childhood exposure or trauma as a result of abuse and neglect,” she added. “We need to realize this and ensure that the program is trauma-informed, so that we come to kindness in different ways. “The researchers therefore introduced terms such as ‘caring for yourself,’ and ‘being gentle to yourself,’ and added loving-kindness practice only after participants had begun learning sitting meditation, she said.

Mothers said two techniques particularly helped them feel more compassion toward themselves, pay more attention to their children, and elicit their children’s cooperation more often, Dr. Abatemarco and her associates reported. These included the STOP practice – which is used in some MBSR courses and stands for “stop, take a breath, observe, proceed” – and the “settle your glitter” approach, in which participants filled a globe of water with three different colors of glitter to symbolize emotions, physical sensations, and thoughts, the investigators said. The mothers then carried the sealed globes around with them and, when stressed, shook them and watched the glitter settle, symbolizing the mental effects of breathing and allowing thoughts and sensations to pass, they reported. “Moms say that just looking at the globe after it is shaken reminds them that they can easily get to a place of peace and that better decisions are available to them,” added Dr. Abatemarco.

The investigators are planning another study to test the intervention’s effects on substance use, parenting, and childhood outcomes, said Dr. Abatemarco. They also are starting a mindfulness-based parenting and childbirth course for inner-city black women who are pregnant and at risk for preterm birth, she added.

The Children’s Bureau of the Administration for Children and Families funded the study. The researchers declared no relevant conflicts of interest.

SAN DIEGO – A tailored version of the mindfulness-based stress reduction (MBSR) program benefited mothers in treatment for opioid addiction, according to a small qualitative analysis presented at the annual meeting of the American Academy of Pediatrics.

The intervention was the first in the United States to teach mindfulness-based parenting techniques to mothers with opioid addiction, lead investigator Diane J. Abatemarco, Ph.D., M.S.W., said in an interview.

“Mindfulness-based parenting is an effective method to enhance parenting, increase bonding and attachment, and reduce parental anxiety, stress, and reactivity,” added Dr. Abatemarco of the department of pediatrics and director of pediatric population health research at Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University in Philadelphia.

Parents with substance-use disorders tend to suffer more stress than do other parents, and stress increases the risk of relapse among former users, Dr. Abatemarco and her associates noted. Mindfulness-based stress reduction – which focuses on compassion, nonjudgment, emotional awareness, and self-regulation – has been explored in studies of addiction and parenting, but rarely as combined approach for both stressors, said the researchers.

Therefore, they conducted a single-arm study of 34 mothers of infants or young children who were in outpatient treatment for opioid addiction, they said. Participants averaged 30 years of age, most were white and unmarried, and about half had a high school education or less, they reported.

As in traditional MBSR, the mothers attended 12 weekly group sessions to learn sitting meditation and loving-kindness techniques, said the investigators. But because of participants’ past substance abuse and high rates of childhood trauma – including family violence, sexual assault, and emotional mistreatment – they struggled with the loving-kindness techniques that are typically used in MBSR courses, said Dr. Abatemarco. “Loving-kindness is difficult for those of us who have had adverse childhood exposure or trauma as a result of abuse and neglect,” she added. “We need to realize this and ensure that the program is trauma-informed, so that we come to kindness in different ways. “The researchers therefore introduced terms such as ‘caring for yourself,’ and ‘being gentle to yourself,’ and added loving-kindness practice only after participants had begun learning sitting meditation, she said.

Mothers said two techniques particularly helped them feel more compassion toward themselves, pay more attention to their children, and elicit their children’s cooperation more often, Dr. Abatemarco and her associates reported. These included the STOP practice – which is used in some MBSR courses and stands for “stop, take a breath, observe, proceed” – and the “settle your glitter” approach, in which participants filled a globe of water with three different colors of glitter to symbolize emotions, physical sensations, and thoughts, the investigators said. The mothers then carried the sealed globes around with them and, when stressed, shook them and watched the glitter settle, symbolizing the mental effects of breathing and allowing thoughts and sensations to pass, they reported. “Moms say that just looking at the globe after it is shaken reminds them that they can easily get to a place of peace and that better decisions are available to them,” added Dr. Abatemarco.

The investigators are planning another study to test the intervention’s effects on substance use, parenting, and childhood outcomes, said Dr. Abatemarco. They also are starting a mindfulness-based parenting and childbirth course for inner-city black women who are pregnant and at risk for preterm birth, she added.

The Children’s Bureau of the Administration for Children and Families funded the study. The researchers declared no relevant conflicts of interest.

SAN DIEGO – Pediatricians should perform frenotomy to release tongue-tie if an affected baby is struggling to nurse and the mother reports breast pain and trauma as a result, according to Dr. Anthony Magit.

“There are so few problems with this procedure, and it works so well that there is really no excuse for not doing it when it’s indicated,” added Dr. James Murphy, a pediatrician and certified lactation consultant based in San Diego.

About 4% of babies are born with tongue-tie (or ankyloglossia), an anatomic variation in the frenulum that restricts the tongue’s movement. The condition impedes nursing and can later cause problems with speech articulation, particularly for languages such as Spanish that require a relatively high amount of tongue movement, said Dr. Magit, professor of surgery at the University of California, San Diego.

©Lev Olkha/iStockphoto.com

Babies with tongue-tie may latch poorly, chomp at the breast, fuss, or fall asleep while nursing, and fail to gain weight normally, Dr. Magit added. Their mothers tend to develop painful, engorged breasts, which increases their risk for mastitis and is a reason to perform frenotomy promptly, he said. “If frenotomy is performed early – at 1 or 2 days of age – you will see more rapid improvement, whereas if it’s done at 2-3 weeks old, the mom is less likely to have problems completely resolve,” Dr. Magit emphasized at the annual meeting of the American Academy of Pediatrics.

If tongue-tie is suspected, a tongue depressor can be used to elevate the tongue and visualize the frenulum, said Dr. Magit. Tongue-tie appears as an unusually short, long, tight, or thickened frenulum (or frenum) that may be pyramidal, triangular, vertical, or even bumplike, Dr. Murphy added. The lateral edge of the tongue may form the shape of a W, V, or heart, and the baby’s lips may appear cobblestoned as a result of trauma during attempts to nurse, he said.

When Dr. Murphy suspects tongue-tie, he said he lays the baby on its back on an examining table with the shoulders slightly elevated on a blanket. Then he pulls the lower jaw gently down with both thumbs while using his palms to restrain the baby’s arms by the sides. This approach enables him to best see the frenulum and to observe the extent to which it is restricting the tongue’s movement, he added. An assistant uses the same hold technique when he performs frenotomies, Dr. Murphy added.

Frenotomy in newborns requires no anesthesia and can be performed in a nursery or office, said Dr. Magit. The infant is swaddled, a grooved retractor is used to direct the tongue toward the palate, the frenulum is clamped to create crush injury and direct the line of incision, and scissors are used to clip the frenulum within 1-2 mm of the junction of Wharton’s ducts, he said. After the procedure, the tongue is swept with a gloved finger and stretched to ensure complete release of the frenulum, Dr. Magit added. Most mothers report an immediate improvement in breastfeeding, including better latch, suction, and milk flow, he said.

Frenotomy in older infants and young children requires general anesthetic in the operating room, while children older than 5 years can undergo the procedure under local anesthetic in an office setting, Dr. Magit said. Complications after frenotomy are “extremely rare,” and include scarring or recurrent ankyloglossia and trauma to Wharton’s ducts, he added. Parents should be told that it is normal for yellow transitional tissue to develop at the wound site during healing, said Dr. Murphy.

Adults with tongue-tie also can benefit from frenotomy because the condition causes chronic tightness of muscles surrounding the tongue, said Dr. Murphy. “When you snip that fibrous band, the surrounding muscles relax, the hyoid bone goes down, and the larynx goes down,” he said. He has released frenula in adults and has had them report a dramatic improvement in sleep afterward, he noted.

Dr. Murphy and Dr. Magit declared no relevant financial conflicts.

SAN DIEGO – Pediatricians should perform frenotomy to release tongue-tie if an affected baby is struggling to nurse and the mother reports breast pain and trauma as a result, according to Dr. Anthony Magit.

“There are so few problems with this procedure, and it works so well that there is really no excuse for not doing it when it’s indicated,” added Dr. James Murphy, a pediatrician and certified lactation consultant based in San Diego.

About 4% of babies are born with tongue-tie (or ankyloglossia), an anatomic variation in the frenulum that restricts the tongue’s movement. The condition impedes nursing and can later cause problems with speech articulation, particularly for languages such as Spanish that require a relatively high amount of tongue movement, said Dr. Magit, professor of surgery at the University of California, San Diego.

©Lev Olkha/iStockphoto.com

Babies with tongue-tie may latch poorly, chomp at the breast, fuss, or fall asleep while nursing, and fail to gain weight normally, Dr. Magit added. Their mothers tend to develop painful, engorged breasts, which increases their risk for mastitis and is a reason to perform frenotomy promptly, he said. “If frenotomy is performed early – at 1 or 2 days of age – you will see more rapid improvement, whereas if it’s done at 2-3 weeks old, the mom is less likely to have problems completely resolve,” Dr. Magit emphasized at the annual meeting of the American Academy of Pediatrics.

If tongue-tie is suspected, a tongue depressor can be used to elevate the tongue and visualize the frenulum, said Dr. Magit. Tongue-tie appears as an unusually short, long, tight, or thickened frenulum (or frenum) that may be pyramidal, triangular, vertical, or even bumplike, Dr. Murphy added. The lateral edge of the tongue may form the shape of a W, V, or heart, and the baby’s lips may appear cobblestoned as a result of trauma during attempts to nurse, he said.

When Dr. Murphy suspects tongue-tie, he said he lays the baby on its back on an examining table with the shoulders slightly elevated on a blanket. Then he pulls the lower jaw gently down with both thumbs while using his palms to restrain the baby’s arms by the sides. This approach enables him to best see the frenulum and to observe the extent to which it is restricting the tongue’s movement, he added. An assistant uses the same hold technique when he performs frenotomies, Dr. Murphy added.

Frenotomy in newborns requires no anesthesia and can be performed in a nursery or office, said Dr. Magit. The infant is swaddled, a grooved retractor is used to direct the tongue toward the palate, the frenulum is clamped to create crush injury and direct the line of incision, and scissors are used to clip the frenulum within 1-2 mm of the junction of Wharton’s ducts, he said. After the procedure, the tongue is swept with a gloved finger and stretched to ensure complete release of the frenulum, Dr. Magit added. Most mothers report an immediate improvement in breastfeeding, including better latch, suction, and milk flow, he said.

Frenotomy in older infants and young children requires general anesthetic in the operating room, while children older than 5 years can undergo the procedure under local anesthetic in an office setting, Dr. Magit said. Complications after frenotomy are “extremely rare,” and include scarring or recurrent ankyloglossia and trauma to Wharton’s ducts, he added. Parents should be told that it is normal for yellow transitional tissue to develop at the wound site during healing, said Dr. Murphy.

Adults with tongue-tie also can benefit from frenotomy because the condition causes chronic tightness of muscles surrounding the tongue, said Dr. Murphy. “When you snip that fibrous band, the surrounding muscles relax, the hyoid bone goes down, and the larynx goes down,” he said. He has released frenula in adults and has had them report a dramatic improvement in sleep afterward, he noted.

Dr. Murphy and Dr. Magit declared no relevant financial conflicts.

SAN DIEGO – Pediatricians should perform frenotomy to release tongue-tie if an affected baby is struggling to nurse and the mother reports breast pain and trauma as a result, according to Dr. Anthony Magit.

“There are so few problems with this procedure, and it works so well that there is really no excuse for not doing it when it’s indicated,” added Dr. James Murphy, a pediatrician and certified lactation consultant based in San Diego.

About 4% of babies are born with tongue-tie (or ankyloglossia), an anatomic variation in the frenulum that restricts the tongue’s movement. The condition impedes nursing and can later cause problems with speech articulation, particularly for languages such as Spanish that require a relatively high amount of tongue movement, said Dr. Magit, professor of surgery at the University of California, San Diego.

©Lev Olkha/iStockphoto.com

Babies with tongue-tie may latch poorly, chomp at the breast, fuss, or fall asleep while nursing, and fail to gain weight normally, Dr. Magit added. Their mothers tend to develop painful, engorged breasts, which increases their risk for mastitis and is a reason to perform frenotomy promptly, he said. “If frenotomy is performed early – at 1 or 2 days of age – you will see more rapid improvement, whereas if it’s done at 2-3 weeks old, the mom is less likely to have problems completely resolve,” Dr. Magit emphasized at the annual meeting of the American Academy of Pediatrics.

If tongue-tie is suspected, a tongue depressor can be used to elevate the tongue and visualize the frenulum, said Dr. Magit. Tongue-tie appears as an unusually short, long, tight, or thickened frenulum (or frenum) that may be pyramidal, triangular, vertical, or even bumplike, Dr. Murphy added. The lateral edge of the tongue may form the shape of a W, V, or heart, and the baby’s lips may appear cobblestoned as a result of trauma during attempts to nurse, he said.

When Dr. Murphy suspects tongue-tie, he said he lays the baby on its back on an examining table with the shoulders slightly elevated on a blanket. Then he pulls the lower jaw gently down with both thumbs while using his palms to restrain the baby’s arms by the sides. This approach enables him to best see the frenulum and to observe the extent to which it is restricting the tongue’s movement, he added. An assistant uses the same hold technique when he performs frenotomies, Dr. Murphy added.

Frenotomy in newborns requires no anesthesia and can be performed in a nursery or office, said Dr. Magit. The infant is swaddled, a grooved retractor is used to direct the tongue toward the palate, the frenulum is clamped to create crush injury and direct the line of incision, and scissors are used to clip the frenulum within 1-2 mm of the junction of Wharton’s ducts, he said. After the procedure, the tongue is swept with a gloved finger and stretched to ensure complete release of the frenulum, Dr. Magit added. Most mothers report an immediate improvement in breastfeeding, including better latch, suction, and milk flow, he said.

Frenotomy in older infants and young children requires general anesthetic in the operating room, while children older than 5 years can undergo the procedure under local anesthetic in an office setting, Dr. Magit said. Complications after frenotomy are “extremely rare,” and include scarring or recurrent ankyloglossia and trauma to Wharton’s ducts, he added. Parents should be told that it is normal for yellow transitional tissue to develop at the wound site during healing, said Dr. Murphy.

Adults with tongue-tie also can benefit from frenotomy because the condition causes chronic tightness of muscles surrounding the tongue, said Dr. Murphy. “When you snip that fibrous band, the surrounding muscles relax, the hyoid bone goes down, and the larynx goes down,” he said. He has released frenula in adults and has had them report a dramatic improvement in sleep afterward, he noted.

Dr. Murphy and Dr. Magit declared no relevant financial conflicts.

SAN DIEGO – Adolescents with substance abuse and depression should be simultaneously treated for both conditions – and preferably by the same provider or clinical team, said Dr. Paula Riggs, professor of psychiatry and director of the division of substance dependence at the University of Colorado at Denver, Aurora.

“It’s hard to be successful in drug treatment under the best of circumstances. If you have an untreated Axis I mental health disorder, it’s not going to go well,” said Dr. Riggs, who is an expert in treating comorbid adolescent substance abuse and psychiatric disorders.

“Adolescent depressions usually do not remit with abstinence” from drugs and alcohol, Dr. Riggs said at the annual meeting of the American Academy of Child and Adolescent Psychiatry. “If you have a kid walk through your door with depression and SUD [substance abuse disorder], treating the SUD won’t make the depression go away. Once you’ve got both, you’ve got two things you’ve got to address – and preferably in an integrated fashion.”

Successful treatment of childhood depression does reduce the risk of later substance abuse, especially if the depression remits within 12 weeks of starting treatment, said Dr. Riggs. “But the converse is not true,” she said.

About 25%-50% of adolescents who present for mental health treatment meet criteria for SUDs, Dr. Riggs said. And more than half of preteens with mental health problems are at risk for developing a SUD by the time they reach adolescence, she said. “By and large, psychiatric problems are pediatric-onset illnesses, and we know from ample research that most adults who suffer from addiction started using when they were adolescents,” she added.

But all too often, teens with comorbid SUD and Axis I disorders go without treatment, said Dr. Riggs.

In a recent pooled analysis of 2,111 adolescents with comorbid major depression and SUD, 48% were treated for depression and 10% received help for substance abuse, she noted. Furthermore, being in the juvenile justice system was the strongest predictor of dual treatment. “I don’t know why people aren’t up in arms about that,” she said. “We kind of require kids to fall in the hole to get treatment.”

In 2013, the Substance Abuse and Mental Health Services Administration recommended that adolescents with comorbid SUD and depression receive integrated, simultaneous treatment for both disorders, Dr. Riggs noted. No matter which problem arose first, “recovery depends on treating both the addiction and the mental health problem,” she said.

Currently, the best treatment for adolescent SUD is motivational enhancement, “totally integrated with cognitive behavioral therapy,” Dr. Riggs said. Motivational incentives should encourage attendance, abstinence, and alternative activities that do not involve drugs, she added.

Individual therapy is more effective than group therapy for treating comorbid substance abuse and psychiatric disorders. But studies also suggest that the patient’s family should be involved in treatment, Dr. Riggs said. Furthermore, coordinating mental health care, substance abuse treatment, and family therapy has been shown to significantly alleviate symptoms in patients with SUDs who also have Axis I major depressive disorder, attention-deficit/hyperactivity disorder, or an anxiety disorder, she said.

Data support the judicious use of antidepressants for adolescents who have major depressive disorder with comorbid SUD, Dr. Riggs said.

In her randomized controlled trial of fluoxetine versus placebo in teens with major depression and SUD, fluoxetine showed “about the same safety profile as in kids who were not using drugs, despite nonabstinence.” And overall treatment gains lasted for a year after treatment, she said. “If you don’t see remission in the first month of substance abuse treatment, I would not hesitate to use fluoxetine,” she added. “You have got to do a comprehensive diagnostic assessment at baseline, and get a really good longitudinal history to map symptom onset. The bottom line is, if you are carefully monitoring the substance, and if the kid is in substance treatment, continue the fluoxetine.”

Clinicians and parents should not look the other way when the substance in question is cannabis, Dr. Riggs emphasized. “Prenatal exposure to marijuana can cause irritable babies, deficits in abstract reasoning and memory, symptoms that look like ADHD, and executive functioning deficits,” she said. “Marijuana use in adolescence doubles your risk of developing depression or an anxiety disorder in your twenties. And all of it adds up to poor academic achievement and underachievement in adulthood.”

Dr. Riggs reported receiving research support from the National Institute on Drug Abuse and the ENCOMPASS substance abuse treatment program.

SAN DIEGO – Adolescents with substance abuse and depression should be simultaneously treated for both conditions – and preferably by the same provider or clinical team, said Dr. Paula Riggs, professor of psychiatry and director of the division of substance dependence at the University of Colorado at Denver, Aurora.

“It’s hard to be successful in drug treatment under the best of circumstances. If you have an untreated Axis I mental health disorder, it’s not going to go well,” said Dr. Riggs, who is an expert in treating comorbid adolescent substance abuse and psychiatric disorders.

“Adolescent depressions usually do not remit with abstinence” from drugs and alcohol, Dr. Riggs said at the annual meeting of the American Academy of Child and Adolescent Psychiatry. “If you have a kid walk through your door with depression and SUD [substance abuse disorder], treating the SUD won’t make the depression go away. Once you’ve got both, you’ve got two things you’ve got to address – and preferably in an integrated fashion.”

Successful treatment of childhood depression does reduce the risk of later substance abuse, especially if the depression remits within 12 weeks of starting treatment, said Dr. Riggs. “But the converse is not true,” she said.

About 25%-50% of adolescents who present for mental health treatment meet criteria for SUDs, Dr. Riggs said. And more than half of preteens with mental health problems are at risk for developing a SUD by the time they reach adolescence, she said. “By and large, psychiatric problems are pediatric-onset illnesses, and we know from ample research that most adults who suffer from addiction started using when they were adolescents,” she added.

But all too often, teens with comorbid SUD and Axis I disorders go without treatment, said Dr. Riggs.

In a recent pooled analysis of 2,111 adolescents with comorbid major depression and SUD, 48% were treated for depression and 10% received help for substance abuse, she noted. Furthermore, being in the juvenile justice system was the strongest predictor of dual treatment. “I don’t know why people aren’t up in arms about that,” she said. “We kind of require kids to fall in the hole to get treatment.”

In 2013, the Substance Abuse and Mental Health Services Administration recommended that adolescents with comorbid SUD and depression receive integrated, simultaneous treatment for both disorders, Dr. Riggs noted. No matter which problem arose first, “recovery depends on treating both the addiction and the mental health problem,” she said.

Currently, the best treatment for adolescent SUD is motivational enhancement, “totally integrated with cognitive behavioral therapy,” Dr. Riggs said. Motivational incentives should encourage attendance, abstinence, and alternative activities that do not involve drugs, she added.

Individual therapy is more effective than group therapy for treating comorbid substance abuse and psychiatric disorders. But studies also suggest that the patient’s family should be involved in treatment, Dr. Riggs said. Furthermore, coordinating mental health care, substance abuse treatment, and family therapy has been shown to significantly alleviate symptoms in patients with SUDs who also have Axis I major depressive disorder, attention-deficit/hyperactivity disorder, or an anxiety disorder, she said.

Data support the judicious use of antidepressants for adolescents who have major depressive disorder with comorbid SUD, Dr. Riggs said.

In her randomized controlled trial of fluoxetine versus placebo in teens with major depression and SUD, fluoxetine showed “about the same safety profile as in kids who were not using drugs, despite nonabstinence.” And overall treatment gains lasted for a year after treatment, she said. “If you don’t see remission in the first month of substance abuse treatment, I would not hesitate to use fluoxetine,” she added. “You have got to do a comprehensive diagnostic assessment at baseline, and get a really good longitudinal history to map symptom onset. The bottom line is, if you are carefully monitoring the substance, and if the kid is in substance treatment, continue the fluoxetine.”

Clinicians and parents should not look the other way when the substance in question is cannabis, Dr. Riggs emphasized. “Prenatal exposure to marijuana can cause irritable babies, deficits in abstract reasoning and memory, symptoms that look like ADHD, and executive functioning deficits,” she said. “Marijuana use in adolescence doubles your risk of developing depression or an anxiety disorder in your twenties. And all of it adds up to poor academic achievement and underachievement in adulthood.”

Dr. Riggs reported receiving research support from the National Institute on Drug Abuse and the ENCOMPASS substance abuse treatment program.

SAN DIEGO – Adolescents with substance abuse and depression should be simultaneously treated for both conditions – and preferably by the same provider or clinical team, said Dr. Paula Riggs, professor of psychiatry and director of the division of substance dependence at the University of Colorado at Denver, Aurora.

“It’s hard to be successful in drug treatment under the best of circumstances. If you have an untreated Axis I mental health disorder, it’s not going to go well,” said Dr. Riggs, who is an expert in treating comorbid adolescent substance abuse and psychiatric disorders.

“Adolescent depressions usually do not remit with abstinence” from drugs and alcohol, Dr. Riggs said at the annual meeting of the American Academy of Child and Adolescent Psychiatry. “If you have a kid walk through your door with depression and SUD [substance abuse disorder], treating the SUD won’t make the depression go away. Once you’ve got both, you’ve got two things you’ve got to address – and preferably in an integrated fashion.”

Successful treatment of childhood depression does reduce the risk of later substance abuse, especially if the depression remits within 12 weeks of starting treatment, said Dr. Riggs. “But the converse is not true,” she said.

About 25%-50% of adolescents who present for mental health treatment meet criteria for SUDs, Dr. Riggs said. And more than half of preteens with mental health problems are at risk for developing a SUD by the time they reach adolescence, she said. “By and large, psychiatric problems are pediatric-onset illnesses, and we know from ample research that most adults who suffer from addiction started using when they were adolescents,” she added.

But all too often, teens with comorbid SUD and Axis I disorders go without treatment, said Dr. Riggs.

In a recent pooled analysis of 2,111 adolescents with comorbid major depression and SUD, 48% were treated for depression and 10% received help for substance abuse, she noted. Furthermore, being in the juvenile justice system was the strongest predictor of dual treatment. “I don’t know why people aren’t up in arms about that,” she said. “We kind of require kids to fall in the hole to get treatment.”

In 2013, the Substance Abuse and Mental Health Services Administration recommended that adolescents with comorbid SUD and depression receive integrated, simultaneous treatment for both disorders, Dr. Riggs noted. No matter which problem arose first, “recovery depends on treating both the addiction and the mental health problem,” she said.

Currently, the best treatment for adolescent SUD is motivational enhancement, “totally integrated with cognitive behavioral therapy,” Dr. Riggs said. Motivational incentives should encourage attendance, abstinence, and alternative activities that do not involve drugs, she added.

Individual therapy is more effective than group therapy for treating comorbid substance abuse and psychiatric disorders. But studies also suggest that the patient’s family should be involved in treatment, Dr. Riggs said. Furthermore, coordinating mental health care, substance abuse treatment, and family therapy has been shown to significantly alleviate symptoms in patients with SUDs who also have Axis I major depressive disorder, attention-deficit/hyperactivity disorder, or an anxiety disorder, she said.

Data support the judicious use of antidepressants for adolescents who have major depressive disorder with comorbid SUD, Dr. Riggs said.

In her randomized controlled trial of fluoxetine versus placebo in teens with major depression and SUD, fluoxetine showed “about the same safety profile as in kids who were not using drugs, despite nonabstinence.” And overall treatment gains lasted for a year after treatment, she said. “If you don’t see remission in the first month of substance abuse treatment, I would not hesitate to use fluoxetine,” she added. “You have got to do a comprehensive diagnostic assessment at baseline, and get a really good longitudinal history to map symptom onset. The bottom line is, if you are carefully monitoring the substance, and if the kid is in substance treatment, continue the fluoxetine.”

Clinicians and parents should not look the other way when the substance in question is cannabis, Dr. Riggs emphasized. “Prenatal exposure to marijuana can cause irritable babies, deficits in abstract reasoning and memory, symptoms that look like ADHD, and executive functioning deficits,” she said. “Marijuana use in adolescence doubles your risk of developing depression or an anxiety disorder in your twenties. And all of it adds up to poor academic achievement and underachievement in adulthood.”

Dr. Riggs reported receiving research support from the National Institute on Drug Abuse and the ENCOMPASS substance abuse treatment program.

SAN DIEGO – More than 263,000 refugees lived in the United States in 2013, according to the United Nations High Commissioner of Refugees. These families often receive no mental health care or orientation to American schools, said Dr. A. John Sargent III, who is chief of the division of child and adolescent psychiatry at Tufts Medical Center in Boston.

But instead of therapy that focuses on problems and conflicts, refugees need help building confidence and resilience by focusing on strengths, cohesiveness, and connections between children and parents, Dr. Sargent and his fellow speakers said at the annual meeting of the American Association of Child and Adolescent Psychiatry.

Therapy for refugees should not center on approaches such as “tell me more about it,” or “how do you feel,” said Dr. Rama R. Gogineni, who is head of the division of child and adolescent psychiatry at Cooper University Health Care in Camden, N. J. “If we just see them as victims, we overidentify with the victim and are not able to treat them, not able to bring out their strength and resiliency.”

In therapy, refugee parents and elders need to learn to encourage their children and enjoy their success, maintain optimism through shared rituals and experiences, and foster a strong work ethic and shared aspirations, Dr. Sargent said. As with dialectical behavior therapy, refugees first need to feel safe and know that their basic needs are met before they begin processing past traumas, he emphasized. “American providers may be influenced by trauma therapy models that don’t apply here,” he said. “We want to get to the trauma right away and that can be disrupting and harmful.”

The ultimate goal of therapy for refugees is a “life worth living,” Dr. Sargent added. “Really feeling good about what you are doing and where you are.”

About 40% of refugees in the United States are children, noted Dr. Suzan Song, a psychiatrist and medical director for Asian Americans for Community Involvement in San Jose, Calif. “I have to be very sensitive, because I don’t want parents to think that they are traumatized and therefore their children will be traumatized,” she said. “I take a resiliency perspective when I speak to these children and their families. I ask parents to go internally and ask what are you proud of; what do you hope for your kids; what do you want your family to look like; what cultural values are most important to you; and what are you willing to let go?”

Mental health providers should avoid reflexively applying a single therapeutic model to all refugees, Dr. Song said. “Just because someone is a refugee doesn’t mean they would benefit from narrative therapy vs. cognitive-behavioral therapy.”Clinicians also should take care not to equate the refugee experience with that of immigrant families, the speaker said.While immigrants come to the United States voluntarily and may be more open to adopting U.S. culture, “refugees want to be home and may insist on retaining their own customs,” Dr. Song said.Refugee parents also might rely heavily on children to serve as cultural and linguistic brokers while simultaneously struggling to understand their children’s Americanized dress and behavior, Dr. Sargent said. Children, for their part, may be “disappointed in their parents” and perceive them as “weak” because of their difficulty in adapting, he said. Perhaps not surprisingly, astudy at Dr. Song’s clinic found that current family stresses were the most common presenting complaint, she said.The journey from a conflict-torn home country to resettlement in the United States involves several areas of stress and challenge, Dr. Sargent said. Torture, poverty, rape, loss, or separation from loved ones, and enslavement are all potential traumas at home, he said. In war zones, “Boy child-soldiers are there to fight,” he added. “Girl child-soldiers are there to be sex slaves.”

During their flight from home, refugee families might face the same stressors as well as hunger and exhaustion, Dr. Sargent said. Families also may split up, only to be relocated in different refugee camps without the means to find one another, he added. And camp life can be a daily struggle that includes sexual assault, impoverished conditions, hunger, exhaustion, sleep deprivation, and high noise levels, he said. “The thing about refugee camps is that people are encouraged to be passive,” Dr. Sargent added. “They do not have power over their well-being. They are encouraged to sit and wait, and they are often pawns in a political struggle.”

After arriving in the United States, refugees face a “completely new environment” as well as poverty, language struggles, limited access to services, and more potential separations from loved ones, Dr. Sargent said. “Those crossing the United States-Mexico border with ‘coyotes’ may be expected to pay with sex,” he added. “For some families, the journey is a source of resilience, and for others, it is disrupting and highly traumatic. We have to learn which is which.”

The speakers declared no conflicts of interest.

SAN DIEGO – More than 263,000 refugees lived in the United States in 2013, according to the United Nations High Commissioner of Refugees. These families often receive no mental health care or orientation to American schools, said Dr. A. John Sargent III, who is chief of the division of child and adolescent psychiatry at Tufts Medical Center in Boston.

But instead of therapy that focuses on problems and conflicts, refugees need help building confidence and resilience by focusing on strengths, cohesiveness, and connections between children and parents, Dr. Sargent and his fellow speakers said at the annual meeting of the American Association of Child and Adolescent Psychiatry.

Therapy for refugees should not center on approaches such as “tell me more about it,” or “how do you feel,” said Dr. Rama R. Gogineni, who is head of the division of child and adolescent psychiatry at Cooper University Health Care in Camden, N. J. “If we just see them as victims, we overidentify with the victim and are not able to treat them, not able to bring out their strength and resiliency.”

In therapy, refugee parents and elders need to learn to encourage their children and enjoy their success, maintain optimism through shared rituals and experiences, and foster a strong work ethic and shared aspirations, Dr. Sargent said. As with dialectical behavior therapy, refugees first need to feel safe and know that their basic needs are met before they begin processing past traumas, he emphasized. “American providers may be influenced by trauma therapy models that don’t apply here,” he said. “We want to get to the trauma right away and that can be disrupting and harmful.”

The ultimate goal of therapy for refugees is a “life worth living,” Dr. Sargent added. “Really feeling good about what you are doing and where you are.”

About 40% of refugees in the United States are children, noted Dr. Suzan Song, a psychiatrist and medical director for Asian Americans for Community Involvement in San Jose, Calif. “I have to be very sensitive, because I don’t want parents to think that they are traumatized and therefore their children will be traumatized,” she said. “I take a resiliency perspective when I speak to these children and their families. I ask parents to go internally and ask what are you proud of; what do you hope for your kids; what do you want your family to look like; what cultural values are most important to you; and what are you willing to let go?”

Mental health providers should avoid reflexively applying a single therapeutic model to all refugees, Dr. Song said. “Just because someone is a refugee doesn’t mean they would benefit from narrative therapy vs. cognitive-behavioral therapy.”Clinicians also should take care not to equate the refugee experience with that of immigrant families, the speaker said.While immigrants come to the United States voluntarily and may be more open to adopting U.S. culture, “refugees want to be home and may insist on retaining their own customs,” Dr. Song said.Refugee parents also might rely heavily on children to serve as cultural and linguistic brokers while simultaneously struggling to understand their children’s Americanized dress and behavior, Dr. Sargent said. Children, for their part, may be “disappointed in their parents” and perceive them as “weak” because of their difficulty in adapting, he said. Perhaps not surprisingly, astudy at Dr. Song’s clinic found that current family stresses were the most common presenting complaint, she said.The journey from a conflict-torn home country to resettlement in the United States involves several areas of stress and challenge, Dr. Sargent said. Torture, poverty, rape, loss, or separation from loved ones, and enslavement are all potential traumas at home, he said. In war zones, “Boy child-soldiers are there to fight,” he added. “Girl child-soldiers are there to be sex slaves.”

During their flight from home, refugee families might face the same stressors as well as hunger and exhaustion, Dr. Sargent said. Families also may split up, only to be relocated in different refugee camps without the means to find one another, he added. And camp life can be a daily struggle that includes sexual assault, impoverished conditions, hunger, exhaustion, sleep deprivation, and high noise levels, he said. “The thing about refugee camps is that people are encouraged to be passive,” Dr. Sargent added. “They do not have power over their well-being. They are encouraged to sit and wait, and they are often pawns in a political struggle.”

After arriving in the United States, refugees face a “completely new environment” as well as poverty, language struggles, limited access to services, and more potential separations from loved ones, Dr. Sargent said. “Those crossing the United States-Mexico border with ‘coyotes’ may be expected to pay with sex,” he added. “For some families, the journey is a source of resilience, and for others, it is disrupting and highly traumatic. We have to learn which is which.”

The speakers declared no conflicts of interest.

SAN DIEGO – More than 263,000 refugees lived in the United States in 2013, according to the United Nations High Commissioner of Refugees. These families often receive no mental health care or orientation to American schools, said Dr. A. John Sargent III, who is chief of the division of child and adolescent psychiatry at Tufts Medical Center in Boston.

But instead of therapy that focuses on problems and conflicts, refugees need help building confidence and resilience by focusing on strengths, cohesiveness, and connections between children and parents, Dr. Sargent and his fellow speakers said at the annual meeting of the American Association of Child and Adolescent Psychiatry.

Therapy for refugees should not center on approaches such as “tell me more about it,” or “how do you feel,” said Dr. Rama R. Gogineni, who is head of the division of child and adolescent psychiatry at Cooper University Health Care in Camden, N. J. “If we just see them as victims, we overidentify with the victim and are not able to treat them, not able to bring out their strength and resiliency.”

In therapy, refugee parents and elders need to learn to encourage their children and enjoy their success, maintain optimism through shared rituals and experiences, and foster a strong work ethic and shared aspirations, Dr. Sargent said. As with dialectical behavior therapy, refugees first need to feel safe and know that their basic needs are met before they begin processing past traumas, he emphasized. “American providers may be influenced by trauma therapy models that don’t apply here,” he said. “We want to get to the trauma right away and that can be disrupting and harmful.”

The ultimate goal of therapy for refugees is a “life worth living,” Dr. Sargent added. “Really feeling good about what you are doing and where you are.”

About 40% of refugees in the United States are children, noted Dr. Suzan Song, a psychiatrist and medical director for Asian Americans for Community Involvement in San Jose, Calif. “I have to be very sensitive, because I don’t want parents to think that they are traumatized and therefore their children will be traumatized,” she said. “I take a resiliency perspective when I speak to these children and their families. I ask parents to go internally and ask what are you proud of; what do you hope for your kids; what do you want your family to look like; what cultural values are most important to you; and what are you willing to let go?”

Mental health providers should avoid reflexively applying a single therapeutic model to all refugees, Dr. Song said. “Just because someone is a refugee doesn’t mean they would benefit from narrative therapy vs. cognitive-behavioral therapy.”Clinicians also should take care not to equate the refugee experience with that of immigrant families, the speaker said.While immigrants come to the United States voluntarily and may be more open to adopting U.S. culture, “refugees want to be home and may insist on retaining their own customs,” Dr. Song said.Refugee parents also might rely heavily on children to serve as cultural and linguistic brokers while simultaneously struggling to understand their children’s Americanized dress and behavior, Dr. Sargent said. Children, for their part, may be “disappointed in their parents” and perceive them as “weak” because of their difficulty in adapting, he said. Perhaps not surprisingly, astudy at Dr. Song’s clinic found that current family stresses were the most common presenting complaint, she said.The journey from a conflict-torn home country to resettlement in the United States involves several areas of stress and challenge, Dr. Sargent said. Torture, poverty, rape, loss, or separation from loved ones, and enslavement are all potential traumas at home, he said. In war zones, “Boy child-soldiers are there to fight,” he added. “Girl child-soldiers are there to be sex slaves.”

During their flight from home, refugee families might face the same stressors as well as hunger and exhaustion, Dr. Sargent said. Families also may split up, only to be relocated in different refugee camps without the means to find one another, he added. And camp life can be a daily struggle that includes sexual assault, impoverished conditions, hunger, exhaustion, sleep deprivation, and high noise levels, he said. “The thing about refugee camps is that people are encouraged to be passive,” Dr. Sargent added. “They do not have power over their well-being. They are encouraged to sit and wait, and they are often pawns in a political struggle.”

After arriving in the United States, refugees face a “completely new environment” as well as poverty, language struggles, limited access to services, and more potential separations from loved ones, Dr. Sargent said. “Those crossing the United States-Mexico border with ‘coyotes’ may be expected to pay with sex,” he added. “For some families, the journey is a source of resilience, and for others, it is disrupting and highly traumatic. We have to learn which is which.”

The speakers declared no conflicts of interest.

SAN DIEGO – Adolescents with attention-deficit/hyperactivity disorder are at increased risk of substance abuse disorders, especially if their parents smoke or abuse alcohol or drugs, said Dr. Iliyan S. Ivanov. Interventions that target schools, communities, and families can help, especially if these programs last more than 10 weeks and include training for children and parents, he said.

© iStock / ThinkStockPhotos.com

Several psychosocial modalities can aid teens with attention-deficit/hyperactivity disorder (ADHD) and substance use disorder (SUD), but the evidence to date particularly supports family therapy, Dr. Ivanov said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Parents with SUDs often don’t realize that their children know about their substance abuse, he emphasized. For this and other reasons, these children might harbor positive feelings about “light” (or soft) drugs, such as cannabis, which further increases their risk of using drugs, alcohol, or tobacco, said Dr. Ivanov, of the division of child and adolescent psychiatry at Mount Sinai Hospital, New York.

In addition to family therapy, adolescents with ADHD and SUD can benefit from “contingency management,” in which they earn rewards if they achieve positive outcomes, he said. “For example, look for the first negative urine test, and use that for positive reinforcement instead of using negative punishment for positive urine screens,” he said. “You really have to be on top of educating the parent or whoever is implementing the rewards that it is a moving target. The rules will change as the adolescent’s feelings change or improve.”

Medications are often key to treating adolescent ADHD; however, evidence is limited on whether they improve or control comorbid SUD in most cases, Dr. Ivanov said. “Stimulants are effective in controlling ADHD symptoms but have limited efficacy in controlling SUD,” he added. “Stimulant treatment is most effective when used concurrently with SUD treatment, and that is best done in a clinic with some kind of behavioral therapy.”

In longitudinal studies, stimulants such as methylphenidate usually have a neutral effect on substance abuse in children and adults, Dr. Ivanov said. An exception is smoking, he noted. Patients with ADHD have an especially hard time quitting tobacco use, but are less likely to start if they receive consistent treatment with stimulants (Pediatrics 2014;133:1070-80), he said. Osmotic-release oral system methylphenidate (OROS-MPH) also has been found to improve substance abuse treatment outcomes in patients who have ADHD with comorbid conduct disorder (J. Subst. Abuse Treat. 2013;44:224-30), Dr. Ivanov said.

Clinicians should carefully monitor adolescents on stimulants who have SUDs because of the potential for abuse, Dr. Ivanov emphasized. “Given the pharmacokinetics of the long-term stimulants, they might be the better choice,” he said. Also consider drugs with different mechanisms of action, such as lisdexamfetamine, a prodrug stimulant that the brain takes up relatively slowly; atomoxetine, which has distinct neurophysiological effects; extended-release guanfacine; omega fatty acids; buproprion; serotonin norepinephrine reuptake inhibitors; and glutamatergic agents, he said.

Clinicians also should educate patients about proper medication use and should closely follow them, use random urine toxicology screens to look for substance use, and check to see whether the patient has sought scripts from other clinicians, Dr. Ivanov said. New York State has passed legislation requiring prescribers to carry out these checks through prescription monitoring registries, he noted.

Because severe substance abuse predicts worse treatment outcomes for both ADHD and SUD (J. Subst. Abuse Treat. 2013;44:224-30), early detection and prevention of SUDs are key, and several screening tools can help, Dr. Ivanov said. The most comprehensive, the POSIT (Problem-Oriented Screening Assessment for Teenagers) tool, assesses patients for SUDs and also for unrelated problems, he added. The tool is self-administered, as is AUDIT (the Alcohol Use Disorders Identification Test), while CRAFFT (which stands for Car Relax Alone Forget Friends Trouble) is intended for interviews, he said.The CRAFFT tool asks about key signals of worsening substance use, such as riding in a car driven by someone who is intoxicated, using substances to relax or while alone, forgetting incidents that occurred while intoxicated, having friends or family express concern about substance use, and getting into trouble while using alcohol or drugs.

Why are teens with ADHD at particular risk of developing SUDs? In part, they might have greater neural reward processing than other children, as well as deficits in conflict resolution, Dr. Ivanov said. These combined factors lead to a cumulative risk effect for SUD compared with either ADHD alone or parental SUD alone.

The brain’s tendency to seek sensation also peaks in early to middle adolescence, making this age particularly vulnerable to substance abuse, whether or not children have ADHD, Dr. Ivanov noted. But ADHD exacerbates this risk. In one study individuals with ADHD were significantly more likely to abuse alcohol (adjusted odds ratio, 14.28; 95% confidence interval, 1.49-138.88) and drugs (aOR, 3.48; 95% CI, 1.38-8.79), compared with controls (PLoS One 2014;9:e105640). These individuals also were more likely to develop drug dependencies as adults, even if they did not abuse substances during adolescence.

Dr. Ivanov reported receiving honoraria from Lundbeck, a pharmaceutical company that specializes in therapies for brain disease.

SAN DIEGO – Adolescents with attention-deficit/hyperactivity disorder are at increased risk of substance abuse disorders, especially if their parents smoke or abuse alcohol or drugs, said Dr. Iliyan S. Ivanov. Interventions that target schools, communities, and families can help, especially if these programs last more than 10 weeks and include training for children and parents, he said.

© iStock / ThinkStockPhotos.com

Several psychosocial modalities can aid teens with attention-deficit/hyperactivity disorder (ADHD) and substance use disorder (SUD), but the evidence to date particularly supports family therapy, Dr. Ivanov said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Parents with SUDs often don’t realize that their children know about their substance abuse, he emphasized. For this and other reasons, these children might harbor positive feelings about “light” (or soft) drugs, such as cannabis, which further increases their risk of using drugs, alcohol, or tobacco, said Dr. Ivanov, of the division of child and adolescent psychiatry at Mount Sinai Hospital, New York.

In addition to family therapy, adolescents with ADHD and SUD can benefit from “contingency management,” in which they earn rewards if they achieve positive outcomes, he said. “For example, look for the first negative urine test, and use that for positive reinforcement instead of using negative punishment for positive urine screens,” he said. “You really have to be on top of educating the parent or whoever is implementing the rewards that it is a moving target. The rules will change as the adolescent’s feelings change or improve.”

Medications are often key to treating adolescent ADHD; however, evidence is limited on whether they improve or control comorbid SUD in most cases, Dr. Ivanov said. “Stimulants are effective in controlling ADHD symptoms but have limited efficacy in controlling SUD,” he added. “Stimulant treatment is most effective when used concurrently with SUD treatment, and that is best done in a clinic with some kind of behavioral therapy.”

In longitudinal studies, stimulants such as methylphenidate usually have a neutral effect on substance abuse in children and adults, Dr. Ivanov said. An exception is smoking, he noted. Patients with ADHD have an especially hard time quitting tobacco use, but are less likely to start if they receive consistent treatment with stimulants (Pediatrics 2014;133:1070-80), he said. Osmotic-release oral system methylphenidate (OROS-MPH) also has been found to improve substance abuse treatment outcomes in patients who have ADHD with comorbid conduct disorder (J. Subst. Abuse Treat. 2013;44:224-30), Dr. Ivanov said.

Clinicians should carefully monitor adolescents on stimulants who have SUDs because of the potential for abuse, Dr. Ivanov emphasized. “Given the pharmacokinetics of the long-term stimulants, they might be the better choice,” he said. Also consider drugs with different mechanisms of action, such as lisdexamfetamine, a prodrug stimulant that the brain takes up relatively slowly; atomoxetine, which has distinct neurophysiological effects; extended-release guanfacine; omega fatty acids; buproprion; serotonin norepinephrine reuptake inhibitors; and glutamatergic agents, he said.

Clinicians also should educate patients about proper medication use and should closely follow them, use random urine toxicology screens to look for substance use, and check to see whether the patient has sought scripts from other clinicians, Dr. Ivanov said. New York State has passed legislation requiring prescribers to carry out these checks through prescription monitoring registries, he noted.

Because severe substance abuse predicts worse treatment outcomes for both ADHD and SUD (J. Subst. Abuse Treat. 2013;44:224-30), early detection and prevention of SUDs are key, and several screening tools can help, Dr. Ivanov said. The most comprehensive, the POSIT (Problem-Oriented Screening Assessment for Teenagers) tool, assesses patients for SUDs and also for unrelated problems, he added. The tool is self-administered, as is AUDIT (the Alcohol Use Disorders Identification Test), while CRAFFT (which stands for Car Relax Alone Forget Friends Trouble) is intended for interviews, he said.The CRAFFT tool asks about key signals of worsening substance use, such as riding in a car driven by someone who is intoxicated, using substances to relax or while alone, forgetting incidents that occurred while intoxicated, having friends or family express concern about substance use, and getting into trouble while using alcohol or drugs.

Why are teens with ADHD at particular risk of developing SUDs? In part, they might have greater neural reward processing than other children, as well as deficits in conflict resolution, Dr. Ivanov said. These combined factors lead to a cumulative risk effect for SUD compared with either ADHD alone or parental SUD alone.

The brain’s tendency to seek sensation also peaks in early to middle adolescence, making this age particularly vulnerable to substance abuse, whether or not children have ADHD, Dr. Ivanov noted. But ADHD exacerbates this risk. In one study individuals with ADHD were significantly more likely to abuse alcohol (adjusted odds ratio, 14.28; 95% confidence interval, 1.49-138.88) and drugs (aOR, 3.48; 95% CI, 1.38-8.79), compared with controls (PLoS One 2014;9:e105640). These individuals also were more likely to develop drug dependencies as adults, even if they did not abuse substances during adolescence.

Dr. Ivanov reported receiving honoraria from Lundbeck, a pharmaceutical company that specializes in therapies for brain disease.

SAN DIEGO – Adolescents with attention-deficit/hyperactivity disorder are at increased risk of substance abuse disorders, especially if their parents smoke or abuse alcohol or drugs, said Dr. Iliyan S. Ivanov. Interventions that target schools, communities, and families can help, especially if these programs last more than 10 weeks and include training for children and parents, he said.

© iStock / ThinkStockPhotos.com

Several psychosocial modalities can aid teens with attention-deficit/hyperactivity disorder (ADHD) and substance use disorder (SUD), but the evidence to date particularly supports family therapy, Dr. Ivanov said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Parents with SUDs often don’t realize that their children know about their substance abuse, he emphasized. For this and other reasons, these children might harbor positive feelings about “light” (or soft) drugs, such as cannabis, which further increases their risk of using drugs, alcohol, or tobacco, said Dr. Ivanov, of the division of child and adolescent psychiatry at Mount Sinai Hospital, New York.

In addition to family therapy, adolescents with ADHD and SUD can benefit from “contingency management,” in which they earn rewards if they achieve positive outcomes, he said. “For example, look for the first negative urine test, and use that for positive reinforcement instead of using negative punishment for positive urine screens,” he said. “You really have to be on top of educating the parent or whoever is implementing the rewards that it is a moving target. The rules will change as the adolescent’s feelings change or improve.”

Medications are often key to treating adolescent ADHD; however, evidence is limited on whether they improve or control comorbid SUD in most cases, Dr. Ivanov said. “Stimulants are effective in controlling ADHD symptoms but have limited efficacy in controlling SUD,” he added. “Stimulant treatment is most effective when used concurrently with SUD treatment, and that is best done in a clinic with some kind of behavioral therapy.”

In longitudinal studies, stimulants such as methylphenidate usually have a neutral effect on substance abuse in children and adults, Dr. Ivanov said. An exception is smoking, he noted. Patients with ADHD have an especially hard time quitting tobacco use, but are less likely to start if they receive consistent treatment with stimulants (Pediatrics 2014;133:1070-80), he said. Osmotic-release oral system methylphenidate (OROS-MPH) also has been found to improve substance abuse treatment outcomes in patients who have ADHD with comorbid conduct disorder (J. Subst. Abuse Treat. 2013;44:224-30), Dr. Ivanov said.

Clinicians should carefully monitor adolescents on stimulants who have SUDs because of the potential for abuse, Dr. Ivanov emphasized. “Given the pharmacokinetics of the long-term stimulants, they might be the better choice,” he said. Also consider drugs with different mechanisms of action, such as lisdexamfetamine, a prodrug stimulant that the brain takes up relatively slowly; atomoxetine, which has distinct neurophysiological effects; extended-release guanfacine; omega fatty acids; buproprion; serotonin norepinephrine reuptake inhibitors; and glutamatergic agents, he said.

Clinicians also should educate patients about proper medication use and should closely follow them, use random urine toxicology screens to look for substance use, and check to see whether the patient has sought scripts from other clinicians, Dr. Ivanov said. New York State has passed legislation requiring prescribers to carry out these checks through prescription monitoring registries, he noted.

Because severe substance abuse predicts worse treatment outcomes for both ADHD and SUD (J. Subst. Abuse Treat. 2013;44:224-30), early detection and prevention of SUDs are key, and several screening tools can help, Dr. Ivanov said. The most comprehensive, the POSIT (Problem-Oriented Screening Assessment for Teenagers) tool, assesses patients for SUDs and also for unrelated problems, he added. The tool is self-administered, as is AUDIT (the Alcohol Use Disorders Identification Test), while CRAFFT (which stands for Car Relax Alone Forget Friends Trouble) is intended for interviews, he said.The CRAFFT tool asks about key signals of worsening substance use, such as riding in a car driven by someone who is intoxicated, using substances to relax or while alone, forgetting incidents that occurred while intoxicated, having friends or family express concern about substance use, and getting into trouble while using alcohol or drugs.

Why are teens with ADHD at particular risk of developing SUDs? In part, they might have greater neural reward processing than other children, as well as deficits in conflict resolution, Dr. Ivanov said. These combined factors lead to a cumulative risk effect for SUD compared with either ADHD alone or parental SUD alone.

The brain’s tendency to seek sensation also peaks in early to middle adolescence, making this age particularly vulnerable to substance abuse, whether or not children have ADHD, Dr. Ivanov noted. But ADHD exacerbates this risk. In one study individuals with ADHD were significantly more likely to abuse alcohol (adjusted odds ratio, 14.28; 95% confidence interval, 1.49-138.88) and drugs (aOR, 3.48; 95% CI, 1.38-8.79), compared with controls (PLoS One 2014;9:e105640). These individuals also were more likely to develop drug dependencies as adults, even if they did not abuse substances during adolescence.

Dr. Ivanov reported receiving honoraria from Lundbeck, a pharmaceutical company that specializes in therapies for brain disease.

SAN DIEGO – Google search terms related to mental illness and violence were highly linked over a 10-year period, an analysis of 7 trillion Internet queries showed.

“We found that, over time, there was a very strong correlation between searches for ‘mentally ill’ and ‘violent,’ and between other common terms for mental illness and violence,” Dr. Matthew Burkey said in an interview. The study methodology “is a public health tool we can use to measure the effects of antistigma campaigns to combat the idea that people with mental health problems are inherently violent,” added Dr. Burkey of the departments of child and adolescent psychiatry at the Johns Hopkins University, Baltimore.

Public surveys have shown that people tend to associate mental illness with violence, but social desirability bias – in which respondents “say what you want them to hear” – can affect survey results, Dr. Burkey said at the annual meeting of the American Academy of Child and Adolescent Psychiatry. When people search the Internet, their behavior is less likely to reflect concerns about how others perceive them, he added. “Online search activity may represent a window into ‘hidden’ perceptions of personal attitudes by revealing patterns in searches for information,” he and his associates noted.

Using the Google Correlate, Dr. Burkey and his associates analyzed 7 trillion Internet queries between Jan. 1, 2004, and Feb. 5, 2014. The search term “mentally ill” correlated most strongly with the search term “violent,” with an r value of 0.90, the investigators found. Among the other 19 search terms that most correlated with “mentally ill,” “crime” ranked fourth, “on violence” ranked seventh, “violence” ranked 10th, and “violence in America” ranked 16th, they reported.

Six searches related to violence also ranked among the 20 terms that were most correlated with searches for “mental illness” (30%; two-sided P value < .000001), the researchers said. Those terms included “violent behavior,” “pro gun control,” “violence in America,” “crime,” “violent crime,” and “crimes committed,” they said. In contrast, searches for “schizophrenia,” “schizophrenic,” and “mental disorder” did not correlate with terms related to violence, they reported.

After the Sandy Hook Elementary School shooting, a substantial spike occurred in searches for “mentally ill” and “violent,” Dr. Burkey said. “In the wake of a shooting, public interest in mental illness grows, and people jump to conclusions about causes.”

He and his associates reported no funding sources or conflicts of interest.

SAN DIEGO – Google search terms related to mental illness and violence were highly linked over a 10-year period, an analysis of 7 trillion Internet queries showed.

“We found that, over time, there was a very strong correlation between searches for ‘mentally ill’ and ‘violent,’ and between other common terms for mental illness and violence,” Dr. Matthew Burkey said in an interview. The study methodology “is a public health tool we can use to measure the effects of antistigma campaigns to combat the idea that people with mental health problems are inherently violent,” added Dr. Burkey of the departments of child and adolescent psychiatry at the Johns Hopkins University, Baltimore.

Public surveys have shown that people tend to associate mental illness with violence, but social desirability bias – in which respondents “say what you want them to hear” – can affect survey results, Dr. Burkey said at the annual meeting of the American Academy of Child and Adolescent Psychiatry. When people search the Internet, their behavior is less likely to reflect concerns about how others perceive them, he added. “Online search activity may represent a window into ‘hidden’ perceptions of personal attitudes by revealing patterns in searches for information,” he and his associates noted.

Using the Google Correlate, Dr. Burkey and his associates analyzed 7 trillion Internet queries between Jan. 1, 2004, and Feb. 5, 2014. The search term “mentally ill” correlated most strongly with the search term “violent,” with an r value of 0.90, the investigators found. Among the other 19 search terms that most correlated with “mentally ill,” “crime” ranked fourth, “on violence” ranked seventh, “violence” ranked 10th, and “violence in America” ranked 16th, they reported.

Six searches related to violence also ranked among the 20 terms that were most correlated with searches for “mental illness” (30%; two-sided P value < .000001), the researchers said. Those terms included “violent behavior,” “pro gun control,” “violence in America,” “crime,” “violent crime,” and “crimes committed,” they said. In contrast, searches for “schizophrenia,” “schizophrenic,” and “mental disorder” did not correlate with terms related to violence, they reported.

After the Sandy Hook Elementary School shooting, a substantial spike occurred in searches for “mentally ill” and “violent,” Dr. Burkey said. “In the wake of a shooting, public interest in mental illness grows, and people jump to conclusions about causes.”

He and his associates reported no funding sources or conflicts of interest.

SAN DIEGO – Google search terms related to mental illness and violence were highly linked over a 10-year period, an analysis of 7 trillion Internet queries showed.

“We found that, over time, there was a very strong correlation between searches for ‘mentally ill’ and ‘violent,’ and between other common terms for mental illness and violence,” Dr. Matthew Burkey said in an interview. The study methodology “is a public health tool we can use to measure the effects of antistigma campaigns to combat the idea that people with mental health problems are inherently violent,” added Dr. Burkey of the departments of child and adolescent psychiatry at the Johns Hopkins University, Baltimore.

Public surveys have shown that people tend to associate mental illness with violence, but social desirability bias – in which respondents “say what you want them to hear” – can affect survey results, Dr. Burkey said at the annual meeting of the American Academy of Child and Adolescent Psychiatry. When people search the Internet, their behavior is less likely to reflect concerns about how others perceive them, he added. “Online search activity may represent a window into ‘hidden’ perceptions of personal attitudes by revealing patterns in searches for information,” he and his associates noted.

Using the Google Correlate, Dr. Burkey and his associates analyzed 7 trillion Internet queries between Jan. 1, 2004, and Feb. 5, 2014. The search term “mentally ill” correlated most strongly with the search term “violent,” with an r value of 0.90, the investigators found. Among the other 19 search terms that most correlated with “mentally ill,” “crime” ranked fourth, “on violence” ranked seventh, “violence” ranked 10th, and “violence in America” ranked 16th, they reported.

Six searches related to violence also ranked among the 20 terms that were most correlated with searches for “mental illness” (30%; two-sided P value < .000001), the researchers said. Those terms included “violent behavior,” “pro gun control,” “violence in America,” “crime,” “violent crime,” and “crimes committed,” they said. In contrast, searches for “schizophrenia,” “schizophrenic,” and “mental disorder” did not correlate with terms related to violence, they reported.

After the Sandy Hook Elementary School shooting, a substantial spike occurred in searches for “mentally ill” and “violent,” Dr. Burkey said. “In the wake of a shooting, public interest in mental illness grows, and people jump to conclusions about causes.”

He and his associates reported no funding sources or conflicts of interest.